Student Name: Brittany S. Wood Date: February 23, 2012 Patient Initials / Room #: W.B.

/ Room 534

Medical Diagnosis p p p p CVA PNUEMONIA HYPOXEMIA LEUKOCYTOSIS

Initial Assessment Patient lying in bed, awake, in semi-fowlers position. Patient alert oriented to person place, not time. Patient has sickly appearance, pale and dusky in color. IV heplock in left antecubital space, dressing was intact with no presence of edema/redness/ warmth. Cardiac monitor resting on patients side with leads attached. Mucous membranes intact and pink, yellow film noted on hard palate. T: 98.1, AP: 100 irregular, RR: 16 labored on 2L O2/nasal canula, with noted use of accessory muscles BP: 87/38 HYPOTENSIVE. I have had this pain between my shoulder blades since I got here. Rated pain at a 6/10 on pain scale of 0-10 and described it as a dull pain that sometimes radiates to chest and down into lower back when he coughs. Productive cough noted with sputum present on tissues lying on bedside table. Sputum noted to be blood tinged and thin as well as light tan colored with a thicker consistency. Patients affect is low, patient stated I guess its good I am alive, but I sure dont know nothing good about being here in this hospital, no news is good news here. Walker noted at end of bed placed against wall for patient to use once ambulation is ordered. Primary Nursing Diagnosis 1. Impaired tissue perfusion: cerebral r/t hypoxia 2 CVA Patient will have improved cerebral tissue perfusion AEB: p Displaying no evidence of ICP p Demonstrating and verbalizing orientation to person place and time p Maintaining ABGs within normal limits p Displaying no signs of dizziness or light headedness p Maintaining HR/RR/O2 sat within normal limits 2. Impaired Gas Exchange r/t decreased O2 saturation 2 Pleural Effusion Patient will have improved oxygenation by end of hospitalization AEB: p Demonstrating O2 sat of 93% or greater on room air p Displays no signs of hypoxia p Demonstrates proper TCDB exercises to mobilize secretions

3. Infection r/t Leukocytosis 2 Pneumonia Patient will be free from infection by end of hospitalization AEB: p Remaining free of temperature p Display of WBC within normal limits p No signs of tachycardia p No change of character in sputum and or culture 4. High Risk for Injury: Falls r/t Left sided weakness and Chronic Anemia 2 CVA Patient will remain free from injury during hospitalization AEB: p Demonstrating proper fall precautions p Displays no signs or symptoms of injury p Remains free of falls p Uses call bell appropriately before attempting to get up.

Summary Assessment I. Neurological: Alert, oriented to person place not time. Left sided weakness r/t CVA. Patients right hand grip is strong, unable to grip with left hand. Limited lower extremity strength assessment obtained r/t fall risk and hypotensive episodes. Patient was not able to lift left lower extremity without assistance during bed bath. Patient is able to maneuver right lower extremity without as much assistance. Patient repeatedly verbalized the wrong time of day. I dont know why they wanna bring me breakfast at 2:00 in the morning. (Patient received breakfast tray at 8:30 A.M.) I sure would like to go to bed since it is so late. (Patient stated @ 10:00 A.m.). Confusion is related to CVA. Patients speech is clear. Patient became teary eyed when Dr. Garcia stepped out of the room. BP Assessments: *Hypotension indicates decrease in blood flow to the brain, standard intervention is to lower HOB and raise foot of Bed up to facilitate circulation of blood to the brain. TIME B/P 0730 87/38 0740 96/53 0800 95/67 0806 94/50 0825 103/55 0830 104/57 0845 102/54 0950 85/45 1000 90/46 1025 93/37 Labs: CO2- 35 H related to pneumonia and inadequate cardiac output. High CO2 levels can cause confusion. p MRI: - Prominent Right side infarct with scattered small bilateral infarcts in cerebellum. - Moderate atrophic changes with diffuse small vessel changes throughout the brain

II.

