D.W. 57 M

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kbennett2041
Mind Map by kbennett2041, updated more than 1 year ago
kbennett2041
Created by kbennett2041 about 8 years ago
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D.W. 57 M
  1. Complaints of vomiting. Dark urine for 3-4 days. Decreased appetite with no food for 3 days. Known gallstones.
    1. Cholecystitis, gallstones, pancreatitis
      1. Complex cholecystectomy
        1. Common bile duct tear
          1. Intraoperative repair. T Tube placed for 6-8 weeks
          2. Intraoperative hemorrage
            1. 2 Units PRBC
            2. Lap chole converted to open surgery
              1. JP tube placed. To remain until cholangiogram passed
              2. VP shunt shifted. Distal portion removed intraop
                1. Head CT
                  1. Likely nonfunctional. No change from baseline with removal
                2. Some gallstones retained
                  1. ERCP in 6 weeks for retained gallstones
                  2. Acute Pain
                    1. Dilaudid
                  3. 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)
                  4. Severe sepsis
                    1. Antibiotics/Fluid resusitation
                      1. Bladder thickening: concern for cystitis
                        1. UA/UC
                          1. Pancreatitis, cholecystitis
                            1. Continue antibiotics
                              1. Followup Culltures
                        2. Ineffective peripheral tissue perfusion
                          1. Delayed surgical healing
                          2. Imbalanced Nutrition: Less than body requirements
                            1. Double lumen PICC inserted R cm
                              1. TPN day 3
                                1. Failed swallow test
                                  1. 2/26 aspiration event
                                    1. Rhonchi
                                      1. Chest X Ray
                                        1. Aspiration Pneumonia
                                          1. Begin Zozyn
                                            1. Possible Vanco to treat MRSA infection. Waiting for lab
                                            2. Atelectasis
                                    2. Swelling in the R arm
                                      1. Venous doppler ordered
                                  2. Vomiting
                                    1. Hypoxic event, possible aspiration, SpO2 87%
                                      1. CCU transfer
                                        1. NRB 100
                                          1. Weaned to BiPap
                                        2. Risk for deficient fluid volume
                                      2. Admitting Vitals: T: 37.1 HR: 49 RR: 17 BP: 99/62 SpO2: 97%
                                        1. Bradycardia
                                          1. NSR, low volt chronic EKG
                                            1. Hold Aspirin
                                        2. History: Brain aneurysm rupture '91. VP shunt. Nail gun accident. Seizure. Cholecystitis '14. Cardiomyopathy s/p viral infection at age 28. Hyperlipidemia. Suspected CVA
                                          1. Nonverbal at baseline. Cognitive deficit.
                                            1. Ineffective Health Maintenence
                                            2. Adult family home for 15 years.
                                              1. DIscharge to Adult Family Home
                                              2. Divorced. One adult son 24. Ex-wife POA
                                              3. KEY
                                                1. H&P; presenting s/s
                                                  1. In hospital occurrence or change
                                                    1. Action taken
                                                      1. Nursing Diagnosis
                                                        1. Planning
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