Nursing Notes

10/7/10

Naomi Wielgos

NUR252

0930: HOB 300, 3 side-rail up, Pt is asleep, trach to vent at rate 12, tidal volume 550, PEEP/control 15, INSP. 1.0, PEEP/support 10, FiO2 45%, vent mode CVM. Pt awakens easily when roused, A&O x3 pupils equal & reactive bilaterally, altered speech d/t trach. Pt communicates by mouthing words. VS: BP 110/50, T 37.40, SpO2 94%, HR 70, R radial pulse 68, strong, regular, adventitious lung sounds; scattered rhonchi bilaterally, RR13 & even. Peg tube to L upper abd quadrant, site is dry & crusty, no redness, cleaned with NS. Tube placement confirmed with air & water & aspirated for stomach contents. Pt is NPO, meds administered via tube, Pt tolerated well, is on continuous feed; Jevity 1.5, 1000ml running at 70ml/hr, 500ml infused. Pt required suctioning with 2 passes, thick white/gray secretions, trach site is C/D, stoma well formed, no redness or swelling, trach: portex #7, filter changed. Pt tolerated well.----------------------------------1115: Pt required mouth-care, mucous membrane is pink, intact, moist, with poor dentition, moisturizer applied to lips & inner mouth, Pt tolerated well. Pt has hep-lock to R dorsal wrist, site is C/D/I no redness, no swelling, 0.9% NaCl 1000ml running at 75ml/hr, 300ml infused. UE bilateral ROM is present but very weak, unable to lift arms above head, no muscle tone to UE bilaterally, neck is very weak Pt is unable to hold up head without pillow support or assist. L radial pulse present, strong and regular, cap refill <3sec. both hands warm to touch. Overall skin is intact, pallor, fair skin tugor, warm to touch. LE ROM present, Pt can partially lift both knees on demand but unable to lift feet off bed, heels inspected, skin is intact without any redness, L pedal pulse present, faint, both feet warm to touch. Pt able to turn self in bed. Foley draining direct to bag, amber, clear urine, 400ml, BM is watery brown green diarrhea, malodorous, sample taken for C.diff culture. Perineal area inspected, skin is C/D/I, multiple small lesions surrounds anus, RN alerted, skin barrier cream applied to perineal, sacral & buttocks area. Pt c/o upset stomach, Phys notified and orders hold for tube feed & to administer Maalox.-----------------------------1120: Pt receives Maalox via tube feed & continuous feed put on hold.. Pt tolerates well, call bell within reach, Pt resting comfortably.---------