G RAND R OUNDS Shelaina Lewis April 17, 2008

C LIENT D EMOGRAPHICS -R.C. 69 year old, DOB 7/12/38 Caucasian Male Single – lives alone No children No Form of Religion English Speaking Height: cm (70 in) — Weight: 145 lb (65.91kg) BMI: 18.8 No known allergies DNR

R ISK F ACTORS Recurrent bilateral pneumonia c pleural effusions Severe malnutrition Smoker – 2ppd, 30 years Chronic alcohol abuser Gastroesophageal reflux disease (GERD) Left lung abscess in 2003 Patient history of: COPD Diabetes Mellitus Type II Atrial Fibrillation Gastrointestinal Bleed Coronary Artery Disease Anemia Hypertension Alcoholic Hepatitis Right-sided heart failure (RHF)

P HYSICAL A SSESSMENT : Blood pressure: /61-98 Map: 71 Pulse: Respirations: Temperature (axillary): 97.5 o - 98 o F CVP: 8-10 Oxygen Saturation: 90-94% Head – bitemporal wasting, dry and brittle hair, some hair loss Neck – tracheotomy with mechanical ventilation midline, neck ties dry and intact Vital SignsHead and Neck

P HYSICAL A SSESSMENT : Eyes – closed, brisk reactive to light, conjunctivae pink and moist Ears – equal size bilaterally, able to hear when spoken to close to ear Nose – symmetric and midline Mouth – poor dental health, several teeth missing, six caries, mucous membranes pink and moist EENT Skin cool, dry, pale Reddened abrasion on right hip Stage III pressure ulcer on coccyx Stage II pressure ulcer on upper back- right Stage I pressure ulcers on left and right heel Mild (2+) peripheral edema in upper extremities and lower extremities Triple lumen central line in right subclavian Peripheral IV in left forearm All IV sites: dressing dry and intact EENTIntegumentary

P HYSICAL A SSESSMENT : Telemetry: 6 second strip indicate Normal Sinus Rhythm borderline tachycardia PR interval: 0.16 QRS: 0.08 QT interval: 0.32 Normal rate and rhythm with no abnormal heart sounds noted Capillary refill < 3 seconds All pulses palpable and equal bilaterally Continuous Mandatory Ventilation AC: 12 TV: 450 FiO 2 : 70 PEEP: 7.5 Abnormal coarse rhonchi on right side Diminished or absent breath sounds on left side Copious, thick, foul smelling secretions with yellowish-tan color CardiovascularRespiratory

P HYSICAL A SSESSMENT : Active bowel sounds in all four quadrants Abdomen softly distended Two large, loose, non- odiferous stools Percutaneous endoscopic gastrostomy tube (PEG tube) in upper left quadrant, patent, residual 20 cc Foley catheter draining to gravity Urine yellow and clear Output 175 ml at A.M. assessment GastrointestinalGenitourinary

P HYSICAL A SSESSMENT : Eyes open to pain, pupil size 2 mm, brisk reaction bilateral Unable to respond due to tracheotomy Responds to localized pain Briefly awakens to voice (eye opening and contact < 10 seconds) Mild weakness in all extremities Passive range of motion to prevent contractures NeurologicalMusculoskeletal

P HYSICAL A SSESSMENT : Family present at bedside for several hours Decision made to terminally wean No request for clergy Psychosocial