NEED A PERFECT PAPER? PLACE YOUR FIRST ORDER AND SAVE 15% USING COUPON:

solved

Question
Answered step-by-step
Asked by tessy1703
Patient Initials Age  Weight & Height Gender Service  Consults  Allergies 
C. Carter 49

210lb.

5’9

M Gastroenterology    ibuprofen, lisinopril, throdrenaline, theophyiline, tomato’s. Reaction: hives/rash

 

Patient Health History

COPD, asthma, alcohol abuse (8-12 beers a day), hypertension, tobacco abuse, acute bronchitis, cholecystectomy, 

Pt presented to the Integris-Yukon ED with 9/10 chest pain and was discharged to home with dx of asthma exacerbation and UTI and prescribed prednisone and ciprofloxacin. Pt came back to Integris-Yukon ED two days later (9/12) with complaints of nausea, vomiting and abdominal pain. A non-infused CT of the abdomen showed possible pancreatitis. The second CT showed some short bowel thickening and possible right colon thickening. He was then admitted for acute pancreatitis.  

 

MAR for C. Carter

Medication Classification Dose/Route/Time  Scheduled Times: Indications/Use
Dilaudid  Opioid algentic  0.5mg/oral/ q3 hrs PRN PRN Pain medication 
labetol antihypertensive 5mg/IV/q 6hrs 0900, 1500, 2100, 0300  Decrease BP
reglan prokinetic 10mg/IV/q 6hrs 0900, 1500, 2100, 0300 Treats nausea and vomiting 
Dextrose 5% IV solution glucose 

40ml/IV/PRN

 

PRN

*To be given for FSBS <50 mg/dL Reduces concentration of glucose in blood Novolog antidiabetic 100units/mL/IV/q 4hrs *175-210= 1unit 211-245=2 units 246-300=3 units 301-345=4units >400 notify MD

Treats high blood sugar
Fluticasone-vilanterol Glucocorticoid  1 puff/resp/daily 0900 Treats COPD
Pepcid H2-histamine receptor antagonist 20mg/IVBID 0900, 2100  Treatment of ulcers
Lovenox Anticoagulant  40mg/subcut/bedtime 2100 For prevention of DVT
Flagyl Antiinfective  500mg/IVPB/q 8 hrs 1200, 2000, 0400 Prevent infection
Duoneb Anticholinergic 3mL/resp/q 6hrs PRN PRN To treat & prevent wheezing or shortness of breath 
Adult central TPN Solution Daily nutrition  Continuous @ 100ml/hr 1800 start new bag Nutrition
Ciprofloxacin in dextrose 5% Antibiotic  400mg/IV/q 12 hrs (BID) 0900, 2100 Prevention of infection
Lomotil  Antidiarrheal  2 tab oral q 6 hrs 0900, 1500, 2100, 0300 Decrease diarrhea 

 

System Assessment 
Neuro/Sensory Awake, Alert and oriented x4; states no dizziness on standing.   
Cardiovascular

BP:139/88 Pulse:78

normal heart rate and regular rhythm with no evidence of murmurs 

cap refill: 2+ pedal pulse:2+ no edema, no cyanosis or clubbing 

Respiratory

RR: 18 O2 sat:93% at room air 

no shortness of breath, no wheezing or coughing, no secretions; 

clear lung sounds bilaterally and in all lobes; even & unlabored respirations 

GI

NPO

a gtube in place to left upper quadrant; 

no nausea or vomiting at this time

persistent diarrhea; (+) guiac occult testing

liquid stool x4 this shift 

abdomen distended and firm, tender on palpation (most tender in upper R Q)

Bowel sounds hypo-active in all quadrants

Intake: PO-0  IV: 1250mL

GU

foley catheter intact; Output: 1188 mL

urine: yellow, clear, no sediment

No flank tenderness to palpation;

Skin

Temp:98.9 F 

Skin is warm, pink and dry with poor turgor; 

with no rashes, jaundice noted

no evidence of breakdown over bony prominences

Braden scale:20, 

picc line in R arm with IVF infusing.  No redness or swelling at insertion site.

Musculoskeletal

assist when ambulating—pt states “I feel so weak.”   

Normal ROM in all extremities, grips/strength equal bilaterally

 

Endocrine

FSBS  0800:221

1000: 188          1200: 201

1400:  196           1600:  155

No history of thyroid disorders

Reproductive No complaints at this time.  Catheter Care performed no skin breakdown noted.
Pain

c/o severe pain in lower abdomen 8/10 on pain scale.

Pain is described as stabbing and constant

Pt reports pain as 5/10 after IV pain meds

Psychosocial Pt states that he has good supportive wife, 3 children, and a job he enjoys
Labs/Diagnostics

WBC: 18,000   RBC: 4.9 hemoglobin: 14.3 hematocrit: 41.6

Amylase:  124    Lipase:   158

Triglycerides: 277    BUN: 8.0    Creatinine:  1.0

Sodium: 142    Potassium: 4.0  Magnesium: 2.0

Chloride: 100    Phosphate: 3.0      AST: 31    ALT:  36

 

Miscellaneous  
Based on Mr. Carter’s clinical manifestations (assessment) and lab results, the health care provider suspects the patient has Pancreatitis and possibly an inflammatory bowel disease. What information from the chart supports the diagnosis? 
Pancreatitis :

 

 

Inflammatory bowel disease:

 

 The patient has a capsule endoscopy done (swallows a camera pill) as a diagnostic test. Results show areas of inflammation in the mucosal layer of the colon only. 
These findings are characteristic of what specific inflammatory bowel disease?

 

How are each of the inflammatory bowel diseases differentiated?

 

 What clinical data from this chart is RELEVANT and needs to be trended because it is clinically significant? 

*in other words—what labs, vitals, symptoms should be watched closely since they indicate a potential complication?

 

 

What are the most likely complications to anticipate based on the patient’s diagnoses and clinical manifestations (assessment)?

 

 

 

 

 

What interventions would prevent these complications from happening?
 

 

 

 

 

 

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 1118

Solution:

15% off for this assignment.

Our Prices Start at $11.99. As Our First Client, Use Coupon Code GET15 to claim 15% Discount This Month!!

Why US?

100% Confidentiality

Information about customers is confidential and never disclosed to third parties.

Timely Delivery

No missed deadlines – 97% of assignments are completed in time.

Original Writing

We complete all papers from scratch. You can get a plagiarism report.

Money Back

If you are convinced that our writer has not followed your requirements, feel free to ask for a refund.