Stephanie Works EAMC ICU Care Given:11/17/10 Pt: 84yo, black, male C/V: Ineffective tissue perfusion r/t unstable B/P sinus rhythm,on assessment, S1&S2 clear, no murmurs, HR 84, BP 110/49; edema present in feet; +2 radial pulse, +1 pedal pulses Monitor B/P , HR and rhythm, pedal pulses qh Goals: HR 60-100, stable BP around 120/40 Goals not met GI: risk for Constipation r/t impaired physical mobility Bowel Sounds present in all four quadrants; soft, round, nontender, no current s/s of constipation or abdominal pain; Diet: regular, but not eating Goal: Pt. will have BM naturally; assess qshift Goals met Fluid/Electrolytes: Imbalanced electrolytes Monitor lab values: Na: 155 (H) K: 5.3 (H) Cl: 124 (H) CO2: 28 BUN: 97 (H) CR: 1.8 (H) Glu: 126 Corrected Ca: 10.4 Mg: 3 (H) WBC: 11.5x10^3 Hgb: 7.4 (L) Hct: 24.1 (L) Platelets: 61x10^3 Goals: Restore imbalanced electrolytes to WNL Goal not met History: End-stage dementia, diabetes, schizophrenia, HTN, stroke Neuro: Chronic Confusion r/t dementia Pt. obtunded, blind (per chart), unable to assess pupillary responses r/t severe swelling of both eyes Assess qh Goal: pt remain comfortable Goal met Medical Dx: hypoglycemia Skin: impaired skin integrity r/t ineffective mobility and lack of body mass 3 IV access: 22g Rt. FA, 20g Lt. AC 20g Rt. AC no redness or swelling noted, all lines patent Impaired skin: deep “healed” ulcer on the left hip, left knee tear, Rt. Buttocks tear Goals: maintain skin integrity by turning and/or promoting patient movement, provide proper wound care, check IV site q2hrs and flush to maintain patency Primary Nursing Dx: Risk for greater AMS Resp: Risk for aspiration r/t reduced LOC Assess: clear upper and lower lobe lung sounds ,Bilateral chest excursion. 4L NC O2 in use, RR 16, O2Sat 100 with 35 second period of apnea with SaO2 ranging 73-88 Goals: assess breathing patterns and sounds in all lobes q1hr or prn; RR 12-20; SaO2> 93; HOB elevated 30 degress, turn, cough, deep breath qh Goals not met GU: Risk for infection r/t suprapubic catheter Urine: amber U.O: 125 ml Continue to assess I&O Goals met