Psychosocial: Patients affect low at times regarding hospitalization. Patient became teary eyed when Dr. Garcia stepped out of the room. When I asked patient what was wrong, he stated, Oh nothing, no good news anywhere in sight for me. Patient became less talkative after that. Patient responded to verbal cues. Patient mentioned he was married twice. Single as of now, stated Neither one of them worked out, but it didnt end ugly with either one of them. p ATIVAN 1 MG Q4H/PRN/PO p XANAX 0.25 MG Q8H/PRN/PR/PO HEENT: Head symmetrical with noted dryness of scalp. Skull intact with no nodules or lumps noted. Patient has glasses at bedside but says he doesnt want them on right now watched TV, stated that aint the right channel go to USA. No squinting noted during shift. Scant amount of watery drainage noted in inner canthus of eyes bilaterally. No lower teeth noted upon inspection of mouth, however patients lower dentures were located in cup at bedside. Upper teeth present, yellow tint related to history of smoking. Nasal membranes intact, nares patent with presence of nasal hairs bilaterally. Oral mucosa pink, moist with yellow coating noted on hard palate. Uvula midline within Oropharynx, trachea midline no deviations noted upon inspection of neck. No JVD or lymphadenopathy noted. Neck non-tender to palpation. Carotid pulse palpable bilaterally. Cardiovascular Sinus Rhythm with flattened T-waves at a rate of 98. BP: 87/38. Patient wearing cardiac monitor, all leads connected and in place. Capillary refill of 4 seconds. Pedal pulses strong bilaterally upon palpation. Negative Homans sign. No tenderness or edema noted to lower extremities bilaterally. Skin warm and dry, flaky patches noted on feet bilaterally. Ejection fraction of 30% noted. p Cardiac enzymes WNL p Chest CT: - Calcified Aortic Arthrosclerosis - Calcification of Coronary Artery noted p Telemetry: - Left Ventricular Diastolic Dysfunction. - Left ventricle (Main pump) not pumping out enough blood with each contraction. p CBC WNL with exception of: - WBC 21.5 H - RBC 3.36 L - HGB 10.2 L - HCT 30.4 L - RDW 17.4 H - SEG ABS 18.9 H - LYMPHOCYE 7 L - SEG NEU 88 H p BMP WNL with exception of: - CREAT 0.63 L - NA + 134 L - CHLORIDE 94 L

III.

IV.

p p p p p p p p p V.

- CO2 35 H - CA 8.4 L ABG: - PH 7.4 - PCO2 36.4 - P02 102.8 - BICARB 22 - O2 SAT ON 2L O2/NASAL CANULA ATIVAN 1 MG Q4H/PRN/PO ECOTRIN 81 MG DAILY/PO FOLIC ACID 1 MG DAILY/PO LORTAB 5/500 1 TAB/Q4H/PRN/PR LOVENOX 40 MG Q24H/SQ THIAMINE (VIT B-12) 100 MG DAILY/PO XANAX 0.25 MG Q8H/PRN/PR/PO ZOCOR 40 MG QHS/PO NS BOLUS 500 ML/IV

