Radford University School of Nursing



Student Name: Kari Smith

Date: 10/20/10

Radford University School of Nursing

N448 Adult II: Case Analysis Project on Care of the Ill Adult

Health Perception/Health Management:

I. DATABASE: Epic ICU/Unit: Vascular ICU

Patient initials: R.D Age:  78   Gender:  Male

Date of Admission: 10/5/10 Date(s) cared for: 10/12/10

Reason for Admission/Chief Complaint: R.D is a 78 year old male who was transferred from Danville Regional Hospital for management of a ruptured aortic aneurysm. The patient has had intermittent abdominal pain for the past several days, and he said he fell within the past week and developed lower back pain. He presented to the emergency room with hypotension. US was obtained that revealed a large aortic aneurysm. Non contrasted CT scan was obtained that revealed a 10 cm AA with retroperitoneal blood. He was transported by helicopter.

Include any surgical procedures and reason for admission to the ICU if applicable: Patient was rushed for an Emergency Abdominal Aortic Repair Surgery and admitted to ICU due to respiratory failure from surgery. He is in ICU for management of abdominal wound and respiratory failure. Patient is now on mechanical ventilation.

Admission Diagnosis:  Ruptured Abdominal Aortic Aneurysm, Respiratory Failure

Succinct review of the ICU course:

Air transport from Danville to OR room immediately. He was suspected of an abdominal aortic aneurysm. Decreased K+ reported at Danville RMC ER of 2.6; treated with 20 mEq KCl.. Frequent PVC’s in route to RMH.

Upon admission to the ED the patient arrived on a stretcher. His abdomen was mildly distended and soft. There was a large, easily palpable pulsatile mass. Vascular exam revealed palpable radial, carotid, femoral pulses bilaterally. There were no pedal pulses. Neurological exam was intact. Both feet were cool and sluggish refill.

Emergency AAA repair was done.

Patient was admitted to the ICU because of Respiratory Failure due to emergency abdominal aortic repair surgery completed on 10/5/10.

6MTN ICU received patient from OR. Mechanical Ventilation with ETTube secured with tube holder 24 at lip.

Patient was alert, mouthed words, headshake to communicate, followed simple commands. His abdominal dressing was saturated after patient lying on side. Dressing reinforced with added gauze and tape.

As of (10/7/10) Patient Extubated to 3Lpm NC- Post extubation expiratory wheezing. Administered 2.5 mg albuteral via mask. OOB to chair without difficulty. Handling extubation properly.

Patient was restless and NG tube drained dark green drainage. Drowsy. Followed commands. Patient was experiencing DT’s from alcohol withdrawal. Haldol was given.

(10/9/10)- Patient pulled out NG tube. Dr. ordered to leave NG tube out for time being.

(10/11/10)- Patient developed Bradycardia then asystole, respiratory arrest. Code called.

(Nurses Notes): 0813 code called. No pulse. CPR begun. Code drugs administered as ordered. Rhythm restored vasopressin/levaphed gtts hung for Bp support. Stool suctioned from mouth.Pt intubated. NG tube placed. Central line and Arterial line in right groin placed by resident.

Patient beings to progress at 100% on vent. Pressors were discontinued.

Day of care (10/12/10) - More stable and patient still on mech ventilation. Patient still confused. Lung course bilaterally. Abdominal soft and non tender. Wound incision intact. Arterial line discontinued. Dressing was moist. Redness at site. Line kinked at insertion site. Infection risk. Patient was withdrawing from pain and doctor order fentanyl gtts 50 mcg/hr for pain. Febrile at times, acetametaphen given and temperature was reduced and VSS and remained a febrile. Patient tolerated TF’s well at 100 cc/ Hr.

(10/14/10) Weaning began. WBC were 11k, VSS, awake and alert. Ng tube removed on night shift. Glucose levels remained stable. Vent mode CPAP/PS Peep 5 PS 10 40 %. Patient tolerated well. Later throughout the day patient was extubated and placed on 3 Lpm NC tolerated well. Coughs on command. Fentanyl drip was decreased to 25 mcgs/hr. CXR showed moderate stable bibasilar opacities; likely combination of airspace disease, atelectatsis, pleural effusion. Mild interstitial pulmonary edema, patient treated for kelbsiella PNA. Tobacco cessation program offered and patient denied any use of program and denied wanting to quit smoking anytime soon.

(10/20/10) Occuapational therapy and Physical therapy. Per nursing report 3 DVT’s in RUE. Therapy held for the day.

As of (10/20/10), the patient has been off the ventilator for several days. The patient had stable vital signs, is tolerating tracheotomy trials and has good oxygen saturation (above 95%) and is on supplementary oxygen (2L/min).

(10/22/10) Patient was able to OOB to chair and tolerated well. Urine is light yellow.VSS a febrile.

Pt for SNF and waiting for bed placement. Possible D/C.

