Sex: Male Age : 49 Allergies: NKDA Code Status: Full code

RESPIRATORY MUSCULOSKELETAL PSYCHOSOCIAL

RESPIRATORY Precautions: Fall secondary to le wekaness,+2 edema bl le.

Admitted on 1/13/11 Generalized

Intermittent
weakness and Pt very
pulse ox
lower extremity pleasent
monitoring
weakness. Pt and
reading 98%, RA
OOB with cooperative
breath sounds Reason For Admission: CHF exacerbation, generalize weakness.
accucheck 63 on admission. Was administered O.J. and Crackers. assistance. with care.
clear to
Accucheck was then 132. Patient admites to"cheating" during the Right shoulder Pt. is
auscultation holidays and waiting to seekmedical attention until after the new year. pain with ROM married
bilat. respiratory
otherwise, MAE. with
Rate 20-22 Secondary Diagnosis: DM, HTN, Obesity, Osteomyelitis
Gait: unsteady children.
unlabored. Pt
Wife and
c/o DOE. No
Son at the
clubbing/
NEURO bedside on
cyanosis.
GI/GU
1/17/11.
INTEGUMENTARY
Awake, Awake,
CV Oral mucosa
alert and
Abd soft, non-tender, non moist and pink, appropriate.
distended. hypoactive bowel skin warm, dry PERRLA 3 mm. Percocet 1 tab po q
Blood pressure 120's- sounds x 4, last bowel and with normal 4 hrs
130's/ 60's-70's. afebrile movement once on 1/17/11, Cranial Nerves
98.3, strong peripheral Pt tolerating 2G Na and 2000
turgor. b/l LE
intact. OOB with Ibproufen 800 mg
hyperpigmentati po q 8 hr
pulses, capillary refil brisk, ADA diet. Denies N/V. assistance.
on, dry and
skin warm, dry, Left wrist
22 G PIV heplocked clean, GU: voiding clear amber urine
scaly. b/l feet Numbness and
dry and scaly weakness b/l LE.
dry and intact. Due to without difficulty. output 725 in with thick
change 1/18/11. +2 7 hours. toenails. Pt c/o right DX #2
edema bl le, +2 b/l pedal shoulder pain Nursing
edema. No JVD. Weight:
321.2 8/10 increased
Accucheck 0800: 115 with ROM. no
Acute pain right
1100: 181 c/o numbness in shoulder related to
right shoulder. unknown trauma as
right cap refill
evidenced by pin
brisk. radial
descripton, pt guarding
pulse present. right shoulder.
Diagnostic Tests
GOAL
#1- Patient will report
Renal u/s: normal satisfaction with pain
CXR pa and lat: relief measures one
pulmonary vascular hour after intervention.
retention Bun 40 -increased in CHF r/t decreased Interventions-
u/s b/l le: No DVT blood flow to kidneys perform assessment of
Medication: Glucose 125 - increased diabeted mellitus pain including location,
Bumex 3 mg 100 Phosphorous 4.7 increased in decreased characteristic, onset,
ml/hr kidney function frequency, duration.
Metoprolol 12.5 PT 17.2 increased secondary to provide optimum pain
mg Q 12 hrs. prophylaxis lovenox relief with medication
lisinopril 40 mg INR 1.14 teach non-
daily pharmacological
asa 325 daily techniques such as
digoxin 0.25 mg heat, distraction,
daily positioning, warm
simvastatin 10 showers
mg qhs GOAL
lovenox 40 mg sc #2- patient
qhs demonstrates ability to
Insulin lispro
DX #1 perform ROM with right
75/25 10 units
Nursing shoulder
Interventions-
determine joint
Excess fluid volume related
limitations to plan
to CHF as evidenced by
appropriate
edema, DOE
interventions
GOAL
assist patient to
#1-.
optimal body positions
Pt will be free free of
to prevent
complications secondary to
complications
CHF.
perform
Interventions-monitor
assisted/passive ROM
respiratory patterns for
exercises as tolerated.
symptoms of respiratory
difficulty.
Perform assessment of
peripheral circulation
(pulses, edema, cap refill,
color and temp)
provide/instruct
appropriate diet to help
control edema

GOAL
#2 Pt will experience
reduced/ absent edema
upon discharge

Interventions:
weight patient daily to
evaluate fluid
retention/diuresis
monitor serum electrolytes
to assess treatment
response
Monitor renal function
-intake and output