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Mr Gonzalez, 67, M FULL Screen Shot 2019-02-09 at 12.32.46 PM (PMH…
Mr Gonzalez, 67, M FULL
Genetics/Family History
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PMH
Diabetes, DM2
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peripheral nueopthy
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ocular degeneration
poor wound healing
Peripheral vascular disease, PVD
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cardiovascular disease, CAD :<3:
hypertension, HTN
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hyperlipidimia, hld
chronic Pain :red_cross:
obesity
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social Hx
: Pt has widowed in 2018 and admits he is heart broken, wife had cervical CA. Pt is a former smoker, and drinks 3-4 drinks daily. Pt has some college education but never finished. He is employed as a mechanic, but due to his peripheral neuropathy he now just answers phones and gives the floor mechanics advice.
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Mr Gonzalez was told by his PCP to walk in through the emergency department because he was having the classic signs and symptoms of a heart attack. His chest pain was an 8/10. Once admitted the ED gave the patient NTG 3x and the S/S did not change. So he is admitted to the floor
LABS: Troponin 45 K: 3.7
NA: 138
BUN:30
Creat: 1.56
BG: 224
WBC: 9
HCT: 11.7
HGB: 34.2
RBC:
Plt: 212
A1C: 7.4
treatments
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pt also CO 8/10 pain can got morphine, ASA, nad was placed on 4L NC oxygen
The elevated BG of 345 was given 8 units Humalog
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the rn called the md to come see pt
pt is referred to pediatry
pt has received NTG x3, and the chest pain is unrelieved.
Medications
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PRN:
NORCO, NTG, Morphine, ASA, Zofran, potassium per protocol, docusate sodium, docolax suppository.
Scheduled:
metformin, Insulin Humalog on a sliding scale ACHS, metroprolol BID, coreg, Prilosec, a multivitamin, lasix TID, gabapentin,
Continuous:
Heparin ggt at 1560 units/hour
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Disposition
: Pt is calm cooperative, feel uncomfortable being in the hospital and is nervous about eminent CV surgery. pt states, "I m afraid to have any kind of surgery but will do it if it will make me feel better."
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prognosis: pt is condition will lead to a heart attack or Pulmonary Embolism if the pt is not treated for the Chest Pain, and if his remain noncompliant with his insulin management and blood pressure medications other comorbidities like a stroke look more eminent
pt was started on Heparin to limit the risks of Heart attach and stroke
pt BP is still nnot controlled and the hospitalist is changing the meds to regulate the pressures
pt was sent to the US wit RO DVTs in BLEs
Roadblocks :forbidden:
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old ways of thinking
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bad habits
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poor role models
lack of education
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unopen to change
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lack of resources to healthful foods
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low income
stress of learning new skill
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unsupportive family
no inspirational figures
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not willing to be a leader
unwilling to exercise
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non-compliant to medications
Watson's Caring Science
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1: Practice loving kindness
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2: desision making
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3:Instill faith and hope
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4: Teaching and learning
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5: Spiritual beliefs and practices
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6: Holistic care
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7: Helping and trusting relationship
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9: Promote expression of feelings
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8: Healing environment
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10: Miracles
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Patient needs to change his lifestyle
new ideas for exercise
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dietary changes
medication compliance
ideas to regulate sugar intake
regular lab check ups
Mastery and growth from the usual
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compliance to medications
positive mental image of future self
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imspiring others to achieve DM2 control
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maintaining a fruit and vegetable diet with low fat/sugars
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radiating health for the wold to see
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loosing pounds and gaining anergy
Inspiration for Self Care
new role models
local trainer
healthy family member
neighbors with similar issues
taking control of ones life
new gym membership
a one month menu and subscrition to gennie craig
buying the local farmers market veggie box
Carpers Ways of Knowing
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esthetic
Emprical knowledge
nursing knowledge
ways to educate patient
personal knowledge
personal stories
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ethic standards