History information should be objective and verified when applicable. The information should be collected from the patient, family or medical record. Source of the information collected should be noted.

➢ Recent illness/exposure to communicable disease – note dates: Patient’s family stated that patient has never set foot in a hospital prior to recent admission. No exposures to communicable diseases noted.

➢ Previous hospitalizations/surgeries – note dates: No previous hospitalizations or surgeries prior to AAA surgery stated by patient’s wife.

➢ Chronic health problems – note onset dates: Medical Records: Hypertension 2000, Hyperlipidemia 2000

➢ Family Medical History: (Source of information ; Patients wife): Patient’s Mother- Hx of Stroke .Patient’s Father Hx of Heart Attack

➢ Most Important Things Patient Does to Keep Healthy (diet habits, exercise, BSE, TSE, folk remedies, regular check-ups and others):

Patient’s wife stated that he eats a normal diet, whatever he wants. Rides a golf cart around the farm and rides in a truck with his son down country roads. Does attend regular check ups with his PCP.

➢ Hazardous Lifestyle Practices (consider what type of risk factors your patient has that may be impacting on his/her overall health status, i.e. tobacco, alcohol use, other drugs, allergies). Include genetic, behavioral and environmental risk factors addressing the patient's willingness and motivation to modify or reduce risk factors):

No Known Drug Allergies. Wife states patient drinks a fifth of liquor a day and a six pack of beer to go along with it. Severe smoking habits. Cigars. No drug use stated by wife. Patient’s wife stated he had no intention on quitting in the near future.

➢ Economic Resources (What type of insurance coverage, if any, does the patient have? Are there any perceived concerns regarding economic resources? Are referrals necessary?): Patient has Humana Gold Choice insurance. The patient’s wife claims no financial problems regarding economic resources . Wife states they have plenty of land if they get into debt.

➢ Health Care Decision Maker Patient’s wife claims he is a full code with no living will, power of attorney, or advance directive.

➢ Discharge Planning/Teaching (With the understanding that discharge planning begins at the time of admission, consider each question.  Note data sources which may include the patient's medical record and patient/family interview.):

-Health beliefs/behaviors: Patient’s wife states that they believe in doing whatever medically or therapeutically to stay in good health.

-Psychosocial adaptations/ maladaptations (apply development stage assessment):

D.R is in Erikson’s psychosocial stage of integrity vs. despair; meaning D.R is reviewing his life, accomplishments, dealing with loss, and preparation for death.

|Developmental task |Achieved or not achieved (An ‘x’ indicates|Comment |

| |that the patient has achieved the task) | |

|Contemplate accomplishments |X |Patient chose to get married; relationship is supportive. Choosing a long term, |

| | |monogamous relationship is another indicator of relationship commitment. Patient was |

| | |a hard working farmer. Retired 15 years ago. Two loving sons that are at the bedside.|

| | |I believe he would be proud of everything he has done and accomplished within his |

| | |lifetime. |

|Retrospection |X | I believe he thinks he has had a successful life. If he looks back and views his |

| | |life as unproductive, or feel that he did not accomplish his life goals, he could |

| | |become dissatisfied with life and develop despair, often leading to depression and |

| | |hopelessness |

|Preparation for death |X |Patient’s wife said he seems content with his life. I believe that at his stage in |

| | |life he has accepted his older age and content with the concept of death, and |

| | |whatever else life may bring. |

Given that the patient has achieved the main developmental tasks for this stage, it is reasonable to conclude that he is successfully negotiating the stage of old age.

Ability and readiness to learn: Not able to assess. Artificial airway intact.

Patient's expectations for self-care: Was not able to assess. Artificial airway intact on day of care.

CURRENT HOME MEDICATIONS: **Home medications came from patient’s chart and Patient’s wife helped verbalize financial impact and medication compliance.

|Aspirin 81 mg PO |Lipitor 20 mg PO |Accupril 20 mg PO |

|Compliance with medications? |Impact of cost of medications? |Knowledge of medications: |

|Patient’s wife stated that he took his medicine on a regular basis as far|Family states there is no financial hardship where cost of | |

|as she could tell, but patient not able to reaffirm statement because of |medication is a problem at current time. |Patient was not able to verbalize. Artificial airway |

|artificial airway. | |intact. |

➢ Nutritional/Metabolic Patterns:

|Height/Weight: 6 ft/102.6 kg/235 lbs 0.2 oz |Hospital Diet: NPO/NG tube related to artificial airway |Usual Home Diet/Fluid Intake: According to wife his diet |

| | |consisted of “southern home cooking. 200 cc of liquor a day. Six|

| | |pack of beer. Wife states he has a 8 oz of orange juice in the |

| | |am with his breakfast |

|Recent Weight gain/loss (intentional?): |Current Appetite: Regular Diet at home |Swallowing concerns: None indicated prior to hospitalization |

|Admission 106.6 kg | |Upon retrieval of patient’s information post care date- |

|Day of care: 102.6 kg | |swallowing study was done and dysphagia was indicated. Advance |

|Loss of 3 pound in one week unintentional. | |diet as tolerated once PO meds can be safely tolerated. |

|Dentures: |Condition of oral mucous membranes? Moist, pink. Mouth care |Edema: Generalized edema |

|Yes- |performed q2 hours by ICU nurses | |

Current Vital Signs/Hemodynamics (low to high range over hospitalization, if monitored, including treatments administered

