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Critical Care Paper

1773 words - 8 pages

“Critical Care Paper”
Critical Care Nursing

Background Information
L.G. is a 75 year old man that presented to Fairfax ED with complaints of SOB and lower extremity edema. L.G. is married with two adult children. He lives with his wife in a colonial style home in Great Falls, Virginia. L.G. hobbies include playing golf with his friends at his Country Club, playing bridge, and gardening with his wife on the weekends.
L.G is a retired Navy Captain with 40 years of active duty service. During his years as an active duty sailor he worked as the “Air Boss”. The “Air Boss” is in charge of every plane and sailor involved on the flight deck of an aircraft carrier. His job was very stressful ...view middle of the document...

Current Medical Admission Data
As previously mentioned, L.G. presented to the Fairfax ED with complaints of SOB and lower extremity edema. L.G. was admitted to the Telemetry North unit for further assessment and evaluation. The patients admitting diagnosis is CHF exacerbation.
Vital Signs | |
BP | 142/64 |
Pulse | 62 |
Temp | 96.4 F |
Resp | 18 |
SpO2 | 96% |
| |
Assessment
Overall appearance: elderly male, well-nourished and dressed appropriately, awake and alert.
Respiratory: Clear to auscultation in RUL, RLL, LUL, LLL, breathing regular and unlabored, no signs of acute respiratory distress.
Cardiovascular: Normal rate, regular rhythm, S1, S2 murmur heard throughout, pacemaker left chest.
RATIONALE: Murmurs reflect valvular stenosis.
Abdomen: Soft, nontender, nondistended, no masses, and audible bowel sounds.
Urinary: Voids amber colored urine in a bedside urinal
Neurological: Alert, oriented, normal speech and rate, sensory functions intact
Musculoskeletal: Full range of motion in all extremities
Extremities: Left femoral and bilateral dorsalis pedis and posterior tibial pulses audible by Doppler
RATIONALE: Decreased cardiac output reflects the diminished pulses.
Integumentary: Normal for ethnicity

Laboratory Results
| 07/25/14 | 07/26/14 | 07/27/14 | 07/28/14 |
WBC | | 6.97 | 6.90 | 7.55 |
RBC | | 3.61* | 3.88* | 3.83* |
HGB | | 9.3* | 10.0* | 9.8* |
HCT | | 30.6* | 32.6* | 32.3* |
PLT | | 148 | 148 | 159 |
NA | | 135* | 138 | 138 |
K | | 4.1 | 4.5 | 4.8 |
CL | | 102 | 105 | 109* |
CO2 | | 23 | 24 | 22 |
BUN | | 62.0* | 52.0* | 42.0* |
CREAT | | 2.3* | 1.8* | 1.6* |
GLU | | 142 | 100 | 93 |
CA | | 8.9 | 9.1 | 8.9 |
BILIT | 0.6 | | | |
ALKPHOS | 75 | | | |
AST | 23 | | | |
ALT | 6.7 | | | |
PROT | 6.7 | | | |
ALB | 3.3* | | | |
PT | 19.5* | | | |
INR | 1.7* | | | |
PTT | 36 | | | |

“*” denotes abnormal laboratory result
RATIONALES FOR ABNORMAL LABS
RBC: Decreased due to anemia
HGB: Decreased due to anemia
HCT: Decreased due to anemia
NA: Decreased due to diuresis – loop diuretics
CL: Decreased due to CHF
BUN: Elevated due to renal insufficiency and diuretics
CREAT: Elevated due to renal insufficiency and diuretics
GLU: Elevated due to Type II DM
ALB: Elevated due to renal insufficiency
PT: Decreased due to anticoagulants
INR: Decreased due to anticoagulants (Hogan, Dentlinger, & Ramdin, 2014)

DIAGNOSTIC STUDIES
Renal Ultrasound with Doppler:
FINDINGS:
Right kidney is atrophic, echogenic and demonstrates cortical thinning. Right kidney measures 6.8 cm in length. The left kidney is normal in size and demonstrated normal cortical thickness and echogenicity. The left kidney measures 13.0 cm in length. There is no hydronephrosis. No perinephric collection is seen.
IMPRESSION:
1. Elevated velocities in the origin and proximal left renal artery, suggestive of renal artery stenosis. Follow-up MRA or...

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