Respiratory: RR: 16, Labored with noted use of accessory muscles. Upon auscultation crackles, rales, and ronchi noted. Patient on supplemental oxygen per nasal canula @ 2L/min. Productive cough with sputum noted. Sputum noted to be blood tinged and thin as well as light tan colored with a thicker consistency. O2SAT of 95%100% noted with supplemental oxygen applied via nasal canula. Patient displayed pursed lip breathing when BP dropped to 85/45 at beginning of bed bath. After hob lowered at foot of bed was raised patients BP increased to 90/46 pursed lip breathing returned to normal respiratory pattern (labored with use of accessory muscles.) Patients color during hypotensive episode became increasingly dusky/ gray. Once BP began to stabilize, color of the face returned to slightly dusky/ with semi pink tint. Im ok just heavy chest feeling at times Breathing the same just slower. Patient frequently cleared throat throughout shift. Patient coughed up sputum and spit into tissues. Color and consistency described earlier in notes. p Chest X-Ray: - Admission: showed bilateral infiltrates (Leukocytosis) - 2-22-12 compared chest x-ray from 2-21 to the x-ray from 2-15 no worsening of interstitial pneumonitis p FEB 15th CT of chest with contrast: - Due to mass seen in repeat chest x-ray performed also on the 15th / Suggested a 6x7.5 cm mass in R Upper Lobe- contiguous with medial & posterior pleura without invasion of chest wall. - Also noted media-stinal lymphadenopathy bilaterally with largest lymph node measuring 1.7x2.3 cm in pre-cardial region. - Enlarged subcranial lymph node. Bilateral pleural effusions (small on L/ Moderate on R). - Lungs appear emphysematous. - Calcified aortic arthrosclerosis with calcification of coronary artery noted. p Sputum Gram Stain: - Normal respiratory flora - Many WBCs p Biopsy Of Lung Mass:

p p p p p p p VI.

Patient noted to have tolerated procedure well no complications noted. Awaiting pathology report 2-22-12 2-23-12 Small cell Lung Cancer (fast growing) Oncology consult ordered to talk with patient relating to newly diagnosed cancer. CBC WNL with exception of: - WBC 21.5 H - RBC 3.36 L - HGB 10.2 L - HCT 30.4 L - RDW 17.4 H - SEG ABS 18.9 H - LYMPHOCYE 7 L - SEG NEU 88 H BMP WNL with exception of: - CREAT 0.63 L - NA + 134 L - CHLORIDE 94 L - CO2 35 H - CA 8.4 L ABG: - PH 7.4 - PCO2 36.4 - P02 102.8 - BICARB 22 AVELOX 400 MG DAILY/1600/PO ATIVAN 1 MG Q4H/PRN/PO LORTAB 5/500 1 TAB/ Q4H/PRN/PR/PO MUCINEX ER 600 MG BID PO RT DUONEB NEBULIZER 3 ML RTQ6H/IH RT DUONEB NEBULIZER 3 ML Q2H/PRN/PR/IH XANAX 0.25 MG Q8H/PRN/PR/PO

Gastrointestinal: Patient diet is regular, patient stated, I sure would like breakfast sometime today. Tolerated breakfast well, consumed 100% of meal/460 ml fluid during breakfast meal. Bowel sounds are hyperactive in all 4 quadrants. No bowel movement noted during shift. Patient verbalized understanding of notifying for assistance for use of bedpan when needed. Abdomen soft, non-tender, with no pain noted during assessment/ no nausea or vomiting noted during shift. p BMP WNL with exception of: - CREAT 0.63 L - NA + 134 L - CHLORIDE 94 L - CO2 35 H - CA 8.4 L p ABG: - PH 7.4 - PCO2 36.4

p p p p p p p p p p p VII.

- P02 102.8 - BICARB 22 ATIVAN 1 MG Q4H/PRN/PO AVELOX 400 MG DAILY/1600/PO COLACE 100 MG BID/PO FOLIC ACID 1 MG DAILY/PO LACTINEX 1 TAB/CHEWABLE/BID/PO LORTAB 5/500 1 TAB Q4H/PRN/PR/PO PROTONIX 40 MG DAILY/PO THIAMINE 100 MG DAILY/PO ZOCOR 40 MG QHS/PO ZOFRAN INJ. 4 MG Q6H/PRN/IV NS BOLUS 500 ML/IV

