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Sepsis/cellulitis (Fluid volume excess related to CHF (Int.: strict I&…
Sepsis/cellulitis
Fluid volume excess related to CHF
Int.: strict I&O's, daily weight (same scale, same time), fluid restriction (1500 mL or less). This will help prevent further fluid overload, and decrease edema
Meds: Lasix 40mg/4mL IVP BID, K-DUR 10 meq PO BID
Patient will have input < output during hospitalization
Labs: BNP (4/19-692), Na (4/19-136, 4/21-138, 4/22-139), K (4/19-3.9, 4/21-3.9, 4/22-4.1), Hgb (4/19-15.7, 4/21-12.7 L, 4/22-13.4 L)
AEB: BNP 692, BLE edema, SOB, input>output
Impaired skin integrity related to physical immobilization
Int.: Turn the patient every two hours to prevent the patient from putting pressure on one side for too long. Frequent skin assessments on the patient for early detection of new pressure ulcer formation. Consult wound care to provide extra care/treatment for the patient. Provide the patient with optimal nutrition to aid in recovery.
Meds: Lotrimin cream topical BID
Patient will have no further skin impairment during hospitalization.
Labs: Albumin (4/19-2.6 L, 4/21-2.0 L, 4/22-2.2 L), Glucose (4/19-130 H, 4/21-105 H, 4/22-111 H)
AEB: Stage 2 pressure ulcer on left buttocks, deep tissue injury on left heel, scaling of BLE, rash under left breast and groin area
Acute confusion related to decreased oxygenation
Int.: Have patient continuous pulse ox to ensure proper oxygenation. Frequent assessment of mental status to see if the patient is getting better or worse. Get orders to obtain an ABG; this may reveal source of the problem.
Meds: Duoneb treatment q4 hours
Patient will maintain or increase LOC during hospitalization
Labs: O2 sats 94% on 4L
AEB: Oriented to self only, restlessness when people are in the room, inability to answer questions
Impaired gas exchange related to CHF and fluid volume excess
Int.: Increase HOB to promote lung expansion. Encourage coughing to mobilize secretions. Increase O2 to maintain sats
Patient will maintain O2 sats >92% during hospitalization
Meds: Duoneb treatment q4 hour
Labs: O2 sats 94% on 4L
AEB: O2 sats 94% on 4L, wheezing, pulmonary edema shown on chest x-ray