Patient Centered Goals Plan

Patient Centered Goals Plan essay assignment

Patient Name: Sacramento John
MedSurg Unit
52 year old white male, came to the Emergency department ℅ severe abdominal pain, nausea, vomiting over the last 2 days. Since yesterday evening, the patient reports feeling dizzy and weak. The patient thought it was the flu-like symptoms, but came to the ED due to stomach pain becoming worse.
The patient reports that he is a widower, who practices Mormon faith. The patient
denies cigarette smoking and alcohol consumption. The patient denies any past medical history or surgeries. In the ED, the nurse reports that the patient vital signs were as follow: T 99 (oral); P 130 bpm, strong, regular; R 18 bpm, regular, labored; O2 sat 90% room air; BP 108/78 sitting, left arm; Pain= 10 +/10. The skin color was pale with poor turgor, oral mucosa dry and pasty and abdomen distended.

The consent forms for treatment are signed.
Lab results:
BMP: Na 150 Creatinine 1.9 Cl 108 BUN 42
CBC: Hb 20 HCT 60 WBC 17
Using SBAR format, please give report to the on-coming nurse.

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