4670896
Descrição
Mapa Mental por kbennett2041, atualizado more than 1 year ago
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Criado por kbennett2041
quase 9 anos atrás
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|
D.W.
57 M
- 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 repair. T Tube
placed for 6-8 weeks
- Intraoperative hemorrage
- 2 Units PRBC
- 2 Units PRBC
- Lap chole converted to open
surgery
- JP tube placed. To remain until
cholangiogram passed
- 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
- Likely nonfunctional. No
change from baseline with
removal
- Head CT
- Some gallstones retained
- ERCP in 6 weeks for retained gallstones
- ERCP in 6 weeks for retained gallstones
- Acute Pain
- Dilaudid
- Dilaudid
- Common bile duct tear
- 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)
- Complex cholecystectomy
- Severe sepsis
- Antibiotics/Fluid resusitation
- Bladder thickening:
concern for cystitis
- UA/UC
- Pancreatitis, cholecystitis
- Continue
antibiotics
- Followup Culltures
- Followup Culltures
- Continue
antibiotics
- Pancreatitis, cholecystitis
- UA/UC
- Ineffective
peripheral tissue
perfusion
- Delayed surgical
healing
- Antibiotics/Fluid resusitation
- 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
- Begin Zozyn
- Atelectasis
- Aspiration Pneumonia
- Chest X Ray
- Rhonchi
- 2/26 aspiration event
- Failed swallow test
- Swelling in the R
arm
- Venous doppler
ordered
- Venous doppler
ordered
- TPN day 3
- Double lumen PICC inserted R cm
- Vomiting
- Hypoxic event, possible
aspiration, SpO2 87%
- CCU transfer
- NRB 100
- Weaned to BiPap
- Weaned to BiPap
- CCU transfer
- Risk for deficient fluid volume
- Hypoxic event, possible
aspiration, SpO2 87%
- Cholecystitis,
gallstones, pancreatitis
- Admitting Vitals:
T: 37.1 HR: 49 RR:
17 BP: 99/62
SpO2: 97%
- Bradycardia
- NSR, low volt chronic EKG
- Hold Aspirin
- Hold Aspirin
- NSR, low volt chronic EKG
- Bradycardia
- 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
- Ineffective Health Maintenence
- Adult
family
home for
15 years.
- DIscharge to Adult
Family Home
- DIscharge to Adult
Family Home
- Divorced. One adult son 24. Ex-wife POA
- Nonverbal at
baseline.
Cognitive deficit.
- KEY
- H&P; presenting s/s
- In hospital occurrence or change
- Action taken
- Nursing Diagnosis
- Planning
- H&P; presenting s/s
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