A patient 66yrs old male with a past medical history of alcohol abuse since age 25, homeless, with history of hypertension

A patient 66yrs old male with a past medical history of alcohol abuse since age 25, homeless, with history of hypertension was brought by the paramedic, who report that he was walking home and got picked up from the ground. Pt unable to recall what happened. All he recalls is he fell and hit his shoulder, denies lost of consciousness but unable to recall incident. On arrival to the hospital the pt blood pressure was 206/120, CT to the head was done which revealed atrophy and small vessel ischemic changes and multiple lacunar infarcts. Ct of the cervical spine reveals no evidence of fracture. At time of examination the patient complained of pain in the shoulder. The patient was very slow to respond knows he is in the hospital and date but not able to recall.
History of present illness: hypertension, history of alcohol use , history of fall.
Past surgical history: history of ankle surgery
Admitting diagnosis: Right shoulder pain
Course of current hospitalization to date: A male patient old, apparently fell yesterday and taken to the hospital by paramedics, upon admission, patient was found to be disoriented given inconsistence answers to simple questions and hence neurological appointment was made, he complained of pain at the right shoulder but denies headache, tingling, parathesias or any paralysis on his side. CT scan of the head and basic workup was done and revealed atrophy and small vessel ischemic changes and multiple lacunar infarcts. X-ray done to right shoulder done to right shoulder during admission, no dislocation or fracture is seen, but there is moderate degeneration and fraying of the glenoid labrium. Patient has been ordered to follow up with orthopedic doctor, due to recurrent falls and diffuse elevated reflexes with reduced range of motion to the right arm. Follow up with neurologist for altered mental status and confusion, slow to respond and multiple lacunar by CT scan. Patient is to follow up with psychiatrist to assess for behavior problems. Patient will have physical therapist, occupational therapist and speech therapist evaluate. Nephrologist to check for renal function due to abnormal BUN and Creatinine 42 and 2.3 respectively, case manager.
Medications are amlodipine 10mg, Aspirin 81mg, clonidine 0.1mg q6h, and hydralazine 20mg IV q6hr
Lab report
Most Recent Significant /Recent Lab Results: (Chemistry? Hematology? Drug Levels? Coagulation tests?)
Date Lab Test Results Norms Comments
5/18/2014 Hemoglobin 13.3 12-16.5 Within normal range
Hematocrit 39.4 36-46 Within normal range
Platelet count 421 140-440 With in normal range
MCV 89.3 81-95 With in normal range
MCH 30.4 28-32 With in normal range
RDW 13.5 11.5-14.5 With in normal range
Sodium 133 132-143 With normal range
Potassium plasma 4,4 3.5- 5.5 With normal range
creatinine 2.3 0,6-1.3 Above normal range
Blood urea nitrogen 42 6-22 Above normal range
Albumin 4.1 3.2-4.9 Within normal range
Triponin 0.02
Medication
Amlodipine 10mg (Norvasc) : is in the calcium channel blockers class. It is used to control blood pressure by relaxing the blood vessel to prevent the heart to pump too hard and chest pain( angina) by pumping enough blood to the heart. Side effects are dizziness, drowsiness, and headaches, stomach upset, swollen in the hand, ankles, lower legs and feet. Nursing implication: to monitor blood pressure for therapeutic effect, 2) monitor for side effect such as edema which can be accompanied by weight gain. Report any postural hypotension 3) assess for heart palpitations
Patient teaching: 1) call primary physician when face swelling and lower legs are notice. 2) eat before taking medication is upset stomach 3) call if any irregular heart beat nausea or constipation. 4) should get up slowing to prevent dizziness and fall.
Chamberlain College of Nursing
NR340 Critical Care Nursing
Interdisciplinary Care Assignment Guidelines
PURPOSE This purpose of this assignment is for the student to present a complete picture of nursing care of a critically-ill individual encountered during the course. The student will demonstrate clinical reasoning skills and will discuss interdisciplinary care that had been incorporated and/or anticipated during the care of the critically-ill individual. COURSE OUTCOMES This assignment enables the student to meet the following course outcomes: CO 1: Provide nursing care to patients and their families in critical and emergent care settings based on theories and principles of nursing and related disciplines. CO 2: Initiate the use of appropriate resources in direct care responsibilities within critical-care and emergent care settings. CO 3: Demonstrate effective therapeutic communication and relationship skills in providing care to patients and families in critical-care and emergent care settings. CO 4: Demonstrate effective clinical decision-making based on critical thinking skills and legal, ethical and professional standards and principles when caring for patients and families in critical care and emergent care settings. CO 5: Implement a plan of for continued personal, professional, and educational development related to nursing practice within critical-care and emergent care settings. CO 7: Use evidence including research findings from nursing and related disciplines to answer clinical questions related to nursing care of patients in critical care and emergent care settings.

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