Hello. I’m gonna be as detailed as possible because this assignment requires a lot of details. To start off, the PDF that I uploaded is just an example my teacher gave us. I cannot use any information whatsoever from that PDF. It is only for me to understand the assignment’s formatting. The docx I uploaded is what I need you to fill out with all the information I’ll give you plsease. I also uploaded two screenshots of the rubric. Everything needs to be in APA format, with in-text citations and references. Please follow the rubric and again there’s another example. let me know if you have questions CJP Info:

Room: 2156
Patient Initials: A.G.M
Admission Date: 2/1/26
Code Status: Full Code
Allergies: Codeine, Gabapentin, Influenza vaccine
Advanced Directive: None

Chief Complaint

Shortness of breath and wheezing.

History of Present Illness (HPI)

A.G.M is a 79-year-old male admitted on 2/1/26 with severe sepsis, acute hypoxic respiratory failure, and multifocal pneumonia. He presented with shortness of breath and wheezing. Chest X-ray confirmed multifocal pneumonia. Bronchoscopy showed concern for interstitial lung disease. He was started on IV antibiotics, steroids, and oxygen therapy. He is currently improving and being weaned off oxygen.

Admitting Diagnosis & Pathophysiology

Severe Sepsis: A life-threatening organ dysfunction caused by a dysregulated response to infection. In this patient, pneumonia triggered systemic inflammation, leading to elevated WBC and respiratory compromise.

Acute Hypoxic Respiratory Failure: Occurs when the lungs cannot adequately oxygenate the blood. Pneumonia causes inflammation and fluid in the alveoli, impairing oxygen exchange.

Multifocal Pneumonia: Infection in multiple areas of the lungs causing inflammation, impaired gas exchange, and increased WBC count.

Past Medical History & Pathophysiology

Hypertension: Chronic elevated blood pressure increasing cardiovascular strain.
Hypothyroidism: Decreased thyroid hormone production affecting metabolism.
Hyponatremia: History of low sodium levels, increasing risk for electrolyte imbalance.
Type 2 Diabetes Mellitus: Insulin resistance leading to hyperglycemia.

No past surgical history.

Social History

Speaks Spanish and understands English.
Hard of hearing.
Family support from wife and daughter.

Height: 175.3 cm
Weight: 72.1 kg
Diet: Carbohydrate-consistent diet.

Physical Assessment

Neuro: A/O x4, follows commands, calm and cooperative. PERRLA. Muscle strength 5/5 all extremities.

Cardiac: No murmurs. Radial and pedal pulses 2+. No edema.

Respiratory: On 2L NC at 98% SpO. Lungs clear bilaterally. Being weaned to room air. RT following.

GI: Continent. Abdomen soft, non-distended. Last BM 2/6. Normal bowel sounds.

GU: Continent. Urine clear yellow. Hourly output 500 mL.

Musculoskeletal: Ambulates independently. Pain 2/10 generalized. PT/OT consult.

Skin: Warm, dry, intact. No wounds.

IV: Left IV present.

Diagnostics

Chest X-ray: Multifocal pneumonia.
Bronchoscopy: Concern for interstitial lung disease.

Lab Values

WBC 15.06 (High) Indicates active infection (pneumonia/sepsis).
HGB 10.4 (Low) Mild anemia.
HCT 29.6 (Low).
Platelets 378 Normal/high normal.
Na 135 Low-normal; history of hyponatremia.
K 3.3 (Low) Risk for cardiac dysrhythmias.
Ca 8.3 (Low).
Glucose 341 Hyperglycemia; insulin administered.
BUN 19 Normal.
Cr 0.80 Normal kidney function.
Lactate 8.3 (Low/normal per facility range).

Medications (Relevant to This Patient)

Cefepime (IV BID) Antibiotic
Purpose: Treat bacterial pneumonia and sepsis.
MOA: Inhibits bacterial cell wall synthesis.
Nursing: Monitor WBC, signs of infection improvement.

Insulin (4 units given)
Purpose: Lower blood glucose of 341.
MOA: Promotes glucose uptake into cells.
Nursing: Monitor glucose levels AC/HS.

Steroids
Purpose: Reduce lung inflammation.
Side effect: Can increase blood glucose.

Bronchodilators
Purpose: Improve airway clearance and reduce wheezing.

Carbohydrate-consistent diet
Purpose: Maintain stable glucose control.

