I have a 75 y/o male pt w/ an admitting diagnosis of Coronary Artery Disease. He has a past history of: HTN, diabetes mellitus type 2, hyperlipidemia, hypercholesterolemia, Gout, Degenerative joint disease, anemia, peptic ulcer disease with gastroesophageal reflux, Benign Prostatic Hypertrophy, Chronic renal insufficiency, non-Q wave MI-complication of a right total knee replacement in 2009, and a right inguinal hernia repair in 2006. He under went a cardiac catheterization on 1/28 and a CABG on 1/29. He was admitted to the telemetry unit on 1/31. His abnormal labs were: BUN 31, Creat. 1.6, Calcium 8.2, phosphorus 1.8, hemoglobin 9.5, hematocrit 27.2, platelets 90, and albumin 2.9. ABG results for 2/1 were ph 7.404, pco2 33.6, hco3 20.5, sa02 95.7, BE -3.3. total Intake 480 and total output 700 for 2/1. Physical Assessment: Alert, oriented X3, heart rate: 80 and regular w/ s1 and s2. Radial pulses and pedal pulses normal and equal. cap refill less than 3, no edema noted. Respiratory rate 20 with eupnic breathing, lungs clear bilaterally, no cough. Stomach rounded, soft and nontender, bowel sounds present in all 4 quadrants. pt complaining of constipation. last Bm 1/28. Skin: warm and dry w/ pink undertone. Dressing to chest dry and intact with slight shadowing. Dry mucous membranes. Last glucose value 109. Activity level up with assistance. ROM and strength normal for age in all extremities. pt complaining of nausea. last set of vitals: 99.0 F- 75-18-132/66 100% on 3 liters of O2 per Nasal cannula.
Some of the diagnoses I came up with were:
Risk for decreased cardiac output r/t myocardial ischemia and increased vascular resistance
Activity Intolerance r/t compromised oxygen transport system s/t cad and anemia aeb pt complaints of dyspnea with activity
Constipation r/t side effects of anesthesia aeb pt complaining of not having a bowel movement for 4 days.
Impaired Skin Integrity r/t surgical incision s/t CABG aeb disruption of skin surface
Risk for infection r/t a site for organism invasion s/t surgery
What do you think about these? and do you have any to add to this? Also im not sure what would be my top priorities. Thanks