Running head: CARE OF 1
BSC NURSIN 108
Critical care RUA
Interdisciplinary
sample.
Care of the Critically-Ill Patient: Interdisciplinary Care
NR 341: Complex Adult
Health May 30, 2017
This study source was downloaded by 100000834306259 from CourseHero.com on 04-07-2022 07:11:54 GMT -05:00
https://www.coursehero.com/file/31125626/Critical-care-RUA-Interdisciplinary-sampledoc/
, CARE OF 2
Care of the Critically-Ill Patient: Interdisciplinary Care
73-year-old, Caucasian, widowed, retired male was admitted to the hospital on May 11,
2017 from his home. He does not have a resuscitation status, and no known allergies.
Admitting diagnosis is mitral valve disease secondary to bacterial endocarditis, and acute
kidney injury.
Past medical history includes obstructive sleep apnea, hypertension, hemothorax, gout, GERD,
diabetes mellitus, atrophy of the left kidney, and alcohol abuse. Recent surgery on May 12, 2017
includes mitral valve replacement with a cardiopulmonary bypass. Significant assessment
findings are as follows: temperature 37o C, pulse 84, respiratory rate 17, blood pressure 140/61,
O2 saturation 94 on room air, and 0 pain reported on a scale from 0 to 10. Foley catheter is in
place, and output measurement is 100 mL at 0900. A peripherally inserted central catheter is
located on his left arm. Student was unable to obtain amount from pleur-evac. Patient was semi-
lucid; therefore, unable to obtain a review of systems. Focused assessment includes as follows:
Integumentary: Skin is warm, dry, and no skin turgor noted.
Head and neck: Normocephalic, and jugular vein distension is absent.
Respiratory: Chest expansion is symmetric, and lung sounds are clear on the right side yet
Diminished on the left side.
Cardiovascular: S1 and S2 are noted on auscultation, and S3 and S4 are absent.
Gastrointestinal: Abdomen is rounded and symmetric, skin is smooth, bowel sounds are present
in all four quadrants, and last bowel movement was the morning of May 14, 2017.
Neurological: Patient is oriented to person, place, and time.
Eyes: Pupils are 3 mm, and equal, round, reactive to light and accommodation.
Laboratory and Diagnostic Tests
Lab Test Result Normal range Comment
Sodium 141 135 – 145
Potassium 4.2 3.5 – 5.3
Chloride 103 98 – 106
CO2 24 23 – 30
BUN 22 10 – 20 High; this is related to his acute kidney injury,
and may be related to previous administration
of gentamicin, which is an aminoglycoside
This study source was downloaded by 100000834306259 from CourseHero.com on 04-07-2022 07:11:54 GMT -05:00
https://www.coursehero.com/file/31125626/Critical-care-RUA-Interdisciplinary-sampledoc/
BSC NURSIN 108
Critical care RUA
Interdisciplinary
sample.
Care of the Critically-Ill Patient: Interdisciplinary Care
NR 341: Complex Adult
Health May 30, 2017
This study source was downloaded by 100000834306259 from CourseHero.com on 04-07-2022 07:11:54 GMT -05:00
https://www.coursehero.com/file/31125626/Critical-care-RUA-Interdisciplinary-sampledoc/
, CARE OF 2
Care of the Critically-Ill Patient: Interdisciplinary Care
73-year-old, Caucasian, widowed, retired male was admitted to the hospital on May 11,
2017 from his home. He does not have a resuscitation status, and no known allergies.
Admitting diagnosis is mitral valve disease secondary to bacterial endocarditis, and acute
kidney injury.
Past medical history includes obstructive sleep apnea, hypertension, hemothorax, gout, GERD,
diabetes mellitus, atrophy of the left kidney, and alcohol abuse. Recent surgery on May 12, 2017
includes mitral valve replacement with a cardiopulmonary bypass. Significant assessment
findings are as follows: temperature 37o C, pulse 84, respiratory rate 17, blood pressure 140/61,
O2 saturation 94 on room air, and 0 pain reported on a scale from 0 to 10. Foley catheter is in
place, and output measurement is 100 mL at 0900. A peripherally inserted central catheter is
located on his left arm. Student was unable to obtain amount from pleur-evac. Patient was semi-
lucid; therefore, unable to obtain a review of systems. Focused assessment includes as follows:
Integumentary: Skin is warm, dry, and no skin turgor noted.
Head and neck: Normocephalic, and jugular vein distension is absent.
Respiratory: Chest expansion is symmetric, and lung sounds are clear on the right side yet
Diminished on the left side.
Cardiovascular: S1 and S2 are noted on auscultation, and S3 and S4 are absent.
Gastrointestinal: Abdomen is rounded and symmetric, skin is smooth, bowel sounds are present
in all four quadrants, and last bowel movement was the morning of May 14, 2017.
Neurological: Patient is oriented to person, place, and time.
Eyes: Pupils are 3 mm, and equal, round, reactive to light and accommodation.
Laboratory and Diagnostic Tests
Lab Test Result Normal range Comment
Sodium 141 135 – 145
Potassium 4.2 3.5 – 5.3
Chloride 103 98 – 106
CO2 24 23 – 30
BUN 22 10 – 20 High; this is related to his acute kidney injury,
and may be related to previous administration
of gentamicin, which is an aminoglycoside
This study source was downloaded by 100000834306259 from CourseHero.com on 04-07-2022 07:11:54 GMT -05:00
https://www.coursehero.com/file/31125626/Critical-care-RUA-Interdisciplinary-sampledoc/
