Date: Feb. 11, 2009
Patient: Wilfred Longbottom
Age: 82
Residence: Saskatoon
Admission Date: Jan. 30, 2009
Admitting Diagnosis: Intraventricular hemmorhage r/t increased INR (4.1)
Diet:
- NPO Promote @ 15cc/ hr (increase 10cc/hr until at goal of 85 cc/hr) This was discontinued as the patient pulled out his duotube and Feb 11th was given full thickened fluids with supplements
Past Medical History
- Cholecystectomy
- Gastric ulcer
- Hypothyroidism
- Kidney problems
- Atrial fibrillation
- Increased INR
- HOH
- Fluid in lungs early January
- Hypertension
- Presentation to Hospital
Jan 30th – confusion while driving, decreased motor skills, decreased speak, son brought him to SCH
Social History
- Lives with wife in house (bungalow, 1 level), no use of community resources for ADLs.
Psychological History - has son in city
- occasional social drinker
- Zero smoking or drugs
- has son in the city
- Wife to visit, is ++ worried that Wilbur will not recover
- Close family ties
- Retired CN engineer
- Daily visitors (wife, son and neice)
Psychological History
- Attempting to pull out NG/EVD
- Restrained
- Loves to talk according to wife
Course in Hospital
Admission ward:
- Emerg SCH
Ward Transfers:
- SPH for CT then to RUH for neurosurg to ICU then Feb 5th to 6300
Results of Important Diagnostics Tests:
Jan 30th
- CT: blood in L lateral ventricle expanding into 3rd R ventricle and temporal
Feb 6th:
- CXR fluid to bases of lungs
Feb10th
- WBC 13.46 (H); neutrophil 10.58 (H); lymphocyte 1.3 (L); monocyte 1.3 (H)
K 3.1 (L), Cl 93 (L) CO2(total) 36 (H) urea 8.3 (H) - CSF (appearance cloudy red fluid)
- CSF differential neutrophil 66%, lymphocytes 6% macrophages 28%
- micro: ventricular fluid moderate polymorphnuclear WBC; sputum abundant polymorphnuclear WBC, moderate squamous epithelial cells, few gram pos bacilli
general 1.B increase sensitive CRP 30.2 (H) (systemic inflammation)
prealbumin 148 (L)
Surgical Events:
- Placement of EVD January 30
- Tracheotomy put in February 4th
Response to treatment:
- GCS: Ranging from 9-11/15
- R paraesis
- edema to extremities
- creamy yellow secretions in tracheotomy
Complications:
- Query ileius and meningitis
- Risk for aspiration pneumonia
- Hematuria
Adverse events:
- Seizures (partial L arm and face)
Discharge planning:
- Working toward maintaining patient stablility and begin rehabilitation. Patient likely unable to return home, consult with CPASS and discuss with family.
Medical Plan of Care:
Focus of Care: Diagnositic and Rahabilitative
- Consults: PT/OT, Urology, General Surg, SLP, NSS, Infectious diseases
- Tests: CBC, lytes 6, TENS bloodwork. daily coags, EEG, ECG, renal U/S CXR, CT, sputum c&s, U/A CSF, MRSA swab (Monitor Diagnostics)
- Medication management
- Pain management
- Nutritional status
Nursing Plan of Care:
Nursing Focus: Rehabilitative and Supportive
- Neurological focus
- Medication management
- Monitor diagnostics
- Pain management
- Supportive care
- Patient and family teaching
- Identify family supports (Possible SW consult)
- Monitor fluid balance
Degree of Stability:
- Stable - Vital Signs: 37.2-66-16 125/70 99% trach hood 35% O2 humidified
Medication Names, Anticipated Effects and Common Side Effects:
levothyroxine 0.1 mg via PO OD 0800
- Class: thyroid hormone
- Receiving for hypothyroidism prior to hospitalization which will maintain secretion of T3 hormone.
- Nervousness insomnia, tremor, tachycardia, palpitations, angina, dysrrhythmias, nausea, diarrhea, cramps, weight loss, fever.
amlodipine besylate (Norvasc) 15 mg PO OD 0800
- Class: antianginal, antihypertensive, calcium channel blocker.
- Treatment of patient hypertension by producing relaxation of vascular smooth muscle and dilating coronary vascular arteries also increasing myocardial oxygen delivery.
- Edema, headache, dysrrhythmias, anxiety, nausea, vomiting, diarrhea, nocturia, flushing, weight gain.
atenolol 100 mg PO/NG OD 0800
- Class: beta blocker, antihypertensive, antianginal
- Maintenance of blood pressure and atrial fibrillation by producing negative inotropic and chronotropic effect.
- fatigue, dizziness, hypotension, mental changes, cold extremities, postural hypotension, second and third degree heard block, nausea, diarrhea.
Insulin Humulin R 100 units/ml SC by sliding scale 1000
- Class: antidiabetic, pancreatic hormone
- Control blood glucose levels d/t clients inability to maintain own in relation to altered health status and stress.
- Hypoglycemia, dry mouth, lipodystrophy, blurred vision, flushing, rash, rebound hyperglycemia.
- Class: antihypertensive, ACE inhibitor
Maintenance of blood pressure by inhibiting development of potent vasoconstrictor angiotensin 2. - Hypotension, hyperkalemia, insomnia, dizziness, tinnitus, dry cough.
