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C.B. - 39 y.o. - Male - Full Code - Coggle Diagram
C.B. - 39 y.o. -
Male -
Full Code
Hospitalized d/t sepsis w/o acute organ dysfunction
Pathophysiology: Bacterial infection that causes inflammatory reaction resulting in systemic s/s of fever or hypothermia, tachycardia, tachypnea, hypotension, and increased WBC
Fever reported to be 103.3 degrees F upon admission
V/S have stabilized; continue to monitor
WBC: elevated to 17.71 (11/4/20)
Co
Treated w/ antibiotics
meropenem administered
Gram (+) streptococcus culture came back & found to have cellulitis on LUE
Antibiotic changed to cipro
S/S: skin red and hot
Nursing intervention: assess frequently; report to doctor if worsening
PLT decreased
Pt fears s/e of C. diff from medication
Teaching: explained to patient that this is often not an immediate s/e but often due to extended use
Allergy to Penicillin and Ciprofloxacin
Pt already has C. diff (diagnosed over 1 month ago)
Higher risk to reoccurance
Monitor for s/s: watery diarrhea (10-15X/day), rapid HR, fever, abdominal pain and cramping
Lifestyle changes needed
Morbid obesity
Type 2 DM
Skin Ulcer of left heal
Broke left calcaneus
External fixation placed in April
still in place d/t slow wound healing
Higher risk for infection
Monitor for s/s of infection: mental status changes, fever, malaise, VS changes
osteomyelitis of L foot
Placed on antibiotics
1 more item...
Bed rest
Increased risk for thromboembolism
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+3 edema in lower extremities
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Necrosis in left foot
Numbness & tingling present
Bil feet: cap refill >3 sec
Pedal pulses diminished: doppler used to find (-1 bil)
Pain present
Higher risk for infections
Nursing Intervention: monitor glucose; admin Lantus at HS; admin lispro per protocol
443 lb
Difficult now d/t ex fix which has resulted in bed rest
Nutrition management needed
Possibly iron deficient: HBG & HCT low
Pain present
8/10 pain score (most of day)
Pain medications bring it down to 7/10
Nursing intervention: talk with provider about increasing dose or changing pain medications
Oxycodone & Tylenol admin
Constipation; at risk
Did have BM on shift
Continue to monitor
Pt comfortable at 5/10
Complains of pain in bil feet and back
D/C Plan
D/C home with wife and home health
At home treatment: antibiotics, bedrest, wound care, monitor for s/s of infection, monitoring glucose closely
F/u w/ MD in two weeks to discuss alternate treatment options
Home health already in place
No specific date set for D/C; doctor wants to continue to monitor pt and treat w/ antibiotics
Continue to meet w/ PT before D/C