swimsalot90
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Case Study Paper for NURS 4022

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swimsalot90
Created by swimsalot90 over 5 years ago
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1 Cardiac Event
1.1
1.2 Vitals: 60/40, 37.2-150-30, Sat 92% on 3L
1.2.1 Sudden complaint of chest pain, weakness and shortness of breath
1.2.1.1 Doctor notified of findings and arrived to assess patient
1.2.1.1.1 Moved to trauma room
1.2.1.1.2 Sedated with Versed
1.2.1.1.3 Electrical Cardioversion at 200J
1.2.1.1.3.1 Reverted to Normal Sinus Rhythm and recovering
1.2.1.1.3.1.1 Vitals: 90/50, HR 100, RR 30 Sat 100% on 8L
1.2.1.1.3.1.2 Bolus of 750cc NS
1.2.1.1.3.1.3 14F Foley Catheter inserted
1.2.1.1.4 Put on telemetry
1.2.1.2 STAT Labs
1.2.1.2.1 ECG showed new onset uncontrolled A-fib
1.2.1.2.2 Troponin 0.6 - Positive, indicator for cardiac damage
1.2.1.2.3 CBC, Chemistry: no significant changes
1.2.2 Anxiety
1.3
1.4
2 Dementia with Paranoia
2.1 Blames Medications for unrelated symptoms
2.1.1 Poor Compliance
2.2 Doesn't trust staff
2.3
3 Health History
3.1 Dislipidemia
3.1.1
3.2 Anemia with previous rectal bleed
3.2.1
3.2.2
3.3 Renal Insufficiency
3.3.1
3.4 Rheumatoid Arthritis
3.4.1
4 Cardiac History
4.1 Previous MI
4.2 Ex-smoker 3 years ago
4.3 Severe Aortic Stenosis
4.3.1 3/6 Ejection Fraction
4.4 Hypertension
4.4.1
5 Medications
5.1 No known allergies
5.2 C.difficile orders: Vancomycin PO, Metronidasole IV, IV Fluids
5.3 Furosemide, Ramapril
5.4 Atorvstatin, Ezetrol
5.5 Hydroxychloroquine
5.6 Ferrous Gluconate
5.7
5.8 Quetiapine, Galantamine
6 Main Complaint: abdominal pain, diarrhea over 4 months, genaralized weakness
6.1 Initial Assessment
6.1.1 Vitals: 102/52, 36.8-80-20, Sat 92% on 3L
6.1.2 Lungs clear, occasional cough,regular heart rhythm
6.1.3 Abdominal pain, bowel sounds present, abdomen distended
6.1.3.1
6.1.4 Not oriented to place or day, lethargic, confused
6.1.5 90 year old female, lives alone, DNR
6.1.6
6.1.7 Fall Risk
6.1.7.1 Rheumatoid Arthritis stiffness
6.1.7.2 Frequent diarrhea
6.1.7.3 Confusion
6.1.7.4 Polypharmacy
6.1.7.5 Weakness
6.2 Strain on Body
6.3 Diagnosis: C. Difficile colitis
7 Initial Labs
7.1 WBC 24.7 - Elevated, sign of infection
7.1.1 Lactate 0.9 - Normal, rule out sepsis
7.2 Liver function tests normal
7.3 Chemistry: Na 132, K 4.1, Normal
7.4 Urea 23, Creatinine 199, Expected high
7.5 Hgb 107 - Result good considering anemia, also rules out rectal bleed

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