Genitourinary: Patient wearing adult brief during shift, no urination noted during shift. Patient stated, If I feel the urge I use that jug on the rail there to pee in. Aint had to go yet, thought I did but it didnt amount to anything. Patient given 500 ml NS bolus to correct fluid volume deficit and stimulate micturation. p UA WNL with exception of: - Urine blood +1 - Hyaline Casts FEW p BMP WNL with exception of: - CREAT 0.63 L - NA + 134 L - CHLORIDE 94 L - CO2 35 H - CA 8.4 L Integumentary: Skin color dusky/ gray at times of severe hypotension, warm and dry with flaky patches noted on feet bilaterally. Skin turgor displayed sluggish recoil. Large scar noted on R antecubital space from lifting incident in the past. . IV heplock in left antecubital space, dressing was intact with no presence of edema/redness/ warmth noted during assessment. Two tattoos noted one per forearm in remembrance of his father and step father. Lesions noted bilaterally on knees r/t fall at home. Both areas have dry scabbed patches with no drainage present. Bruising present on left foot at second and third toe blue in color. Bruising also noted to knees around scabbed patches r/t fall at home, as well as small bruises located on flanks and elbows. Significant clubbing all fingernails and toenails. Musculoskeletal: Limited Rom to all 4 extremities r/t weakness and fatigue. Noted weakness worse on LEFT side r/t CVA. Patient not able to grasp fingers with left hand; grip strong with right hand upon examination of strength. Patient able to lift both arms above head during shift. Walker noted at end of bed placed against wall for assistance with ambulation once patient is able. Bedside toilet in room to be used by patient once ambulation is possible.

VIII.

IX.

X.

Pain: Patient reported pain between shoulder blades. I have had this pain between my shoulder blades since I got here. Rated pain at a 6/10 on pain scale of 0-10 and described it as a dull pain that sometimes radiates to chest and down into lower back when he coughs. Patient complained of slight throbbing headache at beginning of shift, pain was relieved when HOB was lowered, foot of bed was raised, BP was low prior to intervention of bed repositioning but increased after intervention r/t increased blood flow to brain. Increase of BP resolved headache. p ATIVAN 1 MG Q4H/PRN/PO p ECOTRIN 81 MG DAILY/PO p LORTAB 5/500 1 TAB Q4H/PRN/PR/PO p XANAX 0.25 MG Q8H/PRN/PO Did diagnosis change? Yes

NUR DIAGNOSIS Decreased Cardiac Output r/t decreased ejection fraction of 30%, BP of 79/39 2nd Left ventricular dysfunction

SRG Patient will have improved cardiac output during clinical shift AEB:

NUR INTERVENTION

RATIONALE Decrease in LOC can indicate inadequate perfusion Vitals signs indicate patients health status and a decrease or increase can indicate complication Skin color provides clinical picture of perfusion throughout the body Peripheral pulses determine the amount of blood reaching the extremities and at what rate it is reaching them Heart sounds determine adequate flow of blood throughout the body Cold, pale, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation.

EVALUATION Patient did not have improved cardiac output during clinical shift AEB: HR: Sinus Rhythm 98 with flattened T-waves Skin color Dusky/Gray during assessment. Anuria during shift Crackles/ Rales/ Ronchi noted upon auscultation of lungs during shift. Cough controlled, sputum at times, patient spit it out at times but at times would swallow secretions. Ejection Fraction of 30% / CT with

Assessment: Assess patients LOC q shift or as indicated during shift Assess Vital Signs q shift/ as necessary depending on pt status Assess Skin color and temperature q shift Demonstrates Assess peripheral pulses q shift normal HR 60Assess Fluid balance and weight gain q shift 100 Assess heart sounds q shift Assess lung sounds q shift Assess urination pattern and output q shift Improved skin color, decreased Assess telemetry strip q 2H Assess 02 saturation with O2 supplementation q dusky appearance/pink shift tint no evidence Assess tolerance of activity and effects on health of gray coloring status q shift on face. Assess for side effects of medication that could further compromise cardiac output q shift Increased urinary output of Monitor: at least 30 ml/hr Monitor patients LOC q shift or as indicated during shift No evidence of Monitor Vital Signs q shift/ as necessary crackles, Rales, depending on pt status note and report any Ronchi. changes that affect health status p BP Controlled p HR cough with p O2SAT production of p RR sputum to be Monitor for changes in skin color and temperature expelled from q shift mouth to Monitor peripheral pulses q shift

