-THE P.T IS A 65 YEAR OLD
-THE P.T IS A 65 YEAR OLD MALE WITH A HISTORY OF HTN, OBSTRUCTIVE SLEEP APNEA, DM2, DEPRESSION, HYPERLIPIDEMIA, LT HIP OSTEOMYELITIS, ATTENTION DEFICIT DISORDER , PNEUMONIA. WIFE FOUND P.T ON THE FLOOR AT THE HOUSE WITH ALTERED LEVEL OF CONSCIOSNESS ALONG WITH CONFUSION. P.T WAS BROUGHT FROM HOME VIA AMBULANCE ACCOMPANIED BY HIS WIFE “MARIA”. P.T IS FULL CODE STATUS WITH NKA TO MEDICATIONS. ADMISSION DX OF RESPIRATORY FAILURE BILATERAL PNEUMONIA, TREATED WITH IV ANTIBIOTICS. PLACED ON MECHANICAL VENTILATION, TRACHEOSTOMY, PERCUTANEOUS ENDOSCOPIC GASTROSTOMY PLACEMENT WITH A FOLEY CATHETER AND RUNNING IV FLUIDS OF SODIUM CHLORIDE 0.9% ON LT UPPER ARM. MRI OF THE BRAIN SHOWED NO ABNORMALITY & CXR IS PENDING FOR RESULT. HE IS ROUTINELY BEING MONITORED FOR HTN, OSA, DM2, HYPERLIPIDEMIA. P.T IS FEEDING ON TWOCAL HN (CALORIE & PROTEIN DENSE NUTRITION TO SUPPORT VOLUME INTOLERANCE AND OR FLUID RESTRICTION) G/TUBE/PEG AT 45 ML/HR RATE. ATTENDING DR. PLANS IS TO HAVE NEPHRO, CARDIO, PSYCHIATRIC, P.T & O.T CONSULT. -HGB 12.2 BUN 23 GLUCOSE 104 MAG 2.3 A) INEFFECTIVE BREATHING PATTERN AS EVIDENCE BY TACHYPNEA, DECREASE BREATH SOUNDS AND ELEVATED BODY TEMPERTURE SECONDARY TO PNEUMONIA B) INEFFECTIVE CEREBRAL TISSUE PERFUSION RELATED TO RESPIRATORY FAILURE AS EVIDENCE BY LOSS OF CONSCIOUSNESS, CONFUSION C) RISK FOR ULCER PRESSURE RELATED TO SEDATION, BED RIDDEN, DECREASE CONSCIOUSNESS 1. WHAT THE POSSIBLE REASONS WHY THE LABS ARE SLIGHTLY ELEVATED? 2. WHAT ARE THE NURSDING INTERVENTION AND RATIONALES FOR THE NURSING DIAGNOSIS? THANK YOU! SCIENCE HEALTH SCIENCE NURSING NUR 2221
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