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    20 views13 pages

    Critical Care - 2

    Uploaded by

    api-402019114

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    YOUNGSTOWN STATE UNIVERSITY StudentTOn (1 ICCor cy ____— Department of Nursing Date of Care Seficiiiey S¢ __—— 7 Nursing 4840L Clinical Data Base Nurse’s Name Bonnie ___— Pt's Initials Date admitted 1/25/71 _ Height_!70cm1 _ Room #10) (7 sf s ob icicy | Adm. Wei ne ok UT 50: Renta ig dl na THg afoa, im Weis AgelsBlu7 S0yrs isolatish typel0 jan SexMd ___iergies (40 Kaw calldrqies jagnosi un ist $e visit Seécong. n ylergnce Auch RUD RB Bon otro pera, VA, ENA NAL UDC FEEOING Reason for Admission/Events Leading to Current Hospitalization: (Include reason patient is still in Unit > 2 days if appropriate) Peuoncuanic 435/17 preined to ememency dupirtmunt complaining c# cardiac Test Rattan! wos found Uiusponsive uit C Pinitx oF CVA. PE was in cicystote Cure! aceus aclrtinte FA x2 ON wydlind Se pier 10 GdmminigHung ard Ept Approyimately 25 mains oF CPR py a ot ' f Hent+ has not spomtaivous esp edions. Paden wus Found war sponave 04 ON exendid cou Fact Pertinent History of Illnesses/Surgery: Pust Mudiccil | surgical nustory Ro tubunserhon disnln espnngenastrodudenettapy J/s0iI7, Traciostomy Ura pe 0 ( n_aanysyen"” Pt ho From Chi . Per Nuring > pt * uly * fas high Havers typiany (Our Which fy fac extibs 4 Witty hospital Day of Care (ranges): Vent Settings: TICUSE | IWF Gwen ¥50 Qamninodhun ETT (sizefip-li Trach Z orttlsPtengina suc Soy a canoUea Hon map| 16 __ Rate—/E. HRUT 1105 elated Quito tmp Figg 2D RRB_{| 97 _ Ww 450 sp 99 } 94 5 : = PEEPS __ Oxygenation (circle): psy N/A we WA Note Pater t CULrenty Full ede Fei peo ventar wre rio Near eaical ai planning 10 y cea RAP Fio2 30 __ hange to DVR Friday; family Ines sP02 (range) 22 dit pup S fila 30 — Alrovrla Ohio and, plantieg to say ect byes Frdcug | Dit patent RGR Ik Revised 8/16 Ircalcagni & cmshields Papel pt auvdued unable to communicate. Tauro ical; 7 ted Alar c: Auta ontnied x0 orientation: MOE aluvt Or ocwnttdl g ati nfl rig LT hi Opens Eyes: yi N0t to commiiiggs, 6 00070 Pupils: i sare @. i 1G] eas fit, Me Speech: LINGO? te) M1Sass Wars wet 7 Regen: ual ta. Tonguetstitioon ase Smet iii. No (eipenstin rignt eye to llant, et eye minimal responsive USS Cardiovascular: Rhythm: igure Pulse: Heatconis So 2———— Jvo; Unable [2 Cap Refi: (<3 secK@3ses)> cv: {V/A __pcwe: wa Cyanosis Location: UE DWI Pacemaker: Mar present NO Clubbing pres Peripheral Vascular: Doppkr Pulses:(Palp\or Doppler) Radial: R!2_-L2. Pedal: REQ. LEZ Post Tibial: REGAL Levécil f Edema: Yes(io Location: Ni vid presen , reo ema [tsn SE 001 UE Aipocn pie Woe Respiratory: A (acidic) tal ARNEL: Arca oy or La sputum Cle EAM. Sgepiag 7°07" eet Ta LP etry LIACLOSIOM'Y Cough: ¥ (eredveiveNonpreductve mare t ~ S50, Cre tio pe teed, Pedal MENS Haphdefen Diet PO ten-N/A TF (typerate) @rciooedrr (circle) NG Sx Drainage: INIA abdomen: Set on Hendlty Bowel