prevent reentrance to lungs. Increased ejection fraction % > 50%

Monitor Fluid balance and weight gain q shift Monitor heart sounds q shift Monitor lung sounds note any abnormalities from baseline assessment q shift Monitor urination pattern and output of at least 30ml/hr q shift notify physician if output is <30 ml/hr Monitor telemetry strip notify physician of abnormalities or significant changes from baseline readings q 2H Monitor 02 saturation with O2 supplementation q shift Monitor tolerance of activity and effects on health status q shift Monitor side effects of medications administered that affect cardiac output Interventions: Obtain vital signs q shift/ as needed r/t decline in patient health status. Continuously assess skin color/temp/turgor for changes affecting patient status q shift Monitor for changes in urinary elimination noting cessation or increases throughout shift Obtain telemetry strips and notify physician for significant changes that affect patient status q shift/ as ordered per physician Auscultate Lungs for adventitious sounds such as Crackles/ Rales/ Ronchi/ Stridor/ Wheezes notify physician if worsening occurs q shift Auscultate Heart for abnormal sounds such as gallops, murmurs. Q shift Maintain optimal fluid balance q shift Administer ordered fluids: p 500 ml NS bolus IV per physicians orders Hold medications that further compromise patient status r/t cardiac output such as: LORTAB 5/500 q shift Maintain adequate ventilation and perfusion q shift Position patient to facilitate optimal blood flow to brain q shift as necessary Lower HOB and Raise Foot of Bed if BP significantly drops q shift as needed Maintain physical and emotional rest q shift Provide quiet environment q shift Organize medical care to reduce overwork of patient and to decrease stress on patient q shift Provide supplemental O2- 2L/min via Nasal Canula continuously q shift Provide patient with education pertaining to the

Pulses are weak with reduced stroke volume and cardiac output. Capillary refill is slow, sometimes absent. Compromised regulatory mechanisms may result in fluid and sodium retention. Body weight is a more sensitive indicator of fluid or sodium retention than intake and output. The renal system compensates for low BP by retaining water. Oliguria is a classic sign of decreased renal perfusion. Diuresis is expected with diuretic therapy. Rapid shallow respirations are characteristic of reduced cardiac output. Crackles reflect accumulation of fluid secondary to impaired left ventricular emptying. They are more evident in the dependent areas of the lung. Orthopnea is difficulty breathing when supine; PND is difficulty breathing at night. Cardiac output measurement provides objective numbers to guide therapy. Change in oxygen saturation of mixed venous blood is one of the earliest indicators of reduced cardiac output. Cardiac dysrhythmias may occur from low perfusion, acidosis, or hypoxia. Tachycardia,

contrast

following q shift: p Interventions p Drug regimen p Activity schedule/ restrictions p Signs and symptoms to report to HCP

bradycardia, and ectopic beats can further compromise cardiac output. Older patients are especially sensitive to the loss of atrial kick in atrial fibrillation. Physical activity increases the demands placed on the heart; fatigue and exertional dyspnea are common problems with low cardiac output states. Close monitoring of the patient's response serves as a guide for optimal progression of activity. Chest pain indicates an imbalance between myocardial oxygen supply and demand. Assess contributing factors so appropriate care plan can be initiated. Specific etiologies guide treatment. Volume therapy may be required to maintain adequate filling pressures and optimize cardiac output. Depending on etiological factors, common medications include digitalis therapy, diuretics, vasodilator therapy, antidysrhythmics, angiotensin-converting enzyme inhibitors, and inotropic agents. For patients in the acute setting, close monitoring of these parameters guides titration of fluids and medications.

