D.W. 57 M

D.W. 57 M

1. Complaints of vomiting. Dark urine for 3-4 days. Decreased appetite with no food for 3 days. Known gallstones.

   • Cholecystitis, gallstones, pancreatitis
     • Complex cholecystectomy
       • Common bile duct tear
         • Intraoperative repair. T Tube placed for 6-8 weeks
       • Intraoperative hemorrage
         • 2 Units PRBC
       • Lap chole converted to open surgery
         • JP tube placed. To remain until cholangiogram passed
       • VP shunt shifted. Distal portion removed intraop
         • Head CT
           • Likely nonfunctional. No change from baseline with removal
       • Some gallstones retained
         • ERCP in 6 weeks for retained gallstones
       • Acute Pain
         • Dilaudid
     • AST 152 (H); ALT 184 (H); Bili 2.7 (H); Alk Phos 255 (H); Lipase 1146 (H); Albumin 2.7 (L); Protein 5.6 (L)
   • Severe sepsis
     • Antibiotics/Fluid resusitation
     • Bladder thickening: concern for cystitis
       • UA/UC
         • Pancreatitis, cholecystitis
           • Continue antibiotics
             • Followup Culltures
     • Ineffective peripheral tissue perfusion
     • Delayed surgical healing
   • Imbalanced Nutrition: Less than body requirements
     • Double lumen PICC inserted R cm
       • TPN day 3
         • Failed swallow test
           • 2/26 aspiration event
             • Rhonchi
               • Chest X Ray
                 • Aspiration Pneumonia
                   • Begin Zozyn
                   • Possible Vanco to treat MRSA infection. Waiting for lab
                 • Atelectasis
       • Swelling in the R arm
         • Venous doppler ordered
   • Vomiting
     • Hypoxic event, possible aspiration, SpO2 87%
       • CCU transfer
       • NRB 100
         • Weaned to BiPap
     • Risk for deficient fluid volume

2. Admitting Vitals: T: 37.1 HR: 49 RR: 17 BP: 99/62 SpO2: 97%

   • Bradycardia
     • NSR, low volt chronic EKG
       • Hold Aspirin

3. History: Brain aneurysm rupture '91. VP shunt. Nail gun accident. Seizure. Cholecystitis '14. Cardiomyopathy s/p viral infection at age 28. Hyperlipidemia. Suspected CVA

   • Nonverbal at baseline. Cognitive deficit.
     • Ineffective Health Maintenence
   • Adult family home for 15 years.
     • DIscharge to Adult Family Home
   • Divorced. One adult son 24. Ex-wife POA

4. KEY

   • H&P; presenting s/s
   • In hospital occurrence or change
   • Action taken
   • Nursing Diagnosis
   • Planning