I had a earlier post I needed help, my patient assigned to me, admitted with ALOC, decreased speech and decreased interaction and a temp of 100.2
past hx cva -2002, seizure disorder, CAD HTN depression arthiritis, dementia, CABG, Afib for the last 2 years.
non ambulatory...left side paralysis
bp on admin 113/88 HR 83 Temp 100 o2 sat 97
when I had him for the day...his bp 113/81 HR78 temp 35.3 o2 sat 97
when speaking with him he does respond to you but it takes him a few minutes to formulate what he needs to say, with my short stay with him of a whole four hours he did intake water, the amount i do not know...he told me he was thirsty..most of the labs are good except for BUN 38 creatinie 1.24...
he is on oxygen at 2 litres per min
this is what i have so far and it could be completely incorrect
Ineffective tissue perfusion r/t decreased arterial blood flow (BECAUSE OF PAST STROKe) m/b altered level of consciouness.
Decreased cardic output r/t altered contractility (because he has Afib for past 2 yrs) m/b ???? how am I seeing it in him
Impaired physical mobility r/t muscular skeletal impairment m/b left side paralysis
am I on the right track and how do the tops ones look and I need 3 more and this is all the info i have
pleeeeeeeeaaaaaaaaaasssssssssseeeeeeeeee help