Sounds: Prewnt Ky Stool: Y@ Incontinent: Y¥ AQ) FOleY Ostomy (ypey NIA ems; NIA Coloricharac: Mons (aresdrit partious dit pacterial inFechon (s¢pc 1s) x cu: , , Urine: ColorZUION™ clarity SECU Arpuneee | Catheter Type/size: LAI@ Genital irritation YN Dialysis (typersite) Skin: emp: Warna}nce(sweahma\ color: MOY —__ Tae god uid, Mucous membranes: [VLt incisions: sya Rit ti ble bo vizoeliee Uundoble to Cictets rue Chi resin Owdr DUHOCKS WHA Een) TAL UIGOT DIES a DUNG CARD Mild eet onarcte Musculoskeletal: | NONI TY Ace $$, Pahent CAnnot respond to comands t 5 sep oaen elec pani sein Worm to tou Upper Extremities: / / peer UTS O55! omg MI IS, sera 0305 Lower Extremities: 7 Movement 1S ~ srengtnUMAbie 10 ASSESS — sensation LMKIC Loa 855 Revised 8/16 Ircalcagni & cmshields mee Continuous Iv Drips: IV Drips must also be looked up & included on Med Sheet @Brecsication Concentration Rate Site Line a | MFC Oe ans | pare Barrem| Meropenum —_|2qm oe@nrs Deen | lerthand feefnana 33g Intake/OutputWeight: 24 hr. Intake: pi 94 hrOutpul320. Cumulative Fluid Balance (prior day): LBO 7) 6 hr. Intake A Daily Wt (OKO (orion ay: LO KG r. Intake: Fopig6 hr Output: 5 Daily We todayy LULA (orior day Pain/Pain Management: Location: NIA uration: WA Scale 1-10: =e intervention: NIA Evaluation win 30 miny LUA LNAbIe to assess Doheny UNabR F COMMuNICade Pain] fokrand | patent well medicceed Wa NO Suspecting pain ABG Analysis: ABG’s: pH Pcoz_ |POz | HCOs3 | Interpretation 35-US 22-3 ‘Admission 2 Date Tud | 33 [954 | 88 mposnted vespwatory alralosis Day prior Date: Day of care Date: Diagnostic Test: | Results: a Has the Tracheostomy TUDE 1S Appropriceely POSIFIOTUE WTFFITFS | Chest X-Ray PST Tu oF re clavicies Pee ie (include date) No inure Faure ororner giongrmadiives Other pertinent ail Yas; ARrophy, Small Veisel Cs a Se ON MALAI Te pe sizaresti tests Wddie cerebral artury infarcrs OllarcradLy- (include date) NO ade Intra parenchyma pumorrhaqs ornew intracranig ‘id Ins Revised 8/16 Ircalcagni & cmshields rege Admission [Da Day of o Lab Test Values crt ape aie | oeson fot abooeadt a y |N ie Ze onl 7 wncataecl ws Soa a [3p “U5 “es | td |159 wn Suen” eK a5 3.8 13.6 [3-9 vomitlsecmson (siomnicy cr or wu mM BO wncieaced with WS | $\coe 33 33 | NIA 7 3 [Glucose Zi0 ir) [it | 64 Fen (power BORE) BUN -30 2 3 a0 NO (Creatinine Ob-1.0 0-9 (0.9 [104 scene (Calcium * 9B - 104 G1 4 67 wt _ [Albumin 35-59) ad 99d (Wk Chior ni cy & [Total protein NiA NIB | iA | NA 9 /ALP (Alk Phos) 35-100 o? “3s |oa |ALT/SGPT NIA NIA NIA INWA B/AST/SGoT NIA Win [NA [wie Total Bilirubin 0-3-4 head a O-4 ——) _|Magnesium [|.B-2- vs a8 2.0 poor magnssium | ne Phosphate 371-45 2.4 3.4 | 3.4 | | g [Cholesterol 140- 400 190 gO 1190: 3 [Triglycerides 2150 HO HO | 105 | RBC 49-5. $d Sd AGL at @ Hgb 11d 14. tig |B. VY denyaaton ait > Het da -59 U6 143, 4-5} constant oral secierons Platelets 0-40 | 335 |330_[ 305 y 8[wec 3.9 -10 76 [ne | tw pss © |neutrophils 3.0-7.0 a0. a0 At 4+ mp Ons F lymphocytes B~4Y & & 