When fluid overload is an etiology, upright positioning reduces preload and ventricular filling. For hypovolemia, supine positioning increases venous return and promotes diuresis. The failing heart may not be able to respond to increased oxygen demands. Oxygen saturation needs to be greater than 90%. Activity restriction and a quiet environment reduce oxygen demands. Attention to priority care delivery optimizes use of the patient's limited energy resources. Careful activity progression prevents overexertion and stress on the cardiopulmonary system. Rest is important for conserving energy. Both tachydysrhythmias and bradydysrhythmias can reduce cardiac output and myocardial tissue perfusion. Thorough understanding of specific causes for each patient's disease is necessary for appropriate followthrough of treatment plan. Information provides rationale for therapy and aids the patient in assuming responsibility for self-care later.

_____________ NUR DIAGNOSIS Fluid volume deficit r/t anuria, skin turgor recoil >3 seconds, BP: 79/39 2nd Insufficient intake of fluid

_____________ SRG Patient will have improved fluid volume status during clinical shift AEB: Maintaining fluid and electrolyte levels WNL Skin turgor < 3 seconds Increased urinary output of at least 30 ml/hr BP WNL (systolic 100140/diastolic 6090)

________________________________________ NUR INTERVENTION Assessment: Assess weight q day Assess dietary status Assess urinary elimination noting q shift: - Normal pattern - Amount - Urine color - Continence/ Incontinence Assess I&O status q shift Assess Vital Signs q shift Assess BP for orthostatic changes (HOB elevated to HOB lowered q shift as needed Monitor: Monitor weight q day Monitor dietary status Monitor urinary elimination noting q shift: - Normal pattern - Amount - Urine color - Continence/ Incontinence Monitor I&O status q shift Monitor and document Vital Signs q shift Monitor and document BP for orthostatic changes (HOB elevated to HOB lowered) q shift as needed Interventions: Encourage patient to drink prescribed fluid amounts Assist with feeding and fluid intake as needed Provide oral hygiene Maintain IV patency

_________________ RATIONALE Weight facilitates accurate measurement and can be easily compared to indicate decrease in fluid volume. Dietary status indicates how fluids enter the body. Concentrated urine denotes fluid deficit Absence of urinary elimination denotes low fluid volume and the need for volume expansion BP indicates volume drop and significance compared to baseline readings Vital signs indicate effective cardiac output Oral fluid replacement helps facilitate replenishment of fluid volume.

______________ EVALUATION Patient did not have improved fluid status AEB: Fluid and electrolyte levels not within normal limits (BMP abnormal) Skin turgor recoil >3 seconds Anuria during clinical shift BP not within normal limits during clinical shit at times (refer to BP monitoring cart)

Administer IV fluid as prescribed: p 500 ml NS Bolus Provide education to patient regarding the following: p Describe reasons for fluid loss and side effects p Teach importance of consumption of oral fluids p Teach interventions to prevent further decrease in fluid volume

IV patency is required to facilitate adequate infusion of IV fluids and medications IV fluids are necessary to replace fluid volume as needed Education is essential in providing patient with an accurate understanding of how to prevent and treat fluid volume deficits.

NUR DIAGNOSIS Infection r/t Leukocytosis 2 Pneumonia

SRG Patient will have improved infection status during clinical shift AEB: Remaining free of temperature Display of WBC WNL ( 4.5-11.00 K/UL) No signs of tachycardia (HR <100) No change of character in

NUR INTERVENTION Assessment: Assess pt history of respiratory illness upon admission Assess Vital signs q shift Assess for predisposing factors to illness upon admission Assess immunization status upon admission Assess sputum and obtain culture as needed Assess hydration status q shift Assess lab values q shift p WBC Differential may be indicated for further investigation Assess Pulse oximetry and ABGs as indicated Monitor: Monitor pt for worsening of symptoms of present illness q shift Monitor vitals and compare with baseline for

