Critical Care Paper

1757 Words Jan 14th, 2015 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 and he admitted to not sustaining the best diet
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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 | |

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