Student name __
C.G. is a 67yr old Caucasian female admitted
3/6/06 through the ER.
Dx of vomiting, Hyponatremia and prerenal azotemia.
Medical hx of CAD, MI x5, DM type 2,
PVD, HTN and cholecystectomy.
Allergic to codeine, full code status, IV (L) hand NS 75ml/hr, full liquid diet, BRP w/assist, I&O q shift, LBM 3/4/06, nurse aide reported BP of 63/45
Primary nurse and I both took a manual BP of 118/64.
1800 ADA diet, saline lock (L) arm, night shift nurse withheld Toprol b/c BP was 107/48, LBM 3/8/06 diarrhea in
History of present illness:
C.G. presented to the ER with 1-week malaise, general abdominal pain, nausea and vomiting.
ER lab reported leukocytosis.
IV zofran was
administered, but did not control the nausea and vomiting.
Pt was admitted.
include assessment, labs and dx
medications and teaching
Sensory function – WNL
Motor function – WNL
No seizure or tremors
No assessment changes 2
Continue to assess and monitor q shift and prn for mental
status changes or other neuro changes.
Hx of CAD, PVD, HTN, MI x5
Apical pulse: 78,
Radial and dorsalis pedal pulses: weak, regular
(L) foot: anterior localized edema, 1+ nonpitting
BUN 24mg/dl (normal 10-20mg/dl) indicates hypovolemia,
dehydration, CHF, MI, renal disease
RBC 3.20 (normal female: 4.2-5.4) indicates anemia, dietary
deficiency and renal failure
Hgb 9.5g/dl (normal female 12-16g/dl) indicates anemia,
dietary deficiency, kidney disease
Hct 27.4% (normal female 37-47%) indicates anemia, dietary
No other assessment changes 2
Coronary artery disease – atherosclerosis is major
cause of CAD, the vessel lumen narrows and
restricts blood flow and inadequate oxygenation of
myocardial tissues occur – this can cause decreased
Myocardial infarction – myocardial tissue is severely
deprived of O2 and ischemia develops which can
lead to necrosis of the tissues.
PVD – arterial occlusion deprives the lower
extremities of O2 and nutrients – this can cause
decreased pedal pulses.
Encourage pt to maintain a minimum fluid intake of
1500ml/day (7a-3p 600ml / 3p-11p 600ml / 11p-7a
300ml) Consult MD if pt is on diuretics and experiences
significant weight loss (>2lb/day or 5lb/wk), weigh pt
Place pt in semi- to high Fowlers position to
decrease cardiac workload.
Instruct pt to avoid straining