Care plan subjective data?- A&OxO LOC stuporous near vegetative

[JaredOBRN]

I do not know what to do, I am almost done with this care plan, but I need this data for the concept maps also. I am going to copy my parts that are relevant to see if you can help me find something to use, or be able to state something since this is required to receive the points for subjective data. Really I do not know what to put since there is 0 verbal subjective data.

Subjective/ Objective data to support:

1.Respiratory-Ineffective airway clearance r/t retained secretions aeb fine crackles bilateral lower lobes A&P, unable to perform TCDB

2.Cardiac-Imbalanced Nutrition: less than body requirements r/t Inability to absorb fluid and nutrients aeb abnormal Na+, K+, Cl-, Creatinine & Protein lab values

Communication Barrier: Decreased LOC- Stuporous, A&O x 0, unable to articulate feelings and thoughts. Aphasic-speech non-present, and unresponsive to physical stimuli. Arousal to name occasionally, only 3 times for about 5-10 seconds (Pt opened eyes, looked around, went back to sleep). Sitter and previous shift RN stated this was expected behavior, and was reason for "adm to hospital after evaluation in ER because of unresponsive episode while sitting in shower chair." Son was not able to arouse with voice commands. Arousal to pain- ROM with lower legs, calf pain caused patient to wake up with a loud verbal "OUCH" indication of a positive Homan's sign. Notified nurse immediately, who was about to enter room with Dr. for morning assessment. Dr. repeated Homan's sign test and received a lower voice "Ow" on first attempt, and nothing thereafter on either leg after 4-5 more attempts. Dr. stated "calf was cool, soft, non-tender and no support has been below her feet allowing calf muscle to contract." Pillow foot support applied end of bed.

Respiratory

Pt. is bed rest due to A&O x0 LOC stuporous. Resp 0700 16, 1100 17, rate regular, easy non-labored with fine crackles bilateral lower lobes A&P. No pain noticed from body language or facial expression from breathing, no nasal flaring, no purse lipped breathing, no accessory muscles used for respiration. Unable to assess DOE due to LOC. Chest shape normal, non-barrel, and symmetrical, no clubbing of fingers. Pt is on 4L NC with SpO2 at 96-97% and is being Rx by RT with Duoneb inh. QID. There is no cough present to possibly clear sounds, unable to teach TCDB due to LOC. Hx non productive cough previous shifts. Skin race appropriate but pale, warm, dry, loose, cap refill less 3 secs bi-lat hands and feet. Pt has current Dx acute pneumonia, organism unspecified. Chest x-rays were bilateral lower lobe consolidation, atelectasis and infiltrate and were unchanged in past week but improvement from 10/7. Has never smoked. PT Hx is negative for CHF, COPD, sleep apnea or bi-pap. Recent Hx on 10/4 of respiratory alkalosis aeb ABG values, rebreather mask applied. Has positive Hx for anemia, allergic rhinitis, bronchitis, HTN, SOB and unDx diabetes due to elevated A1C assess bid CBG Rx with metaformin.

Lab values: CBC showed Chloride 119H on 10/2/10 and 110H on 10/20/10 indicating Respiratory alkalosis

ABGS showed on 10/4/10 pH 7.48H pCO2 27.1L Base excess -3.1L indicating Respiratory Alkalosis

X rays from 10/2, 10/4, 10/7, 10/18 and 10/20 Continuing to show linear atelectasis changes without any consolidation except for left and right basilar linear atelectasis

Cardiac

Full Code. Apical Pulse 84 at 0700, 78 at 1100. BP 140/86 at 0700, 140/72 at 1100. Rate regular, strong no abnormal sounds. V/S taken while on bed rest HOB 30o A&Ox0 LOC stuporous. Bi-lat radial P 84 at 0700, 78 at 1100 equal, strong, regular, 2+. Bi-lat pedal equal, palpable, regular, 2+. No edema present bilateral. Hx of SOB, light headedness but unable to obtain current due to LOC. No JVD. Resp. regular non-labored no accessory muscles. Unable to obtain chest pain due to LOC. During previous shifts, sitter who has been with patient several times said "when she has been aroused and asked if she is in pain patient slightly shakes head No". No chest tubes, only abd J-G Tube for TPN. Skin all extremities race appropriate but pale, warm, dry and intact, cap refill less 3 secs bi-lat hands and feet. Negative for Homann's sign. Arousal to pain- ROM with lower legs, calf pain caused patient to wake up with a loud verbal "OUCH" indication of a positive Homan's sign. Notified nurse immediately, who was about to enter room with Dr. for morning assessment. Dr. repeated Homan's sign test and received a lower voice "Ow" on first attempt, and nothing thereafter on either leg after 4-5 more attempts. Dr. stated "calf was cool, soft, non-tender and no support has been below her feet allowing calf muscle to contract." Pillow foot support applied end of bed. Light, thinning and short hair on legs, toenails thick, appropriate color and manicured. No Antiembolism Devices, left heel wrapped in protector boot and gauze elevated due to stage 1 pressure sore. Telemetry shows normal sinus rhythm, but Hx adm until 10 days ago sinus tachycardia. No Holter monitor or Doppler use. Hx. Anemia, hyperlipidemia and HTN, taking meds as prescribed. Anticoag therapy used for prevention of PE- SC Lovenox daily in abd. Hypoparathyroidism Rx with synthroid, no Ca+ supplements prescribed. Hx. Anemia, hyperlipidemia, hypokalemia and HTN, taking meds as prescribed. Recent Hx Hypernatremia and hyperchloremia Rx D5W+ 1/2NS to reduce NA+ and Cl-. 10/9/10 received 2 units of blood and premedicated with Benadryl, Tylenol and Lasix. July 2010 CVA. No Hx of diabetes but Hx of elevated A1C and metaformin is prescribed. No Hx MI, CHF, COPD, DM, Cancer, sleep apnea or bi-pap. Also No Hx angina, heart murmur, congenital heart disease, pacemaker, chest pain, palpitations, irregular heartbeat, hypotension, edema, pain in extremities, cold/numb extremities. Family illness Hx includes aunt on maternal side with CVA, also father HTN.

Lab Values:

10/2 WBC 20.6 H, MCHC 32.0L,Na+ 159H,CL- 119H, K+ 3.3L, Creatinine 1.70H, AST/SGOT 47H, Glucose 139H, INR 1.17H, PTT 22.4L, Occult

blood in urinalysis 2+ Color Orange, Cloudy, protein 2+, RBC 17H. WBC >100H. WBC clumps mod H, Urine bacteria Many H, Hyaline

casts 38H, Granular Cats 4H, Mucous many H.

10/4 D-Dimer 11.89H, ABG pH 7.48H, PCO2 27.1L, Base Excess 3.1L, CO2 qty 2.3H

10/17 RBC 3.27L, Hgb 10.2L, Hct 30.0L INR 1.2H

10/20 Creatinine 0.45L, Cl- 110H, K+ 3.3 L, Glucose 143H,Tot protein 5.2L, Albumin 2.2L, RBC 3.27L, Hgb 10.2L, Hct 30.0L, Lymphs 19.0%L

10/4 Microbiology Blood no growth after 5 days