**Patient Coded on 10/11/10 the day before care and was intubated:

|Parameter |Day of Care |Since admission |Since admission |Cause/ |Treatment |

|(if applicable) | |Low Range |High Range |Significance |(if any) |

|HR |81-108 |72 |108 |Heart rate high range likely due to hypoxemia|Suctioning, pain medication (fentanyl |

| | | | |r/t respiratory failure and /or pain from |drip 50 mcg/hr)/ Lorazepam 1 mg q1hr |

| | | | |incision, yet he is not able to verbally |prn. |

| | | | |state his pain. Withdraws from pain. | |

|BP |81/51- |78/50 |178/90 |Patient’s Hx of HTN, hyperlipidemia, and |Lipitor, Lopressor |

| |116/76 | | |Hypoglycemia | |

|MAP |61-89 |61 |97 |Patient’s high MAP is probably due to |Lopressor; if HR is within range for |

| | | | |patient’s hypertension. |medication >60 |

|RR |10-28 |12 |36 |Stress in hospital setting and ventilator | Patient on Mechanical Ventilation. |

| | | | | |Small volume Nebs |

|Sp02 |99-100 |85 |100 |Possible alarm was not placed correctly or |Artificial airway preset with Oxygen |

| | | | |poor tissue perfusion to extremities. |settings |

|TEMP |98.7- |97.2 |102.1 |High stress situation, infection |Antipyretics, Antibiotics, cooling |

| |101.3 | | |Fever due to sepsis and or possible |blankets, cool air fan, |

| | | | |ventilator associated pneumonia) |Tylenol |

|Patient Weight |102.6 kg |100.1kg |106 kg |Muscle wasting, NG tube feedings |Nutrition replacement : Isosource 1.5 |

|Pounds/kg | | | | |cal |

|Intake/Output |1400/875 cc |4462/3248 cc |7377/6225 cc |Watching for dehydration and need for fluid |Continuous infusion of ½ NS of 10cc/hr|

| | | | |replacement |for fluid replacement and TF of |

| | | | | |Isosource 1.5 cal |

(MAP = mean arterial pressure;PAP = pulmonary artery pressure; CVP = central venous pressure; PCWP = pulmonary capillary wedge pressure; CO = cardiac output; CI = cardiac index; SVR = systemic vascular resistance; ICP = Intracranial Pressure)

Patient Assessment Data

|General Survey: 78 yo male in supine position with HOB elevated 30 degrees. Patient on Ventilator Support, ICU monitors, IV pole, Foley Catheter, NG tube with Isosource 1.5 cal running at |

|10cc/hr. Patient had 12 cm midabdominal incision with staples intact. Patient seemed to be resting quietly. ½ NS running at 100 cc/hr. Patient responsive to name. Opens eyes spontaneously. Family|

|at bedside. |

|Head/Neck - (Complete neurological assessment including cognitive status and appropriate cranial nerves, LOC, orientation, PERRLA, eyes/sight, ears/hearing, bruits, dizziness, hand grasp, |

|movement arms/legs, numbness/tingling. sensation, Seizures/ Parkinsons, primary language, speech deficits, long term/short term memory with examples, decision making ability, formal education): |

|Cognitive status: Patient was awake and alert. Patient was orientated to self. Patient was not able to answer questions about person, place, and time, reason for hospitalization and other |

|personal information appropriately due to artificial airway; Patient was however able to open eyes when addressed his name and follow simple commands. |

|Cranial nerves: Patient was not responsive but prior to intubation there was no suspected neurological impairment. Sensation on face, patient was able to open eyes when felt. Cough and gag |

|reflexes were observed to be intact and normal when the patient was suctioned during respiratory therapy. |

|LOC/Orientation: Patient was slightly sedated in terms of sleepiness. He was however conscious; comprehends simple spoken instructions. Eyes open spontaneously; Patient oriented to self and obeys|

|simple commands, such as grasping my hand or blinking eyes. |

|PERRLA/eyes/sight: Pupils equal, round, and reactive to light. Pupil response to light was sluggish and the pupil changed in size from a 4 to a 2 bilaterally. Patient was able to look upward. |

|Patient chart reported history of vision problems and glasses were kept at bedside. Sclera of eyes was slightly yellow. |

