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TH (GU Assessment (Medication (hydrochlorothiazide PO 12.5mg daily),…
TH
GU Assessment
Intake: 240mL of coffee, 240mL of apple juice, & 300mL of water = 780mL
Output: 600mL
Medication
hydrochlorothiazide PO 12.5mg daily
Pt uses urinal. Urine is dark yellow in color with no potent odor. Pt states no pain or discomfort with urination.No devices in place.
Neuro Assessment
Logical: Patient is A/Ox3. PERRLA, pupils 3mm, pt stated
poor peripheral vision
Good judgement. Short and long-term memory present. Affect is consistent with presenting situation, happy, hopeful, realistic, and pleasant to staff and wife who are caring for him at bedside. Pt is conscious and responds to verbal and visual cues. No alerations in speech.
Muscular: Grip strength moderate. Flexion and extension present in upper extremities. Pt has trouble with
L arm abduction
. Plantar and dorsiflexion present in both legs. Swallow present, no aspiration precautions.
Pain
Assessment: before pharmacological intervention -
6/10, dull/achy pain, present behind R eye
,
present since stroke occurred.
After intervention - 0/10.
Medications
acetaminophen [Tylenol] PO 650mg Q6h
ketorolac [Toradol] IV 15mg (15mg/1mL) Q8h PRN
[Tramadol] PO 50mg Q6h PRN
Pt Information
Demographics
Sex: Male
Age: 66
Race: Caucasian
Religion: Christianity
Marital Status: Married
Medical Information
Allergies: Diluadid/hydromorphone (anaphylaxis)
Admission: 9/20/2019; LOS: 4 days; Dx:
Acute Embolic Stroke
Active Orders: Carb consistent diet, QID accucheck, Q4h vitals, HOB at or more than 30 degrees, low fall risk, moderate VTE risk, ST 3x/week, PT 5x/week, OT 4x/week
Significant medical history:
HLD
, OSA and CPAP ordered while sleeping, T2DM,
MI w/ stent in L coronary artery,
HTN
, GERD,
CAD
Significant events since admission: last night (9/23-24/2019) pt was
suddenly short of breath, diaphoretic, lung sounds were clear and then diminished during 5 minute re-assessment,
O2 sat: 98%. Nurse called rapid response. Stat EKG, chest x-ray, CT over thorax; CT shows
minor pericardial effusion
; No specific cause for episode
GI Assessment
Medications
pantoprozole [Protonix] IV infusion over 2min (40mg/10mL)
sucralfate [Carafate] PO (1g/10mL) BID
bisacodyl [Ducolax] PO 50mg PRN daily
[Miralax] PO 17g (mix in 8oz drink) daily
Bowel sounds active in all four quadrants, peristalsis occurring. Abdomen is distended and hard when palpating and following colon. Carb consistent diet. Adequate appetite and nutrition, no concern for dietary supplement. LBM 9/24/2019 d/t laxatives.
Otherwise, LBM 9/19/2019. Pt has moderate amount of stool in entire colon
and is receiving pharmacological intervention to relieve issue. No devices in place.
Skin Assessment
IVs
Right Upper Arm: Flushes well, able to obtain blood return; running NS 100mL/h; used for IV medications; clean, dry and intact dressing; not due for dressing change
Left AC: Flushes well, able to obtain blood return;
running Heparin 18mL/h
(PTT goal of 40-60 seconds); clean, dry and intact dressing; not due for dressing change
Temperature: 97.5-98.3 degrees F. Skin warm, dry, soft, even and is consistent in color to ethnicity. Turgor present, skin is elastic, no tenting of skin.
Scabs on anterior lower legs; pt states they are from him running into objects out of sight.
No lesions. No pressure ulcers found. No suspicious nevi. No ecchymosis found. No discoloration or inflammation. No overly heated areas.
CV/PV Assessment
Medications
amlodipine [Norvasc] PO 5mg daily
aspirin-enteric [Ecotrin] PO 81mg daily
atorovastatin [Lipitor] PO 80mg daily
candesartan [Atacand NF] PO 32mg daily
metoprolol [Lopressor] PO 25mg daily
heparin infusion IV continuous 18mL/h (25000units/250mL)
hydrochlorothiazide PO 12.5mg daily
clopidogrel [Plavix] PO 75mg daily
Patient’s HR is 70-78 bpm at rest as observed from palpation at both radial sites.
BP is 132-138/56-60
before pharmacological intervention. After intervention, BP is 118/52 with a MAP of 74. S2 is clearly heard at aortic and pulmonic landmarks. S1 is clearly heard at mitral landmark. All peripheral pulses present and compared bilaterally, +2 in both arms and +1 in both legs. Capillary refill occurs within 2 seconds, nail beds are pink in appearance. No facial or peripheral edema.
Respiratory Assessment
RR is 18-20 while lying as observed manually. O2 Sat is 94-96%. Breath sounds are present with ability to deep breathe. No adventitious sounds heard. No changes in breathing pattern. No labored or distressed breathing. Coughs on demand. Otherwise, no cough present.
CPAP
on pt while sleeping to minimize symptoms of OSA