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593883
Doris
Description
Case Study Paper for NURS 4022
Mind Map by
swimsalot90
, updated more than 1 year ago
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Created by
swimsalot90
over 10 years ago
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Resource summary
Doris
Cardiac Event
Vitals: 60/40, 37.2-150-30, Sat 92% on 3L
Sudden complaint of chest pain, weakness and shortness of breath
Doctor notified of findings and arrived to assess patient
Moved to trauma room
Sedated with Versed
Electrical Cardioversion at 200J
Reverted to Normal Sinus Rhythm and recovering
Vitals: 90/50, HR 100, RR 30 Sat 100% on 8L
Bolus of 750cc NS
14F Foley Catheter inserted
Put on telemetry
STAT Labs
ECG showed new onset uncontrolled A-fib
Troponin 0.6 - Positive, indicator for cardiac damage
CBC, Chemistry: no significant changes
Anxiety
Dementia with Paranoia
Blames Medications for unrelated symptoms
Poor Compliance
Doesn't trust staff
Health History
Dislipidemia
Anemia with previous rectal bleed
Renal Insufficiency
Rheumatoid Arthritis
Cardiac History
Previous MI
Ex-smoker 3 years ago
Severe Aortic Stenosis
3/6 Ejection Fraction
Hypertension
Medications
No known allergies
C.difficile orders: Vancomycin PO, Metronidasole IV, IV Fluids
Furosemide, Ramapril
Atorvstatin, Ezetrol
Hydroxychloroquine
Ferrous Gluconate
Quetiapine, Galantamine
Main Complaint: abdominal pain, diarrhea over 4 months, genaralized weakness
Initial Assessment
Vitals: 102/52, 36.8-80-20, Sat 92% on 3L
Lungs clear, occasional cough,regular heart rhythm
Abdominal pain, bowel sounds present, abdomen distended
Not oriented to place or day, lethargic, confused
90 year old female, lives alone, DNR
Fall Risk
Rheumatoid Arthritis stiffness
Frequent diarrhea
Confusion
Polypharmacy
Weakness
Strain on Body
Diagnosis: C. Difficile colitis
Initial Labs
WBC 24.7 - Elevated, sign of infection
Lactate 0.9 - Normal, rule out sepsis
Liver function tests normal
Chemistry: Na 132, K 4.1, Normal
Urea 23, Creatinine 199, Expected high
Hgb 107 - Result good considering anemia, also rules out rectal bleed
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