Name: Amanda Simpson

Situation Name: R.P DOB: 10-17-1946 Gender: MALE FEMALE Admit date: 3/8/2013 at 0145 Admit DX: Acute Respiratory Failure and Pneumonia

Date: March 8/9, 2013

Background Age: 66 years old Room # CODE STATUS: FULL DNR Allergy: Penicillin Past Medical Hx: Double lung transplant in 2004 due to his COPD, Coronary Artery Disease, Stent placed in 2003, Ankle Fracture, Single Vessel disease, Hx of atrial fibrillation, diabetes mellitus diagnosed in 2008, large squamous cell tumor resection of his chest with skin graft placed, HTN, chronic kidney disease, history of rejection and chronic host versus graft, chronic kidney disease

Surgical Procedures: On Tuesday March 6, 2013 patient had large squamous cell carcinoma tumor of chest wall resection and skin graft was placed

Assessment
Current VS: VS Q Continuous BP: 159/122 Pulse: 130bpm Resp: 22RR controlled by Vent Temp: 36 degrees Celsius Sao2: 100% DRIPS: 1. NS 0.9% 1000mL @ 40mL/hr. 2.D5W 100mL+Midazolam 50mg @ 6mL/hr. for SEDATION 3.D5W Baxter (DEPH) 100mL+Fentanyl Citrate 1000mcg @ 10mL/hr. for PAIN 4.Heparin 12u/kg=1000u/hr. = 30mL hr. Neuro: Patient under sedation due to being on ventilator. The patient was briefly brought out of sedation and the patient responds to commands but severely agitated, sedation was restarted. Pt. unable to communicate and while awake was able to move all extremities. PERRLA 3mm. LUNGS: Diminished breath sounds bilaterally at the bases. No wheezing or crackles

Neurovascular: PPP, edema +1 pitting, LE cool and dry, LE color blue-purple, capillary refill < 4 seconds, pt. has general edema and appears puffy, skin turgor brisk, UE warm and dry, UE capillary refill < 3 seconds.

Respiratory: NC/NRB/Bi-Pap/Vent Breathing TX: PRN Q6H Albuterol Sulfate 0.5mL nebulized Vent Setting: CMV FiO2: 50 TV: 550 Rate: 22 Peep: 7 Patient is not breathing above Ventilator

Cardiac: rhythm : patient was in NSR then converted to A-Fib with RVR

GI: Abdomen: soft, symmetrical, no distension noted.

Elimination: I & O Q 1H Foley: placed 3/8/13 Last BM: UNKNKOWN

Name: Amanda Simpson

Monitor: Continuous DAILY WEIGHT: 102.4kg

Date: March 8/9, 2013

Flatus: None noted while at clinical Incontinent: Bowel/Bladder

Muscle/Skeletal: Patient when awake was able to move all extremities on command, no spontaneous movement while sedated TX: PT/OT/ST- None scheduled at this time Pain: Scale: Wong-Baker Faces Location: N/A Rating: 0 Last Pain Meds: Patient on continuous Fentanyl drip at 10mL/hr. Psychosocial: Married; lives with wife. Wife at Bedside Family: Wife at bedside

NG/OG/feeding tube: NG tube, right nare @ 58cm. receiving Nepro at 40mL/hr. Bowel sounds: hypoactive in all quadrants. Skin: W/D/I: Upper extremities Diaphoretic: No Cold/Clammy: Lower extremities cold and dry Dressings: Mid upper chest C/D/I Abdominal dressing C/D/I At risk for Ulcers: YES- patient on air mattress Braden Score: 14 IV: Right antecubital 20 gaugepatent. Central Line Site: Right Int Jugular Quad lumen

Activity: Complete bed rest Turn: Turn Q2H Falls Risk: YES Score: 14

Nutrition: NPO feeding via NG tube Nepro at 40mL/hr. Precautions: Patient is not in isolation