- Class: H2 histamine receptor antagonist.
- Treatment of gastric ulcer by inhibiting histamine at H2 receptor sites thus decreasing gastric acid secretion.
- headache, confusion, tachycardia, bradycardia, constipation, abdominal pain, nausea, vomiting, blurry vision.
**known to increase the toxicity of anticoagulants, client is on Warfarin.
- Class: Loop diuretic
- Maintenance of blood pressure through inhibiting reabsorption of NA and Cl thus decreasing vascular fluid volume and excreting it through the kidneys.
- polyuria, hypocalemia, hyponatremia, hypokalemia, hypomagnesemia, hyperuricemia, hyperglycemia, nausea, rash, pruritus, hypochloremia
- Class: thiazide diuretic, antihypertensive
- Maintenance of blood pressure by increasing excretion of water, Na, K, and Cl. This decreases vascular fluid volume by excreting it through the kidneys.
- orthostatic hypotension, polyuria, hypokalemia, dizziness, hyponatremia, hypochloremia, nausea, vomiting, weakness, anorexia, hyperglycemia.
- Class: anticonvulsant, antidysrrhythmia
- Seizure prevention used as a prophylactic after neurosurgery. Works by altering ion transport at the motor cortex to inhibit the spread of seizure activity.
- ataxia, decreased coordination, mental confusion, slurred speech, diplopia, nystagmus, hyperplasia, N&V.
- Class: antihypertensive, direct acting peripheral vasodilator
- Maintenance of blood pressure through decreasing vascular resistance through vasodilatation.
- headache, angina pectoris, palpitations, tachycardia, N&V diarrhea, anorexia, lupus-like syndrome, headache, tremors, dizziness, anxiety.
- Class: anti-infective
- Prophylaxis after surgical procedure to prevent development of infection. Patient at particular risk d/t EVD. Inhibits bacterial cell wall synthesis causing cell death.
Query pneumonia - fever, pain, hypotension, ototoxicity, tinnitus, leukopenia, neutropenia, superinfection, increase BUN, Creatinine and albumin.
- Class: Broad-spectrum antibiotic, 3rd generation cephalosporin
- Prophylaxis after surgical procedure to prevent development of infection. Patient at particular risk d/t EVD. Causes osmotic instability leading to cell death.
Query pneumonia - phlebitis, thrombophlebitis, macropapular and erythematous rashes, urticaria, pain, sterile abcessess, temperature elevation,
clonidine 0.1 mg PO Q1H PRN for SBP> 150
- Class: antihypertensive
- Alleviate hypertension by decreasing BP, pulse rate, and cardiac output.
- drowsiness, dizziness, sedation, constipation, dry mouth, pruritis, fatigue, orthostatic hypotension, palpitations, CHF, nausea, vomiting, rash, depression.
acetaminophen/codeine 325-30 1-2 tab PO Q4H ORN
- Class: opiate analgesic, antitussive, antipyretic.
- Treatment of moderate pain by depressing pain impulse transmission and improving client comfort.
- constipation, headache, drowsiness, sedation, seizures, circulatory collapse, bradycardia, lethargy, nausea, vomiting, anorexia, urinary retention, flushing.
- Class: opioid analgesic
- Treatment of moderate to severe pain by depressing pain impulse transmission and improving client comfort.
- constipation N&V, euphoria, clouded sensorium, bradycardia, shock, cardiac arrest, respiratory depression, respiratory arrest, apnea, palpitations, urinary retention, constipation.
dimenhydrinate 25-50 mg IV/PO Q4H PRN
- Class: antiemetic, antihistamine, anticholinergic
- Treatment of motion sickness, nausea, vomiting and vertigo. Effects result in decreased vestibular stimulation and blockade of chemoreceptor trigger zone.
- Drowsiness, hypotension, dry mouth, constipation, nasal congestion, restlessness, insomnia, hypertension, palpitations.
- Class: nonopioid analgesic, antipyretic
- Treatment of mild by blocking pain impulses peripherally. Treatment of fever through inhibition of prostaglandins in CNS.
- Hepatotoxicity, hepatic seizures, renal failure, anemia, stimulation, drowsiness, nausea, vomiting, abdominal pain, rash.
- Class: laxative, saline
- Treatment of constipation by increasing peristalsis and water retention.
- Dysrhythmias, cardiac arrest, hypotension, nausea, cramps, diarrhea, electrolyte and fluid imbalance, widening QRS complex.
- Class: laxative, stimulant
- Short-term treatment of constipation by acting directly on the intestine and increasing motor activity.
- Muscle weakness, nausea, vomiting, anorexia, cramps, rectal bleeding, tetany, hypokalemia, electrolyte and fluid imbalance.
- Class: laxative-stimulant
- Treatment of acute constipation by stimulating peristalsis and softening feces by increasing water and electrolytes in the large intestine.
- Nausea, vomiting, anorexia, cramps, diarrhea, flatulence, hypocalcemia, tetany.
Docusate sodium syrup 100 mg/25 mL 100-200 mg PO BID PRN
- Class: laxative, emollient, stool softener.
- Treatment of constipation by increasing water, fat penetration in intestine thus allowing for easier passage of stool.
- Bitter taste, throat irritation, nausea, anorexia, cramps, diarrhea, rash.
