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71 Male DNAR/+ETT TELE White/Caucasian Regular diet NKA 5'8/81kg…
71 Male
DNAR/+ETT
TELE
White/Caucasian
Regular diet
NKA
5'8/81kg
BMI: 28.13
A-Fib
Imaging:
EKG
TELE
CXR
Labs:
BMP
CBC
NDX:
Risk for ineffective cerebral tissue perfusion
Medications:
amiodarone
CHF
Imaging:
CXR
Labs:
BMP
BNP
Creatinine
Albumin
Urinalysis
Medications:
metoprolol tartrate
senna
NDX:
activity intolerance r/t weakness, fatigue
constipation r/t activity intolerance
excess fluid volume r/t impaired excretion of sodium and water
Acute delirium
Medication:
lorazepam
olanzipine
NDX:
Impaired verbal communication r/t physiological impairment, delusional thinking
Risk for other-directed violence
Risk for self-directed violence
Labs:
BMP
CBC
Imaging:
CT
Traumatic open wound of right lower extremity
Labs:
BMP
CBC
Imaging:
CTA extremity
US arterial lower extremity
Medication:
meropenem
acetaminophen
morphine sulfate
oxycodone
NDX:
Impaired tissue integrity r/t wound, presence of infection
Risk for imbalanced fluid volume
Type 2 Diabetes
Labs:
BMP
Glucose
NDX:
Ineffective health maintenance
Risk for impaired skin integrity
Imbalanced nutrition less than body requirements r/t inability of body to adequately metabolize and use glucose and nutrients
Medications:
Insulin
Hypothyroidism
Labs:
TSH
T4
Imaging:
ultrasound
Medication:
levothyroxine
senna
NDX:
Risk for overweight
constipation r/t decreased gastric motility