Please enable JavaScript.
Coggle requires JavaScript to display documents.
43 yo female Full code NKDA BMI: 24.69 (INTERVENTIONS (Strict I/O,…
43 yo female
Full code
NKDA
BMI: 24.69
MDX:
GI hemorrhage
R sided CVA with 7mm midline shift
Infective endocarditis
DKA
Hydronephrosis with emergency stent placement
R ankle ulcer
hypovolemic shock and PEA x4
Bacteremia
PMH:
Uncontrolled diabetes
HTN
Meth use and homelessness
CKD stage 2
LABS:
H/H 7.7/22.1% L
BUN 39 +35 H
Creatinie 1.18 +1.08 H
Albumin 2.2 +1.9 L
BG:
160
163
158
180
MEDS:
TPN 60 mL/hr continuous
D5W 40 mL/hr cont.
Meropenem
Ampicillin
Protonix
Zofran
Insulin aspart and glargine
IMAGING:
chest xray:
Picc out of optimal
placement
Head CT:
R CVA with 7mm
midlin shift
Nuclear med
no active gi bleeding
TEE:
Infective endocarditis
EGD:
Gastritis, gastric
and duodenal ulcers
POSSIBLE NDX:
Risk for injury
Fluid volume deficit r/t gi bleed and NPO
Imbalanced nutrition r/t NPO, GI loss, hyperglycemia
Ineffective health maintenance
Risk for unstable blood glucose
Impaired skin integrity
Impaired verbal communication
INTERVENTIONS
Strict I/O
Maintain safe environment,
decrease clutter, bed low
and locked, call light near
Assess VS Q4hr and PRN
Assess line patency to PICC, PIV, foley, and rectal tube
Assess BG and s/sx of hypo or hyperglycemia
Assess urine output, color,
clarity and odor Qhr
Assess bowel sounds, stool amount, color
Tele monitoring
NPO
Assess LOC, CMS, A+O