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B.P. - Male - 92 y.o. - Coggle Diagram
B.P. - Male - 92 y.o.
Secondary Diagnosis impairing current health
Anemia
Thiamine: 400 mg once daily
Decreased HTC & HGB
Inflammatory conditions: diverticulitis, Barrett's esophagus, chronic polyps, cancers (pancreatic, prostate, bladder)
Decreased HTC & HGB
Continue to monitor
Increased Platelet
Thromboembolism, at risk
aspirin: 81 mg once daily
PEG tube in place/NPO
Nutrition impairment, risk for
Labs and weight monitored
Medication admin
aspirin, busPIRone, lansoprazole, thiamine
Line flushed for patency
Increased Rate from 40 mL to 50 mL
Pt pulling at, risk for dislodgment
abdominal binder placed to keep pt from pulling at PEG
Assessed for distension, abdominal pain, skin integrity
Tube placement assessed: abdominal xray
450 mL nutrition admin
Mg increased
Magnesium Sulfate: 2g/50mL NS (administered once)
Monitored infusion
At risk for bleeding, ulcers, GI distress, heart burn, weight loss, fatigue nausea/vomiting, pain, death
Pt. denies pain
Dementia/ memory loss
confusion, chronic
Told pt were he was at and spoke softly
Anxiety
CHF, cardiomyopathy, LBBB
Na+ increased (CHF)
Fluid overload
Impaired Kindney function
Increased GFR
K+ increased (maybe r/t CHF)
Will continue to monitor all labs and assess for associated s/s
CL- decreased
BUN/creatine ration increased (CHF)
Slowed heart rate (LBBB) r/t to cardiomyopathy
PVCs
Clinical manifestations: SOB, edema. dry cough, weight gain, fatigue, cardiac arrest, sudden death
COPD
Increased RR
Assessed RR and monitored for signs of respiratory distress
Crackles in lower bases
Likely d/t 105 pack-year smoking hx
Quit smoking in April, 2020
Cl- decreased (may be correlated)
Accessory muscle use
3 L NC
Assess flow rate
Skin integrity impairment, at risk
Assessed for pressure ulcers on posterior ears
Clinical Manifestations: chronic bronchitis, emphysema, difficulty breathing, sputum production
D/C Planning
Touchmark will accept pt back, but pt has denied
SWS looking into other facilities (Sunshine & Royal Park)
Facilities pending acceptance
Pt needs to be restraint and tele free for 48hrs
Telemetry removed (9/30)
Restraints were attempted to be removed, but patient is still pulling at tubes (Foley, O2, PEG)
Health care team will continue to monitor and attempt removal
OT and PT using low-intensity therapy and are also recommending SNF
Fell from ground level
EMS called and admitted to E.D
Pt. diagnosed with Severe sepsis w/ acute respiratory distress
Pathophysiology
Bacterial infection that causes inflammatory reaction resulting in systemic s/s of fever or hypothermia, tachycardia, tachypnea, hypotension, and increased WBC. Severe sepsis causes dysfunction of major organ system or unexplained metabolic acidosis.
Major Organ Dysfunction: Acute respiratory distress
Hypoxia
Administered 6 L NC EMS
Returned to baseline O2: 3L NC
Elevated WBC
UTI: h/o UTI w/ E. coli & Morganella
Chronic Foley d/t bladder cancer
Ceftriaxone: 1g q daily
I&O reported
Bag below bladder and line strapped to leg
Urine assessed for color, sediment, and odor
Dark yellow, no sediment, no foul odor
Hospitalization
Fell during hospitalization
Bedrest
Mobility, impaired
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Skin integrity, impaired
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GLUC elevated (possibly r/t inactivity)
Constipation, at risk
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High anxiety
Fidgeting, pulling at tubes, attempting to get out of bed
Restraints ordered
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busPIRone: 5 mg
Used touch and soft tone w/ pt to help relieve anxiety
Confusion
Rt. antecubital IV site changed to upper forearm d/t continual occlusion of line and mild infiltration.
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BP: 103/65; MAP: 70 RR: 45; BG: 155
Vitals monitored regularly
SOB
Chest xray performed
Stable appearance
POA:SON
medical POA/decision maker
Son was not present but has been contacted and is involved in d/c planning
DNR