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natrgrrl 8,554 Views

Joined: May 6, '06; Posts: 412 (16% Liked) ; Likes: 108

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  • May 11 '17

    Thanks for your help. The examples and advice you all offered have been very helpful. What do you think about my shift assessment? Have I forgotten anything? Anything I should reconsider?

    Pt is (race, age, sex) with severe CAD, CHF, Hx multiple MI, glaucoma, DM. Alert and oriented x3, denies pain at this time. VS 97.1, 66, 18, 73/36. Abdomen round, firm, nontender. IV lock in Right hand with no redness or swelling noted. Pt reported a period of paresthesia in Left arm due to laying on Left shoulder and fistula in Left arm. Pt reports normal feeling at this time. Slight nonpitting edema noted at both ankles. 2L O2, activity as tolerated. Pt is DNR, no feeding tube or urinary catheter. BP normally runs in 80s systolic but dropped to 70s most of the evening. MD was notified, came to assess pt. MD requested reassessment of BP in 1 hr, report to MD if no improvement. Cardiac surgeon talked to pt about AICD surgery scheduled for Friday. I viewed 2 videos with pt explaining AICD. Pt ambulated to hall to sign consent for surgery. Lower lung sounds were diminished. At 2000 pt requested 2 extra blankets, reported chills, cough. Cough resolved without intervention by 2100. Lisinopril and Carvedilol were held at 2100 due to BP 73/36. Pt refused miconazole at 2100. Patient was awake, laying in bed and watching TV when I left the room.