Devices: SCDS, continuous cardiac monitoring at bedside

Diabetes: BS Checks Q6H

Skin Care/Wound Care: Drains: No Drains Bed bath completed Q8H or PRN, dressings C/D/I, instructed not to remove or change dressings. Routine checks were done to check overall skin integrity Recommendations Special treatments/Needs: Previous Nurse had stated that the patient was stable and that there were plans to have the patient flown to an out of state hospital, where he received his lung transplant. Everything was prepared for the patients transport. Abnormal Labs: Albumin 2.9 Low: Arterial Bicarb 17.8 Low: PCO 31 Low: pH 7.29 Low: pO2 87.3 High: BUN 54 high: Calcium 7.9 Low: CO2 18 Low: CPK: 315 High: Creatinine 2.80 High: HGB 8.2 Low: HCT 25.7 Low: PT 15.8 High: PTT 93.4 High: INR 1.27 High: Ionized Calcium 5.14: Lactic Acid 5.5: BNP: 2547.5: WBC 15.33 high: Medications: Docusate Sodium 100mg BID Heparin 5000 units in 1 mL Injection Sub cut Q8H for DVT prophylaxis Solu-Cortef 100mg IV Q8H Apidra 2-7 units sub cut three times daily and at bedtime Meropenem 500mg = 100mL IV Q12H Metoprolol tartrate 50mg tablet via NG tube BID

Name: Amanda Simpson

Date: March 8/9, 2013

Micafungin 100mg=100ml IV Q24H Mycophenolate Mofetil HCL 500mg=250mL IV Q12H Pantoprazole IV 40mg=101mL Q24H protocol Tacrolimus 0.5mg capsule via NG tube Q12H Warfarin 2mg tablet via NG tube every evening List Significant Data: Patient converted to NSR in the 70-80bpm range to atrial fibrillation with RVR, the physician was called and the patient was started on an IV drip of Heparin 12u/kg= 100units per hour = 30mL/hour. The client currently has bilateral soft wrist restraints. Plan is to send the patient out of state; we are awaiting a bed at the receiving hospital. The patient is immunosuppressed and is currently septic. The patient is fluid volume overloaded. The patients lab data has improved since his admission early yesterday morning. An attempt was made during the day to wean the patient of the ventilator but was unsuccessful as the patient could not maintain oxygen saturation greater than 92%. My interpretation of the ABGs indicating partially compensated metabolic acidosis. Lab/Diagnostics: Chest X-ray on 3/8/13 indicated cardiomegaly with evidence of fluid overload and small bilateral pleural effusions. Right mid lung edema or superimposed infection Vital Sign Ranges for last 24 hours: BP: 123/67- 159/22 HR: 69-150bpm RR: 22 VENT SET Temp: 36-36.4 degrees CO/CI/PAP/PAWP: Not Applicable Pulse Ox: 100% BS Ranges: 181-213 Admit Weight: 100Kg Current Wt.: 102.4K Recommendations for the next nurse: The patient is currently on a Heparin drip that had to be started in the middle of the night because he converted to atrial fibrillation with RVR, the patient has not converted back to NSR as of yet; The protocol is in the chart. We are still waiting for the patient to be life-flighted to an out of state hospital and everything is ready in the chart. We have been watching his rhythm closely since the conversion and suggest you do the same. Labs have been ordered for this morning at 0800 including CBC, CMP, Mag, Phos, ABGs and a PTT. The patient should also have the results from this mornings CXR soon. Other than the conversion the night went smoothly, the physician stated he would be back this morning to evaluate how the Heparin is working. The patient has an IJ central line with quad lumens; all of the lines are patent. Pain Scale: 0- Wong Baker faces Scale Pt. has fentanyl drip to control pain 24 hour I&O: Input: 2603mL Output: 1020mL Net: 1583mL 24 Drain Output: Not Applicable Diet %: Breakfast: NPO Lunch: NPO Dinner: NPO TPN Intake: 480mL last 12hours Residuals: __10-20mL