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56 yo Male NKDA BMI: 27.8 (Meds: (Hydralazine, Azithromycin,…
56 yo
Male
NKDA
BMI: 27.8
Possible NDX:
Decreased CO r/t altered blood pressure
Excess fluid volume r/t impaired kidney function
Activity intolerance r/t imbalance between O2 supply and demand 2* anemia and influenza
Risk for impaired skin integrity r/t excess fluid volume aeb edema
Fatigue r/t imbalance between O2 supply and demand
2* to anemia and influenza
Intervention:
Assess VS, HR, BP, RR, and temp
Assess WOB and activity tolerance
Continuous telemetry monitoring
Auscultate lung sounds x2 a shift and PRN
Daily weights
Assess edema and location
Strict I/O
Assess LOC and mental status
HOB 30-45*
MDX:
influenza A
sepsis
PMH:
Acute on chronic renal failure
Chronic renal transplant rejection
Osteoarthritis
Hypertension
Meds:
Hydralazine
Azithromycin
Ceftriaxone
Furosemide
Amlodipine
Bisacodyl
Flecainide
Heparin
Tacrolimus
Sodium Bicarb
Prednisone
Mycophenolate sodium
Oseltamivir
Labs
Decreased H/H
Decreased platelets
Decreased albumin
Increased PTT
Increased BUN
Increased creatinine
Decreased GFR
Positive influenza A
Imaging:
EKG: Sinus rhythm with 1st degree AV block.
Transthoracic echo:
pending
Chest xray: multli focal left upper lobe infiltrates. Cardiomegaly unchanged