Care plan- nursing

Description

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Care plan- nursing
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Patient information

Initials- EA

Age:45

Male

No allergies

Problems:

Obesity

Hyper tension

Acute kidney injury

Hyponatremia

Left artial dilation

Grade 1 diastolic dis function

Mild tricuspid valve regurgitation

Pulmonary hypertension

Right ventricular dilation

Right ventricular systolic disfunction

Chronic right heart failure

Obstructive sleep apnea

Acute hypertension

Severe edema

Leg wounds

Former tobacco use – 2 pack a day for 10 years

Diet general consistency- 2-3 grams of sodium

Main diagnosis

Varicose vain

Lab values:

Glucose 100

Urea nitrogen 70

Creatinine 1.8

Sodium 129

Chloride 91

Red blood count 2.82

Hemoglobin 7.8

Hematocrit 24.7

Vital signs:

BP 114/73

HR 99

Temp 97.6

Resp 18

Height 5,10

Weight 281

BMI 40.43

Spo2 98

Meds:

Epoetinalfa (Epogen/Procrit) 10 thousand units

Pumetanide (Bumex) 2Mg oral tablets

Polyethylene glycol ( miralax) 17G oral powder

Potassium chloride 20Mg oral

Tramadol (ultram) 50 Mg oral

Spironolactone ( aldactone) 50Mg oral

Ferrous sulfate 325Mg (16Mg iron)

Cyclopenzaprine (flexeril) 5Mg oral