RATIONALE History of illness predisposes patient to infection Vital signs are an indicator of patient health status and give a baseline for comparisons Immunizations can prevent illness from occurring Sputum color and stain can show type of bacteria or infection from

EVALUATION

sputum and or culture.

significant changes that affect patient status q shift Monitor for sputum noting color/ consistency/ amount/ odor Monitor hydration status q shift Monitor lab work for increases or decreases in WBC q shift/ as indicated/ physician orders Monitor pulse ox. And ABGs for significant changes that may affect patients status Interventions: Obtain vitals q shift Talk with patient about history of work and or illnesses that may contribute to diagnosis q shift Teach patient the importance of immunizations q shift Obtain sputum cultures as indicated by physician order Inspect sputum for color/consistency/ amount/ odor q shift/ as indicated Review lab values and notify physician of changes that affect patient status q shift Closely monitor patients oxygenation and ABG values for changes that can affect patient status q shift Administer antibiotics q shift: AVELOX 400 mg Daily/1600/PO

within the lungs Lab work such as WBC with Diff. provide information pertaining to type of infection and whether or not the body is fighting it off Pulse oximetry and ABGs correlate with patients oxygenation status.

MEDICATIONS
Medication ATIVAN 1 MG Q4H/PRN/PO Classification BENZODIAZEPINE Anti-anxiety/ Antiemetic/ Sedative Hypnotic/ Skeletal Muscle Relaxant/ Anti- convulsion Antibacterial/ Fluoroquinolone Rationale Reduce anxiety r/t hospitalization and confusion

AVELOX 400 MG DAILY/1600/PO

Treatment of susceptible infections due to s. Pneumoniae Stool softener for those who need to avoid straining during defecation/ relief of constipation related to hard/dry stools Platelet aggregation inhibitor in the prevention of transient ischemic attacks / treatment of Acute ischemic stroke/ Cerebral thromboembolism Treatment of chronic anemia Probiotics to protect stomach while taking antibiotics

COLACE 100 MG BID/PO

Bulk Producing Laxative/ Stool Softener

ECOTRIN 81 MG DAILY/PO

Anticoagulant

FOLIC ACID 1 MG DAILY/PO LACTINEX 1 TAB CHEW/BID/PO

Coenzyme/ Nutritional Supplement

LORTAB 5/500 1 TAB Q4H/PRN/PR/PO LOVENOX 40 MG Q24H/SQ MUCINEX ER 600 MG BID/PO NS FLUSH 10 ML SYRINGE 10/QSHIFT/IV

Narcotic Analgesic/ Antitussive Low Molecular Weight Heparin/ Anticoagulant Expectorant Isotonic Solution

Non productive Cough Prevention of ischemic complications Symptomatic treatment of cough Maintain patency of IV access/ Flushing of IV port after Medication administration. Provide Fluid Volume due to severe FVD GI prophylaxis to prevent GERD/ulcerations during hospitalization Relieves bronchospasm/ Reduces airway resistance

NS BOLUS 500 ML QH (DC after infusion) PROTONIX 40 MG DAILY/PO

Isotonic Solution Proton Pump Inhibitor

RT DUONEB NEBULIZER 3 ML RTQ6H/IH

Bronchodilator

RT DUONEB NEBULIZER 3 ML Q2H/PRN/PR THIAMINE (VIT B-12) 100 MG DAILY/PO XANAX 0.25 MG Q8H/PRN/PR/PO ZOCOR 40 MG QHS/PO

Vitamin B complex Benzodiazepine/ Anti-anxiety Anti-hyperlipidemic

Treatment of thiamine deficiency Reduce anxiety r/t hospitalization and confusion Secondary prevention of cardiovascular events in patients with increased cholesterol Prevent nausea and vomiting

ZOFRAN INJ. 4MG Q6H/PRN/IV

Antiemetic/ Anti- nausea