1. Stephanie Works EAMC ICU Care Given:11/17/10 Pt: 84yo, black, male
C/V: Ineffective tissue perfusion r/t unstable B/P
sinus rhythm,on assessment, S1&S2 clear, no murmurs, HR 84, BP 110/49; edema present in feet; +2 radial pulse, +1 pedal pulses
Monitor B/P , HR and rhythm, pedal pulses qh
Goals: HR , stable BP around 120/40
Goals not met
GI: risk for Constipation r/t impaired physical mobility
Bowel Sounds present in all four quadrants; soft, round, nontender, no current s/s of constipation or abdominal pain;
Diet: regular, but not eating
Goal: Pt. will have BM naturally; assess qshift
Goals met
Fluid/Electrolytes: Imbalanced electrolytes
Monitor lab values:
Na: 155 (H)
K: 5.3 (H)
Cl: 124 (H)
CO2: 28
BUN: 97 (H)
CR: 1.8 (H)
Glu: 126
Corrected Ca: 10.4
Mg: 3 (H)
WBC: 11.5x10^3
Hgb: 7.4 (L)
Hct: 24.1 (L)
Platelets: 61x10^3
Goals: Restore imbalanced electrolytes to WNL
Goal not met
History: End-stage dementia, diabetes, schizophrenia, HTN, stroke
Neuro: Chronic Confusion r/t dementia
Pt. obtunded, blind (per chart), unable to assess pupillary responses r/t severe swelling of both eyes
Assess qh
Goal: pt remain comfortable
Goal met
Medical Dx: hypoglycemia
Skin: impaired skin integrity r/t ineffective mobility and lack of body mass
3 IV access: 22g Rt. FA,
20g Lt. AC
20g Rt. AC
no redness or swelling noted, all lines patent
Impaired skin: deep “healed” ulcer on the left hip, left knee tear, Rt. Buttocks tear
Goals: maintain skin integrity by turning and/or promoting patient movement, provide proper wound care, check IV site q2hrs and flush to maintain patency
Primary Nursing Dx: Risk for greater AMS
Resp: Risk for aspiration r/t reduced LOC
Assess: clear upper and lower lobe lung sounds ,Bilateral chest excursion. 4L NC O2 in use, RR 16, O2Sat 100 with 35 second period of apnea with SaO2 ranging 73-88
Goals: assess breathing patterns and sounds in all lobes q1hr or prn; RR 12-20; SaO2> 93; HOB elevated 30 degress, turn, cough, deep breath qh
Goals not met
GU: Risk for infection r/t suprapubic catheter
Urine: amber
U.O: 125 ml
Continue to assess I&O
Goals met