|Ears/hearing: Patient had no apparent auditory problems, as he was able to appropriately respond to all verbal instructions. No drainage/exudates were found in or around both ears. Patient’s |

|wife stated no use of hearing aid. |

|Bruits, dizziness: Patient could not state if he was dizzy. No carotid bruits to auscultation bilaterally. |

|Hand grasp: Patient is able to grasp my hand with his hand to command bilaterally and release my hand. His grasps were weak due to slight sedation. |

|Movement arms/legs: At the time of the exam, I was unable to assess the patient’s posture and gait. While OT was in the room I was able to accompany her in performing ROM exercises and he had |

|full ROM in both arms and legs. |

|Deep tendon reflexes: DTR’s were not assessed. |

|Numbness/tingling. Sensation: Was not able to assess tingling, however patient could open eyes to sensation to let me know he felt the cotton swab on his face and extremities when asked to. |

|Seizures/Parkinson: Patient has no history of seizures or Parkinson’s disease. |

|Primary language: English |

|Speech deficits: Patient was not able to talk due to artificial airway, but according to chart and patient’s family there were no speech deficits prior to hospitalization. |

|Long term/short term memory with examples: Patient’s short term and long term memory were not able to be assessed due to artificial airway. |

|Decision making ability: Was not able to assess. |

|Formal education: High school degree. |

|CHEST- (Respiratory and Cardiac assessment – apical pulse, peripheral pulses, BP, peripheral edema, chest pain, JVD, pacemaker, A-V shunt, capillary refill, RR, shallow, rapid, labored, dyspnea, |

|nocturnal dyspnea, orthopnea, exertional dyspnea, cough, productive, sputum description, lung sounds, oxygen use, ventilator settings): |

|Apical pulse rate: 91 |

|Heart rhythm: Regular, normal sinus rhythm |

|Heart sounds: S1, S2, no murmurs, rubs, or gallops heard |

|Peripheral pulses: Pulses were heard using a Doppler with good peripheral pulses. Brachial 1+, Radial 2+.Popliteal unable to assess by palpation, |

|Dorsalis pedis, 1+ |

|BP range during day of care: 81/51- 116/76 |

|Peripheral edema: Slight, generalized edema was present |

|Cyanosis: None |

|Clubbing: None |

|Chest pain: Not able to assess. |

|JVD: No jugular venous distension. |

|Pacemaker: No pacemaker. |

|A/V shunt: None noted. |

|Capillary refill: RUE < 3 seconds RLE < 3 seconds LLE < 3 seconds LUE < 3 seconds |

|Respirations: Range during day of care: 12-26. During the exam, the respirations were observed to be even, regular, unlabored respirations; did not use accessory muscles to breathe. |

|Chest tube: No chest tube present. |

|Cough :Productive thick creamy when suctioned. |

|Lung sounds: Bilateral rhonchi, upper lobes bilaterally. Rhonchi diminished after suctioning. |

|Ventilator settings: Peep: 5, Vt:450 Rate: 22 Fi02: 48 % |

|Abdomen - (GI assessment – bowel sounds, bruits, tenderness, guarding, distention, diet, nasogastric or feeding tube, xrays): |

|Bowel sounds:Hypoactivce bowel sounds in all 4 quadrants |

|Bruits: No bruits noted |

|Tenderness: Non tender |

|Guarding: None noted |

|Distention: NO abdominal distention |

|Diet :NPO due to NG tube |

|Nasogastic tube or feeding tube: Nasogastic tube with low intermittent suctioning receiving Isosource 1.5 |

|Xrays: None noted on abdomen. |

|Pelvis - (bowel/bladder frequency, character, discomfort, incontinence, diarrhea, constipation, use of laxatives/enemas, last BM, ostomy): |

|Last Bowel Movement: on day of care 10/12/10 in the am. Loose brown stool with minimum odor with no grimacing. |

|Ostomy: None |

|Diarrhea/Constipation/Laxatives/Enema: Upon arrival to ICU patients chart did not record constipation. Nurse stated his body was regular at BM’s on a daily/bi daily schedule without the use of |

|laxatives or enemas. No diarrhea on day of care |

|Incontinence: Patient had a Foley Catheter in place draining by gravity. Patient had BM on day of care. Loose/brown stool without foul odor. |