PRIORITY PROBLEMS

Priority Problem #1

Infection r/t bacterial pneumonia AEB WBC 15.06 and multifocal pneumonia.

Goal: Patient will show decreasing WBC and stable vital signs during hospitalization.

Interventions:
Monitor WBC trends
Administer antibiotics BID
Monitor temperature and respiratory status
Encourage pulmonary hygiene

Evaluation: Infection improving; no progression of sepsis.

Priority Problem #2

Imbalanced Blood Glucose r/t Type 2 DM and steroid therapy AEB glucose 341.

Goal: Patient will maintain glucose within ordered range.

Interventions:
Monitor glucose AC/HS
Administer insulin per sliding scale
Maintain carb-consistent diet
Monitor for hyper/hypoglycemia

Evaluation: Glucose controlled with insulin therapy.

Priority Problem #3

Risk for Electrolyte Imbalance r/t history of hyponatremia and current Na 135.

Goal: Patient will maintain sodium within normal range.

Interventions:
Monitor sodium levels
Monitor mental status
Monitor fluid balance

Evaluation: Sodium remains stable; no neurological changes.

Plan of Care

Continue antibiotics, steroids, breathing treatments, diabetes management, and oxygen weaning. PT/OT consult for mobility. Plan for discharge to rehab unit (RU) once stable.

1. Acetaminophen (Tylenol)

Class: Non-opioid analgesic, antipyretic
Indication: Mild pain, fever
Dose/Route/Frequency: 650 mg PO every 4 hours PRN
Contraindications: Severe liver disease
Nursing Considerations: Monitor liver function, assess pain/temperature
Side Effects: Nausea, hepatotoxicity (overdose)
Teaching: Do not exceed 4,000 mg/day; avoid alcohol

2. Budesonide (Pulmicort)

Class: Corticosteroid
Indication: Reduce airway inflammation
Dose/Route/Frequency: 0.25 mg inhalation BID
Contraindications: Acute bronchospasm
Nursing Considerations: Rinse mouth after use; monitor for thrush
Side Effects: Oral candidiasis, hoarseness
Teaching: Not for acute attack; rinse mouth after use

3. Hydralazine (Apresoline)

Class: Vasodilator, antihypertensive
Indication: Hypertension
Dose/Route/Frequency: 50 mg PO TID
Contraindications: Hypotension, CAD
Nursing Considerations: Hold if SBP < 100; monitor BP
Side Effects: Tachycardia, dizziness
Teaching: Change positions slowly

4. Insulin Lispro (Humalog)

Class: Rapid-acting insulin
Indication: Type 2 DM, hyperglycemia
Dose/Route/Frequency: Sliding scale subcutaneous before meals
Contraindications: Hypoglycemia
Nursing Considerations: Check glucose before giving
Side Effects: Hypoglycemia
Teaching: Eat within 15 minutes of injection

5. Tamsulosin (Flomax)

Class: Alpha-1 blocker
Indication: BPH
Dose/Route/Frequency: 0.4 mg PO nightly
Contraindications: Hypotension
Nursing Considerations: Monitor dizziness
Side Effects: Orthostatic hypotension
Teaching: Take 30 min after same meal daily

6. Vitamin B Complex

Class: Vitamin supplement
Indication: Prevent deficiency
Dose/Route/Frequency: 1 tablet PO daily
Contraindications: Hypersensitivity
Nursing Considerations: May cause mild GI upset
Side Effects: Bright yellow urine
Teaching: Take with food

7. Cefepime (Maxipime)

Class: 4th-generation cephalosporin antibiotic
Indication: Bacterial pneumonia/sepsis
Dose/Route/Frequency: IV BID (per order)
Contraindications: Cephalosporin allergy
Nursing Considerations: Monitor WBC, monitor for allergic reaction
Side Effects: Diarrhea, rash
Teaching: Complete full antibiotic course

8. Steroids (Prednisone or Methylprednisolone)

Class: Corticosteroid
Indication: Reduce lung inflammation
Dose/Route/Frequency: Per provider order
Contraindications: Systemic fungal infections
Nursing Considerations: Monitor blood glucose (can increase levels)
Side Effects: Hyperglycemia, immunosuppression
Teaching: Do not stop abruptly; monitor blood sugar

Requirements: stated

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NURS 211L – Intermediate MedSurg, Complete the Clinical judg…