SUBJECTIVE: Mr. W.G. is 73 years old patient and was admitted to ICU from home on November 20 for COVID-19 Pneumonia (presented by SOB and weakness), which eventually required him to be intubated. On December 31, he was transferred to the ward with a tracheostomy. As of now, his Covid-19 Pneumonia was resolved, and the tracheostomy tube was removed since the patient no longer needed it. His vital signs were stable afterwards. He was in an NG tube, but insertion can sometimes cause him distress; that is why a PEG tube was inserted last January 05 that required a long discussion with her wife with the physician because she was against it at first. He has developed a stage III pressure ulcer in his coccyx on the unit but reported no pain. He has muscle weakness in his lower extremities (right and left leg); an indwelling catheter was inserted last January 07 and in diaper incontinence. Social History: He was retired, lives with his wife in a house, and has two children. He speaks English and is independent with ADLs before testing positive in Covid-19. He quit smoking in 2018 and has previously used cannabis (none recently). Past Medical History: No known allergies.Hypertension, CVA (left parietal -occipital stroke 2015), Ex-smoker, CKD, AAA, Dyslipidemia Home Medications:Acetylsalicylic Acid, amlodipine, hydralazine, garlic, omega-3 DHA/EPA/fish oil, ubidecarenone, atorvastatin, hydrochlorothiazide Current Medications:Acetaminophen 1000 mg PO/Tube tid SCHAcetylsalicylic acid 80 mg PO/Tube daily SCHAmlodipine besylate 10 mg PO daily SCHLipase/Protease/Anglase 1 cap tube as directed PRN- declogging tubeAscorbic acid 500 mg PO daily SCHAtorvastatin calcium 20 mg PO bedtime SCHBisacodyl 10 mg PO bedtime PRNBisoprolol fumarate 10 mg PO daily @ 1600 SCHChlorhexidine/LidocaineDoxazosin mesylate 8 mg PO bedtime SCHGlycerin 1 Supp PR daily PRN- constipationIpratropium bromide 2 puff inhaler q4hr/prn Lactated Ringer’s 1000 ml @75 lm/hr IV q13h 20M SCHLactulose 30 ml PO BID PRN – bowel movementLansoprazole 30 mg PO daily SCHMultivitamin Centrum 1 tab PO daily SCHOndansetron HCI 4 mg IV q6hr PRNPolyethylene glycol 17 g daily SCHQuetiapine fumarate 12.5 mg PO QID/PRNSalbutamol sulfate 2 puffs Inhale q4h/PRN- SOBSennosides 2 tabs PO/Tube, bedtime/PRN- constipationSodium bicarbonate 500 mg tube PRN- declogging tubeTinzaparin sodium 4500-unit subcut daily SCHVitamin D 1000-unit PO daily SCH OBJECTIVE: Height: 1.71 m Weight: 68.3 kgAppears on his stated age. BMI: 24.3 (Normal weight)Vital Signs: Temperature: 36.9 degrees CelsiusPulse: (bilateral-radial)- 73 bpm, regular, 2+(apical)- 72 bpm, regular, 2+(bilateral-dorsal pedis): 74 bpm, 1+Blood Pressure: 153/77 mmHg (right arm- supine) Range: 152-159/ 76-77 mmHgRespiration: 16 times per min. (non-labour, normal depth, eupnea, equal symmetry, no adventitious sounds auscultated in lungs, no cough, no sputum)Oxygen Saturation: 96% (room air)Pain Scale: 0 PQRSTUV: NoneI/0 – Intake: 1000 ml (PEG tube) Output: 650 mL (as of 1500hr)Last 48 hrs: BUN 18.9 mmol/L high, Cr 20.5 umol/L high, Albumin 29 L high Hair distribution: balding, symmetricalSkin: normal, warm, dry, elastic, smooth, normal colour appropriate with his ethnicity (low risk:15-18)Neurological: alert, awake, oriented to time, place, and person, arousable to speech and light touch, obeys command and able to respond to simple questions. No sensory and hearing deficits.Mood: appropriate, calm, relaxed, jokes around, cooperative, easily fatigued, but memory and judgments are intact.Speech: hypophonic voice (weak and breathy), clear and normal Diet/ Fluid: NPO, in PEG tube, rate: 85 ml/hrOral Cavity: Mucous membrane and tongue are pink, no denturesAbdomen: soft and firm, nontender bowel sounds present in all four quadrantsHydration Status: skin turgor is normal, no tenting, no edemaCSM arms and legs: no CSM deficits in arms, weak pulses in legs but has warm and normal colourNail beds: pink, cap refill: less than 2 secondsActivity Order: Total AssistanceAssistive Devices: Mechanical lift to Geri-chairMobility concerns: muscle weakness, limited ROMFall Risk: 0ADLs: 1 person assistUrinary Continence: Diaper IncontinenceStool: Copious We need to do Nursing Care Plan.Please help me identify 1 actual diagnosis and 1 potential diagnosis for the patient using the NANDA and the information above. Identify 2 goals on each diagnosis (one short term and one long term goal). 4 goals in total Health Science Science Nursing NURS 2018 Share QuestionEmailCopy link Comments (0)
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