Author: Jeana

Walker

Weak Gait

PT/OT

Spinal Stenosis

Urinary Incontinence

Freq. Peri-care

BMI 37.3

Degenerative Joint
Disease

Age 91

acetaminophen

Position Changes

5/11: Bilirubin 1.5

CBC on 5/14
RBC 3.49
Hgb 11.1
Hct 33.1%

Distraction

5/11: CK 4850
5/16: CK 223
5/17: CK 130

5/11: CK-MB 28.2

5/11: CK Index 0.5

5/11: Echocardiogram:
EF 50%
Mild MI– unable to determine when it had happened.

5/11 BNP 429

5/11: Troponin 0.5

Weak & Unsteady Gait

Poor manual dexterity

↑ In Chair w/ 2 assist
as tolerated

Pain 5/10

Compression Fx

PT/OT

Back Brace

kyphosis

X-Ray Spine:
Severe Stenosis
L4-L5
Compression Fx
T12 & L2

X-Rays:
CXR
Pelvis
Femur

CT Head: Normal

5/16: Oral Intake 3382

Monitor I&O

7 Voids Past 24H

Dizziness and Loss
of Balance

Blood Culture:
Showed gram + coccobacilli
Sent for further testing
Dr. Blank believes it was a
contamination of the specimen
and is treating it as a negative
culture; will repeat to verify

Acute Fall

Fall Precautions

Impaired
Physical
Mobility

Dehydration

Dizziness and Loss
of Balance

Sick Sinus Syndrome

0.9% NaCl

20 ga. IV in RFA

Na Restricted Diet

Weight 95.6 kg

Daily Weight

Apical 49/min

Essential HTN

metoprolol

BP 153/67

lisinopril

K+ 4.1
BP 146/70
Pulse 49

Decreased Peripheral
Pulses, B/L

Lack of exercise

Peripheral Artery
Disease

BMI 37.3

Age 91

Thickened toenails

Thick, discolored
skin on b/l lower
legs

Fall Score 81

Fall Precautions

Rhabdomyolysis

Urinalysis:
Yellow/Hazy
Proteins: 50
Ketones: +1
Blood: +3
Nitrite: Positive
Leukocyte Esterase: +4
WBC 10-19
Bacteria 2+

Fatigued

Generalized Weakness

Weak Gait

Suspected UTI

Urine Culture:
Negative for UTI
Contaminated sample

Monitor I&O

5/14: Na 134
K+ 4.1
Cl 10.4

High Risk for Skin
Breakdown

Mild Confusion

0.9% NaCl

Daily Weight

Encourage Fluids

HR 49
BP 146/70

amiodarone

HR @ ER of 176

Fall Precautions

VS q4h

Telemetry

A-Fib

Fatigued

DVT Prevention
Protocol in place

PVC’s

Dry Flaky Skin on Legs

Lotion to Dry Skin

Dizziness and Loss
of Balance

Fall Precautions

VS q4h

Freq. Repositioning

Air Mattress

Heels Elevated off bed

Pressure Ulcer L Hip

Pressure Ulcer Dressing
change BID

Fatigued

EKG:
Super-ventricular arrhythmia
Ventricular Arrhythmia
A-Fib w/ RVR
Significant change from 09’

heparin

5/14: PT 13

CBC on 5/14
RBC 3.49
Hgb 11.1
Hct 33.1%
Platelets 174

Kristin Davis Date of Care: May 17, 2012

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