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|Sexuality-Reproductive - (menstrual pattern/changes, pregnancy history, birth control, vaginal discharge/lesions; prostate problems, penile discharge/lesions; satisfying relationship, changes, |

|problems): |

|Menstral patterns/pregnancy/birthcontrol/vaginal discharge/lesions: Not applicable to patients gender |

|Prostate problems: None noted in chart. |

|Penile discharge/lesions: No penile discharge or lesions noted. |

|Sexual relationship/changes/problems: Patient’s wife stated they no longer are engaged in sexual activity, but continue to cuddle and have intimacy. |

|Skin Condition – (warm, dry, cool, moist, turgor – supple/firm/fragile/dehydrated, color pink/pale/dusky/cyanotic/jaundiced/mottled, edema; wounds, drains, dressings, any skin problems): |

|Skin was warm and dry with good turgor, firm; skin did not tent when pinched at sternum The patient’s coloring was pink but slightly jaundice. Patient is a chronic alcoholic. Otherwise, color |

|consistent with ethnicity. No cyanosis or mottling was present. Slight, generalized edema was present Braden score: 13 Wounds: 12 cm mid-abdominal incision with staples intact with minimal |

|drainage from AAA rupture repair. |

|Comfort/Pain - (pain level, location, type, onset, duration, management): |

|Patient was not able to verbalize pain level; however, patient seemed to grimace when moved so Fentanyl drip 50 mcg/hr was given to relieve pain. After pain medication started to infuse patient |

|seemed to be more relaxed. |

|Sleep/Rest – (usual patterns, adeqate, factors affecting sleep/rest, methods to promote sleep, history of sleep disturbances, sleep/rest since hospitalization): |

|Patient was not able to verbalize sleep patterns, but wife stated that pt has no trouble in the evening falling asleep or staying asleep throughout the night. Patient’s nurse on night shift |

|stated that he was not receiving adequate rest and frequently awoke during the night. |

| |

|ADL/Mobility/Self-Care Rating: |

|0 = Independent |

|1 = Assist with device |

|2 = assist with person |

| |

|3 = Assist with device/person |

|4 = Total dependence |

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|Rate ADL Status as anticipated at Discharge:**Note: Plans for this patient upon stabilization and off ventilator patient will be transferred to a SNF. Patient was extubated on 10/14/10 and |

|medical chart states patient is tolerating well. |

|Feeding:1 |

|Bathing:3 |

|Dressing:1 |

|Grooming: 0 |

| |

|Toileting:1 |

|Bed Mobility:3 |

|ROM: 1 |

|Chair Transfer:1 |

| |

|Meal Prep:2 |

|Cleaning:3 |

|Shopping:3 |

|Laundry:4 |

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|Ambulation:1 |

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|Reasons for ADL/mobility limitations: Muscle weakness due to inactivity since 10/5. Generalized weakness due to critical care. RUE weakness r/t DVT, PT recommended use of walker for ambulation |

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|Usual Physical exercise: PT while in hospital setting. Patient’s wife stated he gets out in the farm during the day. |

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|Leisure Activities: Reading, gardening, house maintence, riding golf cart, watching old western movies are some activities wife stated he participates in. |

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|Transportation needs: Prior to admission to ICU there was no transportation need, After PT/OT treatments, patient will need car that is proper for walker placement and until strength is restored,|

|have someone drive. |

| |

|Self Perception/Self Concept – (describe yourself, strengths/weaknesses, major losses, anxiety, depression, frustration, anger, hope, concerns): Patient was not able to describe himself. Family |

|explained that D.R is a very loving father and grandfather. Hardworking with extreme determination to get over this hump. They state his weakness is that he doesn’t like to ask for help which |

|could hinder his recovery. No major losses. Family feels he is very anxious to get out with frustration as well. They have concerns on his recovery. |

|Developmental Stage and Achievement of developmental tasks (list): D.R is in Erikson’s psychosocial stage of integrity vs. despair; meaning D.R is reviewing his life, accomplishments, dealing |

|with loss, and preparation for death. See page 4. Patient is 78 y.o, married with children, he was a hardworker throughout his life. He is in the stage where he is accepting death and reviewing |

|all his choices he made throughout his life whether he is satisfied or dissatisfied. |

|Culture (describe traditions, practices, folk remedies, beliefs, spiritual needs): |

|The source of this information is from the patient’s wife. She explained that their family is native to the Danville, Va. They consider their background as southern, Appalachian, and very |

|liberal. Stated they do not attend church but believe in God and if had to define which branch it would be of Christian religion. In terms of their health care practices, the wife said that they |

|rely on the opinion of health care expert. “We do not allow them to walk all over us, if we need a second opinion, we get one”. She states they trust their HCP and says that they are well taken |

|care of, and their doctor is kind and attentive. |

|Role/Relationships – (description of family, lives alone/spouse/children/parents/others, family problems/support, occupation, retired, participation in community/social/church activities): |

|Patient has been married for 35 years and had two children that both live within 10 miles of his house. He is retired and his wife states his community involvement includes helping neighbors with|

|yard work and household maintence when needed. |

|Coping/Stress/Tolerance – |

|No major changes in his life except his hospitalization. His support is his wife of 25 years, and has a loving family for support. He is a chronic alcoholic and smoker. This causes stress on his |

|family members because they are worried for his health. He uses going out on the farm and riding around all day as a stress relief and something he enjoys doing on a daily basis. |

|Value/Beliefs – (belief in God, denominational preference, participation in church activities, use of prayer/meditation, religious restrictions, important plans for the future, what is most |

|important in life, belief in health care system): |

|Patient’s wife states they believe in God and consider their selves Christian, yet they do not believe in attending a weekly service. She says they can have their beliefs without ever leaving the|

|home, and are content with the way things are at home. Important plans for the future are to recover from his surgery and help take care of the grandkids. “They are what we live for each day”. |

|The wife exclaimed that her husband loves to take the grandkids out for the day and eat ice cream with them before bedtime. |

