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65 y.o male NKDA DNAR/DNI BMI: 24.28 (Interventions: (Assess skin and…
65 y.o
male
NKDA
DNAR/DNI
BMI: 24.28
PMH:
Spina bifida with paraplegia
Hypertension
Labs:
Low RBC, Hgb, Hct
May be r/t anemia or
nutritional deficit
Low anion gap, High BUN, Low
Creatinine, and Low albumin
May be r/t inadequate protein intake,
dehydration and decreased
muscle mass
Possible NDX:
Impaired skin integrity r/t decreased sensory perception
2* to neurological impairment
Impaired physical mobility r/t neurological impairment
Risk of constipation r/t impaired mobility
2* to neurological impairment
Risk of urinary incontinence r/t neurological impairment
Pain r/t skin
infection
Self care deficit
Risk for infection r/t invasive device aeb PICC line therapy
Risk of acute confusion r/t increased intracranial pressure 2* Spina bifida
Risk for falls
Meds:
Aspirin
Prevent MI and CVA
Risk of: bleeding, tinnitus, gi upset
Enoxaparin
Anticoagulant,
Prevent DVT,
Pt bed bound.
Risk of: bleeding, anemia, HA, rash
Nystatin
powder
Antifungal
Skin fold rash
Risk of: skin irritation
Simvastatin
HMG COA inhibitor.
Hyperlipidemia
Risk of: Rhabdomylosis, HA, N/V, hyperglycemia,
increased liver enzymes
Ertapenem
Antibiotic.
R. buttock wound.
Risk of: SZ, HA, CDAD, N/V, phlebitis
Finasteride
Androgen Inhibitor.
Enlarged Prostate.
Risk of: Gynecomastia, prostate CA,
decreased libido
Lactobacillus
Good bacteria.
Antibiotic use
Risk of: Gas and bloating
Lisinopril
ACE inhibitor. HTN
Risk of: hypotension, weakness, angioedema,
cough, tachycardia, hyperkalemia
Psyllium
Prevent constipation
Risk of: Diarrhea, cramps, N/V
Admit DX:
Right ischial pressure sore. Stage 4.
Interventions:
Assess skin and turn Q 2 hours
Keep skin clean and dry
Perform ROM to BLE
Assess temp, HR, RR, and BP Q4h and PRN
Assess pain level using pain scale and medicate PRN
Assess bowel sounds Q6h and LBM
Assess hydration status and appetite
Assess continence, urine color, clarity, and odor
Hand hygiene, PICC line care protocol
Assess self care abilities
Assess LOC, A+O Q rounding
Assess wound vac output and dressing integrity
Wound Vac 150 mmhg continuous suction
Imaging:
Chest X-ray 1/3:
Confirm PICC placement.
Heart and lungs norm.