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ClinicalsMNDee, Integumentary - trach site in advanced stage of healing from prior self-extubation - PICC above left AC - trach sutured in place after third insertion - saline lock in right AC - bilateral lower extremities show signs of patchy, brown discoloration - trace edema of lower extremities bilaterally - dry, slightly reddened skin in coccyx area 5 Psychiatric - hx of schizophrenia - Geodon - has hx of med non-compliance and unintentional self-harm behavior, Cardiovascular - depressed ST segment - cor pulmonale - bedside chest AP showed cardiomegaly w/possible left effusion - coronary artery disease - ventricular systolic dysfunction - hx of sleep apnea - paroxysmal atrial flutter 3 Respiratory - on ventilator - admitting dx of hypoxemia and respiratory failure - lung sounds clear and slightly diminished - O2 sat ranged from 87% - 90% - COPD - pulmonary htn - trach collar during day & vent during night - pneumonia - 5 cm focal abnormality in right lung base, Cardiovascular - depressed ST segment - cor pulmonale - bedside chest AP showed cardiomegaly w/possible left effusion - coronary artery disease - ventricular systolic dysfunction - hx of sleep apnea - paroxysmal atrial flutter 8 Nutritional/Metabolic - NG to low intermittent suction - TPN - morbidly obese (314 lbs) - Accuchecks q6h - hypoglycemia protocol - hyperactive bowel sounds - green drainage from NG - recovering from ileus - malnutrition - type II diabetes, Integumentary - trach site in advanced stage of healing from prior self-extubation - PICC above left AC - trach sutured in place after third insertion - saline lock in right AC - bilateral lower extremities show signs of patchy, brown discoloration - trace edema of lower extremities bilaterally - dry, slightly reddened skin in coccyx area 4 Respiratory - on ventilator - admitting dx of hypoxemia and respiratory failure - lung sounds clear and slightly diminished - O2 sat ranged from 87% - 90% - COPD - pulmonary htn - trach collar during day & vent during night - pneumonia - 5 cm focal abnormality in right lung base, Health Management - significant tobacco use - poorly managed psychiatric illness - hx of alcohol use 6 Psychiatric - hx of schizophrenia - Geodon - has hx of med non-compliance and unintentional self-harm behavior, Nutritional/Metabolic - NG to low intermittent suction - TPN - morbidly obese (314 lbs) - Accuchecks q6h - hypoglycemia protocol - hyperactive bowel sounds - green drainage from NG - recovering from ileus - malnutrition - type II diabetes 2 Cardiovascular - depressed ST segment - cor pulmonale - bedside chest AP showed cardiomegaly w/possible left effusion - coronary artery disease - ventricular systolic dysfunction - hx of sleep apnea - paroxysmal atrial flutter, Labs - Glucose ↑ 171 - Sodium ↑ 148 - BUN ↑ 52 - WBC ↑ 14.5 - RDW ↑ 16.8 - Plt ↓ 126 - Prealbumin ↑ 563 - Albumin ↓ 2.8 - MCH ↓ 26.6 - MCHC ↓ 29.5 - Triglycerides ↑ 665 - Digoxin ↓ 7 - Phos ↑ 5.2 1 Nutritional/Metabolic - NG to low intermittent suction - TPN - morbidly obese (314 lbs) - Accuchecks q6h - hypoglycemia protocol - hyperactive bowel sounds - green drainage from NG - recovering from ileus - malnutrition - type II diabetes, Health Management - significant tobacco use - poorly managed psychiatric illness - hx of alcohol use 7 Cardiovascular - depressed ST segment - cor pulmonale - bedside chest AP showed cardiomegaly w/possible left effusion - coronary artery disease - ventricular systolic dysfunction - hx of sleep apnea - paroxysmal atrial flutter