Cabg Report Nursing

PLAN: I have reviewed the chest x-rays available here and agree with the finding of bleb formation in the right and left upper lobes. Despite the fact that the patient has had a high INR, because of his history of tuberculosis and hemoptysis I believe obtaining sputum for TB is very, very important. We should rule out any other endobronchial lesions as the cause for his bleeding. I have discussed this matter with the patient and his wife. I have told them that there is the possibility of observing the condition by x-rays and repeated tests of his sputum. They understand that this is an option; however, they decided that because of concern regarding his repeated hemoptysis, they would consent to bronchoscopy. We will arrange for the patient to have a bronchoscopy done. He is off Coumadin.

A 68 year old male presented to the emergency department at 0800 hours via ambulance after experiencing chest discomfort and intermittent palpitations since 0500 hours. Prior to presentation, the patient stated he

The patient is 72 year old female who smokes. She complains of extreme fluid retention in lower two limbs and lower abdomen. Breathing is difficult and she is only able to sleep while sitting erect in a reclining chair.

The patient did have black soot around his nose and mouth. Thats when first responders started manual ventilation's via BVM and 02 at 15 LPM. At this time Medic 1 assumed patient care. Medic 1 assigned first responders to obtaining vitals signs that are stated in the vital section of the report. It was at this time that Medic 1 applied a OPA after first measuring on what size to use. First responders also applied fast patches to the patients right upper chest and left midaxillary line At this time Medic 1 assigned first responders to start chest compressions a 15:2 ratio. Medic 1 at this time started a IO in the patients plateau region of the right leg. The Plateau region is inferior and lateral to the knee cap. At this time Normal Saline bolus was started with a 60 drop per ML set. Medic 1 found the patient to be in a sinus rhythm At this time miscommunication with Medic 1 and first responders happen with chest comparisons started. We then secured the patient on the cot via 4 straps and transported a code red patient to the nearest hospital. While enroute to hospital radio report was given with chief compliant and treatments listed in the appropriate category of the report. Vitals was continued to be taken every 5

BH was referred to a cardiologist in May, 2015 for complaints of chest pain. He denies chest pain or tightness at present.

Shallow breathing and pain altered this patient’s comfort. Therefore, one of the nursing diagnoses can be stated as “Breathing Pattern, Ineffective r/t pain and anxiety, as evidenced by respiratory depth changes" (Ackley & Ladwig p. 175). We briefly discussed the specifics of incentive spirometry use before initiating the intervention. After return demonstration, the patient was ready to use his incentive spirometer.

The beneficiary was an 82 year old man who had a history of multiple health problems, including chest pain, coronary artery disease, elevated cholesterol, high blood pressure, diabetes, chronic kidney disease, and obesity. In 2014 he underwent a cardiac catheterization and the repair of an abdominal aortic aneurism.

On Tuesday August 30, 2016 a Male 63 years of age came into Christus Spohn South Heath Center with a diagnostic order for chest and rib x-rays. He was being seen because of chest pain on his right side due to a fall. He had an extensive patient history of x-rays that went as far back as 2014. For the year of 2016 he received approximately 12 different x-ray series. For example, on January 12, 2016 he received a chest 1 view image and cardiac catheterization. On May 21, 2016 he received a chest 1 view and a complete 4 view foot. On May 30, 2016 he received a cardiac catheterization. On June 1, 2016 and again on June 2, 2016 he received a chest 1 view. On June 10, 2016 he received a catheterization. On August 25, 2016 he received a chest 2 view. On August 26, 2006 an upper extremity without contrast. The patient also has a history of open heart surgery and receives dialysis treatments and is on oxygen.

is Pneumonia. This is based on the patient’s subjective and objective data. The collaborative diagnosis to address this problem is Pneumonia r/t immobilization; r/t pleural effusion, and r/t debilitation (Carpenito, 2013, p. 859-860). The nursing goal for this patient on the day of care is to control and reduce the complication of pneumonia (Carpenito, 2012, p. 860). The nurse will monitor the patient’s respiratory status while assessing for sign and symptoms of infection, and inflammation (Carpenito, 2012, p.

This is a 61 years old man who was OSU in October for pneumonia. During his hospitalization, pt suffered from lung perforation during lung biopsy. Chest tube was in place until Dec 2nd. He was also treated for A-fib and started on Coumadin before he was sent to rehab. He was in rehab for 18 days. Before he discharged to home, he was told to hold talking Coumadin until next PT/INR- which is on Dec 21st. in addition, pt has a chronic ABD wound which is independent taking care of. The wound 1x1cm. The incision at chest tube removal site is approximated with steri strips and not s/s of compilation or infx.

The patient is a 59-year-old gentleman who is a resident of Lincoln Park nursing home on hemodialysis end-stage renal disease, has multiplicity of medical problems including diabetes, hypertension, afib, anxiety, either schizophrenia and/or bipolar disease, coronary artery disease, peripheral vascular disease, had a below the knee amputation in 2015. The patient was referred to the ER from the Lincoln Park nursing home because of an ulcerated lesion on his left upper anterior chest over where a porta cath resided. My clinical review of his chart determines that the patient had no fever, no white count, no induration or erythema. He simply had an ulcerated lesion and the porta cath needed to be removed which was done by interventional radiology,

A: Janie is a 60 year old Female with PMH of A-Fib, COPD, Hypothyroidism, HTN, Lung Cancer and recently diagnosed Pulmonary Embolism. Janie presents to ER for evaluation on SOB, cough with greenish sputum, sore thoart, hoarseness and generalized weakness. Janie lives at home with her husband, use to smoke ½ pack per week, but quit many years ago, denies alcohol or drugs. Family history is non-contributory. Allergies: NKDA. Differential diagnosis includes worsening Lung Ca, PE, COPD and CHF. Janie uses home O2 at 4 L/NC. V/S: T=98.7, HR=89, R=16, B/P=132/56, O2 sats=100% on 4L/NC, Pain=6/10. Labs: WBC=7.6, H&H=8.5/27, Na=141, Troponin=0.08/0.06, BNP=495, INR=4.2, UA=3+ protein, 1+ blood and 6-10 RBC. CXR: Impression:1). COPD with nonspecific coarsening of the basilar interstitium. 2). Mild cardiomegaly with borderline cardiac compensation. 3). Right

Pulsus paradoxus (exaggeration of the normal variation in the pulse volume with respiration, becoming weaker

The patient is a 73-year-old gentleman who presented to the ED from the subacute rehabilitation after dislodgment his tracheostomy tube. In the ER there were many attempts by the ED doctor to replace the trach tube. The patient had a size 6 cuffless trach so a size 4 cuffless trach was placed. The patient evidently pulled the trache in the emergency room and the ER physician was unsuccessful in putting it back. He also tried to have a surgical resident replaced it. Blood work in the emergency room, which revealed him to have a white count of 17,000 with a left shift. The patient's medical history is significant for chronic respiratory failure, intracranial hemorrhage, dysphasia, hypertension, dementia, a craniotomy, a PEG tube in place

He was managed with non-invasive bi-level positive airway pressure (Bi-PAP) ventilation, noradrenaline, dobutamine along with diuretic via infusion pump, parenteral corticosteroids and strict intravenous fluid monitoring. Subsequent chest x-ray and ECG was normal after 48 hours of initiating this treatment and was discharged on fifth day from admission. Follow up of patient after two weeks was absolutely normal.