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Grand Rounds St. Thomas 2A. Erin Woodby Middle Tennessee State University School of Nursing April 17, 2008. 86 y/o; DOB 3/31/22 Male Caucasian Retired military Protestant Married Four living children; 3 boys and 1 girl Lives in LTC facility. English speaking Weight=167lbs (75.9 kgs)
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Grand RoundsSt. Thomas 2A Erin Woodby Middle Tennessee State University School of Nursing April 17, 2008
86 y/o; DOB 3/31/22 Male Caucasian Retired military Protestant Married Four living children; 3 boys and 1 girl Lives in LTC facility English speaking Weight=167lbs (75.9 kgs) Height=72 inches (6 ft) BMI=22.7 Allergies: ACE inhibitors, Hydrocodone, Micardis, Percocet, Prinvil, Quinidine, Versed Client Demographics-R.M.
Assessment: Vital Signs at 0700 • Blood Pressure: 127/59 • Heart Rate: 80 • Mean Arterial Pressure: 82 • Respiratory Rate: 13 • Oxygen Saturation: 99% • Temperature: 97.7°F axillary
Assessment: EENT • Eyes- open to speech, conjunctivae pink and moist, no drainage noted • Ears- bilateral hearing aides • Nose- L nostril has dobhoff tube; no breakdown noted • Mouth- contained endotracheal tube, lips were cracked and dry, drooling, teeth still present
Assessment: Integumentary • Skin- warm, pick, dry • CVP line in L jugular; dressing dry and intact; Continuous infusion of NS @ 75cc/h; removed @ 1445 • Splint on L forearm • Double lumen PICC line placed in R brachial @ 0957; dressing dry and intact • Ecchymosis all over arms and large bruise on R hip • Perineal dermatitis
Assessment: Cardiovascular • No abnormal heart sounds noted • Telemetry • 6 second strip indicates a fib with v paced • P-P: uc; R-R: 70; PRI: uc; QRS: 0.08; QTI: uc • All peripheral pulses palpable and equal bilaterally • Capillary refill < 3 seconds • 3+ peripheral pitting edema on all extremities
Assessment: Respiratory • Continuous Positive Airway Pressure • FiO2: 40% • TV: 650 • PEEP/PSUPP: 5/5 • Extubated @ 1200 • Coarse breath sounds in RUL, RML, and LUL • Diminished breath sounds in RLL and LLL • Suction revealed thick white sputum/secretions
Assessment: Gastrointestinal • Bowel sounds present in all 4 quadrants • Two large brown stools • Receiving Pulmocare through dobhoff tubing at 55cc/h for nutrition
Assessment: Genitourinary • Foley catheter draining to gravity • Urine clear and yellow • Total UOP from 0700-1400 was 1250cc
Assessment: Neurological • Opened eyes to verbal stimulation; motor response to tactile stimulation • pupils measured 2mm with sluggish reaction to light, and no deviation • Weakness in all extremities
Assessment: Musculoskeletal • Generalized weakness in all extremities • Passive range of motion • Stiff joints
Assessment: Psychosocial • Wife and children present at bedside and participating in care • When extubated showed signs of confusion and psychosis