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76 y/o M, Guillain-Barre Syndrome, Primary Dx: NSTEMI, HTN, Sources:
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76 y/o M
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Medications:
Tylenol 500 mg
Amlodipine 10 mg
Aspirin 81 mg
Atropine 0.5-1 mg
Cyclobenzaprine 5 mg
Famotidine 20 mg
Heparin 8 units/kg/hr
Hydralazine 10 mg
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Patient will not have any further injury (such as pressure ulcers, lacerations, or otherwise) as a result of the paresthesia he is experiencing by time of discharge.
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Patient will have improved cardiac output, as evidenced by improved EF, activity tolerance, and stable blood pressure, by time of discharge.
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Patient will show improved symptoms of autoimmune disease as evidenced by WBC WDL, lack of fever, and ... by time of discharge.
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Patient will have a pain rating of 3 or less and have no complaints of chest pain by time of discharge.
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Guillain-Barre Syndrome
Patho: Neurological autoimmune disorder that causes the immune system to destroy the myelin sheath in the peripheral nervous system, lasting usually a few weeks (3).
Etiology: Causes of GBS are unclear, but it is thought to be associated with a pre-existing viral or bacterial infection (4).
Epidemiology: GBS is relatively rare with 1.3 cases per population of 100,000. Most patients are able to fully recover, but approximately 20% are left with severe disability and 10% of cases are fatal (5).
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Diagnostics:
Lumbar puncture - elevated protein in CFS
Spinal MRI - degenerative disc changes
Brain MRI - non-specific white matter changes
Nurse will ensure safety in the environment by making sure the bed is in the lowest position, two side rails up, call light within reach, and room free of clutter to reduce fall risk.
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Nurse will perform proper hand hygiene before touching the patient, before aseptic procedures, after contact with bodily fluids, after touching the patient, and after touching the patient's surroundings to reduce risk of secondary infection (7).
Nurse will collaborate with a dietician and promote good nutrition to support the immune system (7).
Nurse will perform passive range of motion exercises and encourage patient to perform active ROM exercises to improve mobility.
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Primary Dx: NSTEMI
Etiology: Caused by a blood clot or plaque rupture blocking blood flow and oxygenation to the cardiac cells
Epidemiology: Heart disease is the leading cause of death in the U.S., affecting approximately 82.6 million people. Of this population, 7.9 million people have had a heart attack (myocardial infarction). About 15% of people who suffer from a heart attack die from it (1).
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Nurse will administer medications as prescribed, including aspirin and heparin to prevent clots, and nitroglycerin for chest pain.
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Nurse will assess for pain by instructing the patient to report any chest pain and looking for non-verbal cues such as guarding, facial expression, restlessness, etc.
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HTN
Patho: Increased blood pressure as a result of increased cardiac output and/or increased peripheral resistance (2).
Etiology: Primary HTN has an unknown cause. Secondary HTN is caused by another disease process, such as hepatic or renal impairment.
Epidemiology: Heart disease is the leading cause of death in the U.S., affecting approximately 82.6 million people. Of this population, 76.4 million people have hypertension (1).
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Diagnostics:
Blood pressure monitoring - 142/78
Chest CT - severe coronary artery calcification
Heart Cath - severe triple vessel disease
BUN - 40 mg/dL
Albumin - 3.3 g/dL
Nurse will monitor blood pressures q4h, assess postural blood pressures when indicated, and administer hypertension medications as prescribed.
Nurse will assess skin color, moisture, temperature and capillary refill q4h to monitor perfusion status.
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