♣ Patient reports general discomfort, but still states pain is at zero.
♣ History of one ventricle physiology, triscuspid atresia, complete heart block, atrial arrhythmia, cardiac pacemaker, chronic atrial fib, heart failure. Patient reports shortness of breath and difficult breathing. Peripheral edema is present in all extremities. Extremities are dusky.
♣ Shortness of breath. Occasional non-productive cough. Patient is on oxygen and reports frequent nose bleeds from nasal cannula. Reports nasal congestion.
♣ Last bowel movement 2/6/17
♣ Voiding without difficulty. Patient reports urine is pale yellow, no odor, no pain with urination. Fluid restriction of 1800mL/day.
♣ Reports skin discomfort at PICC site. Skin is dusky. Slight cyanosis of lips. Skin is intact. Occasional nosebleeds from nasal cannula.
♣ Patient reports joint stiffness and general weakness. Does not report problems with range of motions.
♣ Client states feeling like she is in an okay place, and believes that everything is in Gods hands. She is ready for a transplant, and thinks she is emotionally well equipped since she has been facing heart complications her entire life. She would like to speak with doctors regarding life sustaining treatments, as she wants to put a time limit on this.
♣ Patient is not employed. States she lives far away from hospital, which puts her at risk of not being able to get immediate help if she is having any health problems.