4 sis monocytes, | 4 i eosinophils g @ g basophils g az @lPT 6 | 10.8 |g 8 INR. I-15 “LO Lo 1a | OlHPTTIPTT Nip Nia Ni | N/A | [ck 38-174 Nip N/A | NIA | S[CK MB O- 3 NiA Nip | NA | & |Troponin Zou Nia [Nip [Nia © Tepe nanvete ppiae (BNP) |< 100 Nia [wa [in i e 6 * Calcium part of BMP in some facilities Revised 8/16 Ircalcagni & cmshields Page 4 ECG Interpretation: [Posté second ECG strip here or on back (no identifiers). Interpret using 8 step method. 1CUN7 9/26/2017 17 “993 WR 97° Siwus RUTIN PULSE 99 PVC 0 MBP 103/48 161) RESP 28 “Sp02 100 25 ma/sec A; | | { | t Hl | : It Nesp re Iw ~w, PII pa ep ee ee ee ECG Analysis: — 4.Rater 47 2. R-R Interval Regular: (7) N 3. P wave present: WN 4.PRInterval: 2:30 _ Constant(Y) 5. P precedes each QRS: (VN 6. QRS Interval; C/O sv cords 7. QT Interval: 0:30 __ 8.ECG Interpretation: SIOUS Physpng @ Pathophysiology of primary diagnosis &/or surgery: iNVT WE, oat Mypcordial ischamia cecuit 1 4 yn innacilie cind extracelila. MEE ent a ay ent epee cited arpol WIIG {fod fo mrt al wlan rr “The rm Pe the. it dhendee Sq CF Con whith May to aac Book used & page no. Psychosocial Considerations: R " as el, cannot fund unable tn commande. Paden VA CoC Wd up MUL to 10 WIRE 7 ICV Revised 8/16 Ircalcagni & cmshields Pages Priority Nursing Diagnoses: Priority #1 @o. wgmed 9) evenanoe General Goat: INCASE (jos eychanpe Outcome JN nave ABGs WirEin dltérud limps Li trae yi Fd? WIM SAds > 99% On AG OF CAE Interventions: Pt. Responses: 4, ASSesS brea) sounds 4, Dun thy a prafh sounds Bilquerollg anreriarly fervor 2, Assess ABGs , SC 2.¢athn ysatecl vespuatory LOSIS 3, Asis: “io Lge xrays. 3, NO nA toes or other Abrprmalits 4, ASSASS ‘Blea ‘oucty 4, NOsans oF Ov Yan foxicl by ak ins Hine 5, Ele ad cf bid 30° 5, blac OF bel Alevatecl to Improve HOS SxC ge Evalyation: DOHIZNt Progressing From UNneomocnsaka +40 Gmpiniakd e a OSS, pou it 1S No She CIE HF enovgn fo preathe without Priority #2 no: Left chive Away Caran |2isk For (NKLHO, Ocal durway C14 andl no sia ns | syiny toms Outcome: LOC MeAsec! powatiice cin -——_—— fection Evaluation. 2M pants tmp IS /0U'F progressing to |OVF lbties dnd | non ph ace wifngenpics. J qyenol and non pharmacdiog lc miasores Priority #3 no: Lpaire S | . + Wil intain Wormals Vi emi tie ser Hah pnI evel LS ey an, cal Evaluation. LEN? MAUTAINING NOMA Sins thy wan, vital signs Tables , RR.90, FairrraLe 113 e Revised 8/16 Ircalcagni & cmshields rage Medications @irersies: No enon ¢Liraies — upm “pm Gani Bau Brand j Name Reqian mum proton plavit Generic Name [rrurociopromick Frgripenim — | pantoprazele | qiopidogrdl Dose Toma |v pusn | a grams & Enis UQtrg PO @D 154 Route/How |]V Hush ai over linFuse Over shrd 0 al 710 PO AD Pa [EEO ee oe ee ice te) fon a lip a MTD CAUInnE ante ulcer annpiat itt |Action shin uddes mai (es ed aT INnIDITs proton ALF UMP achwiry oy | MbirS plateler GF upper Gl tl Maer rat binain ve nuda Alggteqahon td Wncreases lawer ad

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