Daily Goal The patient will verbalize 3 risks and 3 benefits of adhering to the

Daily goal the patient will verbalize 3 risks and 3

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progression of disease symptoms. Daily Goal : The patient will verbalize 3 risks and 3 benefits of adhering to the medication regime before discharge. Patient Demographics: 55 y.o. male presented to the ER with c/o chest pain and SOB., was then transferred to the ICU cardiac unit Medical Diagnosis: Atrial Flutter with Rapid Ventricular Response Labs & Diagnostics 8/29: Gallbladder Ultrasound: HX-Transaminitis. Enlarged fatty liver. Positive Murphy’s sign with diffuse pain and tenderness. 8/29: AST: 171 (3-44 u/L) ALT: 89 (0-40 u/L) Assessment/History: Pt has a history of A-fib, as well as past diagnosis of uncontrolled diabetes, hypertension, Hep. C +, and previous knee surgery. Patient has clear lung sounds bilaterally, and symmetrical chest expansion. Patient is alert and oriented x4, as well as up ad lib. Pt has history of non-compliance to his medication regimen, as well as leaving AMA. Pt rated his pain at a 6/10 upon beginning of assessment, specifically in his chest, which was only relieved through medication (Tylenol 3). Skin is warm and intact bilaterally on upper and lower extremities. Bowel sounds were present on all 4 quadrants, normoactive, with the last BM being on 8/28.
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  • Spring '17
  • collins
  • Nursing, Health care provider, atria. Pt

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