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MEDICATION HISTORY Explore the reason this patient is most likely taking each drug and add your summary statement/comments; compliance, cost, knowledge about the medications): (Wilson, B., Shannon, M. & Stand, C. 2009)

|Name of Drug |Medication taken at|Dose, Route, Frequency |Reason you patient is receiving this |Drug Category/Mode of Action |

| |home | |particular medication | |

| |Yes or No | | | |

|1/2 NS Infusion |No |100 ml/hr, IV |Fluid replacement |Hypertonic Solution: has an osmolality greater than 340 mOsm/kg.|

| | | | |Hypertonic solutions exert more osmotic pressure than the |

| | | | |extracellular fluid so when these solutions are infused, fluid |

| | | | |gets pulled into the vascular system. |

|Ipratropium (Atrovent) |No |.5mg, inhalation, every4 hours |Breathing treatment; drug decreases |Anticholinergic; antimuscarinic; bronchodilator. Results in |

| | | |airway resistance. |bronchodilation by inhibiting acetylcholine at its receptor |

| | | | |sites, thereby blocking cholinergic bronchomotor tone |

| | | | |(bronchoconstriction); also abolishes vagally mediated reflex |

| | | | |bronchospasm triggered by such nonspecific agents as cigarette |

| | | | |smoke, inert dusts, cold air, and a range of inflammatory |

| | | | |mediators (e.g., histamine). |

|Aspirin |Yes |81 mg, NG tube, daily |Prophylactic- transient left lower |Analgesic-antipyretic, antiplatlet |

|Acetylsalicyclic | | |embolic event |Action: inhibiting the formation of prostaglandins involved in |

| | | |Running low grade fevers- used as an |the production of inflammation, pain, and fever. Analgesic |

| | | |antipyretic |action: principallyperipheral with limited action in the CNS in |

| | | | |the hypothalamus, results in relief of mild to moderate pain. |

|Acetaminophen (Tylenol) |Yes, but not as a |650 mg, NG tube, q4h porn |To manage fever |Nonnarcotic analgesic, antipyretic; Produces analgesia by |

| |solution | | |unknown mechanism, but it is centrally acting in the CNS by |

| | | | |increasing the pain threshold by inhibiting cyclooxygenase. |

| | | | |Reduces fever by direct action on hypothalamus heat-regulating |

| | | | |center with consequent peripheral vasodilation, sweating, and |

| | | | |dissipation of heat. Unlike aspirin, has little effect on |

| | | | |platelet aggregation, does not affect bleeding time, and |

| | | | |produces no gastric bleeding. |

|Sublimaze (Fentanyl) |No |50 mcg/hr IV Continuous |Patient withdrew from pain and |Binds with stereo specific receptors at many sites within the |

| | | |grimaced in bed. To manage pain |CNS, increases pain threshold, alters pain reception, inhibits |

| | | | |ascending pain pathways |

|Lorazepam(Ativan) |No |1mg Intravenous every hour as needed.|Pain management/Sedation/ decrease |Anxiolytic; sedative-hypnotic; benzodiazepine. Therapeutic: |

| | | |agitation |Antianxiety. Effects are mediated by the inhibitory |

| | | | |neurotransmitter GABA. Action sites are thalamic, hypothalamic, |

| | | | |and limbic levels of CNS. Anti anxiety agent that also causes |

| | | | |mild suppression of REM sleep, while increasing total sleep |

| | | | |time. |

|Albuterol sulfate nebulizer |No |2.5mg, inhalation, every 4 hours |Breathing treatment; drug decreases |Bronchodilator (respiratory smooth muscle relaxant); |

| | | |airway resistance. Facilitates mucous |beta-adrenergic agonist. Moderately selective beta2-adrenergic |

| | | |drainage from pneumonia, and increases|agonist with comparatively long action. Acts prominently on |

| | | |vital capacity |beta2 receptors (particularly smooth muscles of trachea, |

| | | | |bronchi, uterus, and vascular supply to skeletal muscles). |

| | | | |Inhibits histamine release by mast cells. Produces |

| | | | |bronchodilation by relaxing smooth muscles of bronchial tree. |

|Metoprolol tartrate (Lopressor) |No |5mg, IV, every 6 hours prn |Hypertension |Beta-adrenergic antagonist; antihypertensive; antianginal. |

