Patient: C.H.J. 84 y/o female
08/28/2020
Full Code
Primary diagnosis: Sepsis and Pneumonia
History: diverticulitis, C. diff. colitis, chronic pain syndrome, GI bleed and anemia, PVT, sarcoidosis, cerebral aneurysm
Comorbidities: HTN, end stage renal disease, liver cirrhosis, leukemia, hypothyroidism
Allergies: Clarithromycin and Azithromycin
Patho: Sepsis cause severe inflammation in the whole body due to infection from bacteria, virus, fungus, or parasite (Lewis et. al, 2017).
Personal goal: I will teach the patient at least two interventions by the end of shift.
Evaluation: Goal met I taught pt. proper hand hygiene and cough and deep breath technique.
MS
gout
allopurinol (Zyloprim) 100 mg PO 0900
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CV
BP: 141/62
Hydralazine (Apresoline) 10 mg IV 0900
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HTN
Carvedilol (Coreg) 25 mg PO 0900
minoxidil (loniten) 2.5 mg PO 0900
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previous PVT
Heparin 5,000 units SQ 1300
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Respiratory
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O2 sat: 93%
1) Impaired gas exchange related to decreased systemic vascular resistance as evidenced by SOB, O2 Sat of 89-90%, and RR of 20/min (Ackley, 2017, p. 106).
listen to pt. breath sounds at least every 2 hours and check for the presence of crackles and wheezes (Ackley, 2017, p. 421).
teach pt. the cough and deep breathing technique and remind them to practice it every hour. Explain the purpose and why it is imperative to her recovery (Ackley, 2017, p. 422).
pt. is at risk for falling due to her generalized weakness and the side effects of her meds.; make sure she is on fall precautions, inform her to use her call light before getting up, and turn on the bed alarm (Ackley, 2017, p. 410)
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Goal: Patient will use cough and deep breathing techniques at least 3 times before the end of shift.
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history of pneumonia
sodium chloride minibag and piperacillin/tazobactam 100 mL/3.375 gm 0900 q6hr
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GI
diveritculitis
Pantoprazole sodium (protonix) 40 mg PO 0900
C. diff. colitis
Pantoprazole sodium (protonix) 40 mg PO 0900
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decreased bowel sounds
Polyethylene glycol 3350 (miralax) 17 gm PO 0900
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psychosocial and neuro
anxiety
Alprazolam (xanax) 0.5 mg PO 1300
Erickson: Integrity; pt. states, "I love my family's support and I am living the best life I can."
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Skin
edema 1+
Bumetanide (Bumex) 1 mg PO 0900
Temp: 37.3 C
acetaminophen 650 mg PO 1300
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endocrine
hypothyroidism
Levothyroxine sodium (synthroid) 100 mcg PO 0900
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immune system
WBC: 13.7
sodium chloride 0.9% with vancomycin HCL 250 mL/750 mg 1300
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leukemia
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3) Increased risk for infection related to ineffective immune system as evidenced by increase WBC, abnormal blood cell production, and imbalanced nutrition (Ackley 2017, p. 73).
Assess pt. for symptoms of infection which include redness, warmth, discharge, and increased body temperature (Ackley, 2017, p. 547).
Assess pt's temperature especially if she becomes neutropenic because of her leukemia (Ackley, 2017, p. 547).
Assess pt. symptoms for MRSA or other multidrug-resistant organisms (MDROs) (Ackley, 2017, p. 547).
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GU
end stage renal disease
2) Imbalanced nutrition related to generalized weakness as evidenced by inflammation of the colon, decreased liver function, history of a cerebral aneurysm, and loss of kidney function (Ackley, 2017, p. 106).
Caution the pt. to stay away from high protein diets because it may worsen her liver cirrhosis and end stage renal disease (Ackley, 2017, p.653).
administer antiemetic and pain medications (Ackley, 2017, p. 653).
Help pt. determine foods that do not irritate her colon and excite her to finish her meals but also are high in nutrients (Ackley, 2017, p. 2017).
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