| | | | |Beta-adrenergic blocking agent with preferential effect on beta1|

| | | | |receptors located primarily on cardiac muscle. At higher doses, |

| | | | |metoprolol also inhibits beta2 receptors located chiefly on |

| | | | |bronchial and vascular musculature. Antihypertensive action may |

| | | | |be due to competitive antagonism of catecholamines at cardiac |

| | | | |adrenergic neuron sites, drug-induced reduction of sympathetic |

| | | | |outflow to the periphery, and to suppression of renin activity. |

|Atorvastatin (Lipitor) |Yes |20 mg, P.O, H.S |Hyperlipidemia |Antilipemic; Statin. Inhibitor of HMG-CoA which is essential to |

| | | | |hepatic production of cholesterol. Lipitor increases the number |

| | | | |of hepatic LDL receptors thus increasing LDL uptake and |

| | | | |catabolism of LDL. HDL cholesterol blood level increases with |

| | | | |use of atorvastatin. Reduces LDL and total triglyceride |

| | | | |production as well as increases the plasma level of HDL. |

|Ondansetron (Zofran) |No |4mg, IV, every 4 hours prn |Nausea |Antiemetic; 5-ht3 antagonist; Selective serotonin (5-HT3) |

| | | | |receptor antagonist. Serotonin receptors are located centrally |

| | | | |in the chemoreceptor trigger zone (CTZ) and peripherally on the |

| | | | |vagal nerve terminals. Serotonin is released from the wall of |

| | | | |the small intestine and stimulates the vagal efferent nerves |

| | | | |through the serotonin receptors and initiates the vomiting |

| | | | |reflex. |

|Insulin Aspart (Novalog) |No |Low Corrective coverage, injection |High Blood Sugar |Hormone, antidiabetic agent;insulin; rapid acting. A recombinant|

| | |pen, 4times daily SC | |insulin analog that is more rapidly absorbed than human insulin,|

| | | | |with a more rapid onset and shorter duration than regular human |

| | | | |insulin. Provides better blood glucose control than regular |

| | | | |human insulin when given before a meal. |

|Isosource 1.5 cal |No |10ml/hr Intravenous, continuous |Nutritional Replacement |Enteral Nutrition: nutritional replacements for patients who are|

| | | | |unable to get enough nutrients in their diet. These formulas are|

| | | | |taken by mouth or through a feeding tube and are used by the |

| | | | |body for energy and to form substances needed for normal body |

| | | | |functions |

| | | | | |

|Calmoseptine |No |Topical, 2 times daily |Wound care for decubitous ulcers |Menthol: External analgesic, antiseptic, antipruritic zinc |

| | | | |oxide: skin protectant, moisture barrier. Promotes wound |

| | | | |granulation and re-epithilialization. |

|Esomeprazole sodium (Nexium) |No |40mg, IV, daily |Peptic ulcer prophylaxis |Proton pump inhibitor; Isomer of omeprazole. A weak base that is|

| | | | |converted to the active form in the highly acidic environment of|

| | | | |the gastric parietal cells. Inhibits the enzyme H+K+-ATPase (the|

| | | | |acid pump), thus suppressing gastric acid secretion. |

| | | | | |

| | | | | |

| | | | | |

| | | | | |

|Glucagon (Human recombinant) |No |1mg, IM, prn |To treat severe hypoglycemia |Hormone; antihypoglycemic agent. Recombinant glucagon identical |

| | | | |to glucagon produced by alpha cells of islets of Langerhans. |

| | | | |Stimulates uptake of amino acids and their conversion to glucose|

| | | | |precursors. Promotes lipolysis in liver and adipose tissue with |

| | | | |release of free fatty acid and glycerol, which further |

| | | | |stimulates ketogenesis and hepatic gluconeogenesis. Action in |

| | | | |hypoglycemia relies on presence of adequate liver glycogen |

| | | | |stores. |

|DEXTROSE 50% (D50) |No |25ml, IV, prn |To treat severe hypoglycermia |Caloric agent; Rapidly increases blood glucose levels, Transient|

| | | | |osmotic diuretic |

|Zolpidem (Ambien) |No |5 mg p.o. every evening prn |Treatment of insomnia |Anxiolytic; sedative-hypnotic, non-benzodiazepine. An agonist |

| | | | |that binds to the BZD1 subunit on the gamma-aminobutyric acid |

| | | | |(GABA)-A receptor chloride channel, thus inhibiting the action |

| | | | |potential. |

|Piperacillin/tazobactum (Zosyn) |No |4.5 g IV 25 ml/hr q8h to be infused |Probable Ventilator Associated |Antibiotic;Penicillin. Two drug combination has antibiotic |

| | |over 4 hours |Pneumonia |activity against an extremely broad spectrum of gram positive, |

| | | | |gram negative, and anaerobic bacteria. Tazobactam is an |

| | | | |inhibitor of a wide variety of bacterial beta lactamases. It has|

| | | | |little antibacterial acitivty itself; however in combination |

| | | | |with penicillin, it extends the spectrum of bacteria that are |

| | | | |susceptible to piperacillin. |

Summary Statement (evaluation regarding home medications):

Patient was not able to be evaluated regarding home medications and compliance due to artificial airway. Patient’s wife however stated that he does take his medicine regularly, but she could not say whether he knew details about them or if he knew what they were taken for. Patient’s wife stated they have Humana insurance. They do not qualify for Medicare due to the patient owning 10 acres of land in his name.

ECG strips (if available). Rate: 107 PR interval: 0.16 QRS interval: 0.08

Rhythm interpretation:

Normal Sinus Rhythm

Significant diagnostic tests and/or procedures

|Test/Procedure |Results |Significance |Why was the test/procedure indicated? |

|CXR |A layering left sided pleural effusion is |Patient intubated. No evidence of |Placement of Endotacheal tube and to assess for signs of Pneumonia.Interval |

| |stable. There is silhouetting the right |Pneumothorax. |placement of Nasogastric tube. |

| |hemi diaphragm consistent with atelectasis | | |

| |and is small pleural effusion. The | | |

| |endotracheal tube is in correct placement | | |

| |as well as Nasogastric tube. | | |

|Ruptured Abdominal Aortic |Successful repair of the Abdominal Aorta. A|AAA has ruptured and needed IMMEDIATE |Emergent open repair of ruptured AAA with a 16 x 8 mm bifurcated Hemashield |

|Aneurysm Repair |large amount of laminated thrombus was |SURGERY or patient could have hemorrhaged |graft. |

| |removed. The aneurysm has eroded | | |

| |posteriorly into the spine. The aneurysm | | |

| |sac was closed over the graft with a 3-0 | | |

| |nylon suture. | | |

|CT Scan |10 cm aortic aneurysm with retroperitoneal |Diagnostic Method for AAA, |Patient presented to RMH with complaint of abdominal pain for several days |

| |blood | |prior. |

|Echocardiogram |Normal Left Ventricular size and preserved |Is a diagnostic method to observe for AAA |Status post systolic cardiac arrest. Recent AAA repair. Mechanical Ventilation|

| |function. No pericardial effusion/tamponade|as well as post AAA repair. | |

| |indicated. | | |

|RUEV |DVT found in the prox subclavin (focal and |Occupational and Physical therapy held due|Patient was having decreased grasp in Right arm. |

| |non occlusive) and in the Axill V Prox |to DVT’s and risk of PE. | |

| |venous flow patterns were altered. | | |

Laboratory Test Values (Examine your patient’s laboratory reports. Focus on the abnormal values and significant normals only. Complete the table as indicated. You will need to consider in writing, what significance the results of the tests are for your patient, considering his/her medical problems. (Pagana & Pagana, 2007)

|LAB |Patient’s Lab Value |Normal Range(Pagana & Pagana, 2007) |Potential Significance to this Patient |

|Ph |7.48 |7.35-7.45 |pH is slightly elevated; any acid-base problem is because of a compensatory mechanism that must |

| | | |be determined |

|Chloride |123 mmol/L |98-110 mmol/L |Possible indication of respiratory alkalosis, possible sign of hyperventilation, possible kidney |

| | | |dysfunction |

|Creatinine |1.17 mg/dl |.5-1.2 mg/dl |Debilitation, decreased muscle mass |

|Phosphorus |5.1 mg/dl |2.5-4.6 mg/dl |Possible symptom of kidney dysfunction |

|pCO2, Arterial |30 mmhg |35-45 mmhg |Respiratory alkalosis or symptom of acute hypercarbic respiratory failure |

|pO2 |147 mmhg |74-107 mmhg |Patient is on ventilator. |

|Bicarbonate, Arterial |20.7 mmol/L |21-29 mmol/L |Possible metabolic alkalosis |

|Hematocrit |27 |Male 42-52 |Decreased levels indicate anemia |

|Hemoglobin |9.2 |14-18 |Decreased levels indicate anemia and/ or bleeding |

|WBC |12.4 |5000-10000 |An increase in WBC indicates infection, inflammation,. Trauma or stress, either emotional or |

| | | |physical, may increase the WBC count. In the elderly population increase WBC can be a late sign |

| | | |of sepsis. |

|Calcium |7.9 |8.5-10.7 mg/dl |Calcium is responsible for the hearts contractility |

|BNP |970 |140 |

|Cardiac monitoring |OT/PT evaluation and treatment |Small volume Nebulizer |Restraints Non Behavioral Restraint 24|Saline Lock IV- As needed |

| | | |Hour- Wrist | |

| | | |Reason: Picking tape, dressings, or | |

| | | |other medical equipment. | |

|Consult to vascular surgery: arterial |Notify MD if urine Output is ................
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