Subjective Years Patient Question & Answer Guide (With Explanation)

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Original Question

SUBJECTIVE: Mr. W.G. is 73 years old patient and was admitted to ICU from home on November 20 for COVID-19 Pneumonia (presented by SOB and weakness), which eventually required him to be intubated. On December 31, he was transferred to the ward with a tracheostomy. As of now, his Covid-19 Pneumonia was resolved, and the tracheostomy tube was removed since the patient no longer needed it. His vital signs were stable afterwards. He was in an NG tube, but insertion can sometimes cause him distress; that is why a PEG tube was inserted last January 05 that required a long discussion with her wife with the physician because she was against it at first. He has developed a stage III pressure ulcer in his coccyx on the unit but reported no pain. He has muscle weakness in his lower extremities (right and left leg); an indwelling catheter was inserted last January 07 and in diaper incontinence. Social History: He was retired, lives with his wife in a house, and has two children. He speaks English and is independent with ADLs before testing positive in Covid-19. He quit smoking in 2018 and has previously used cannabis (none recently). Past Medical History: No known allergies. Hypertension, CVA (left parietal -occipital stroke 2015), Ex-smoker, CKD, AAA, Dyslipidemia Home Medications: Acetylsalicylic Acid, amlodipine, hydralazine, garlic, omega-3 DHA/EPA/fish oil, ubidecarenone, atorvastatin, hydrochlorothiazide Current Medications: Acetaminophen 1000 mg PO/Tube tid SCH Acetylsalicylic acid 80 mg PO/Tube daily SCH Amlodipine besylate 10 mg PO daily SCH Lipase/Protease/Anglase 1 cap tube as directed PRN- declogging tube Ascorbic acid 500 mg PO daily SCH Atorvastatin calcium 20 mg PO bedtime SCH Bisacodyl 10 mg PO bedtime PRN Bisoprolol fumarate 10 mg PO daily @ 1600 SCH Chlorhexidine/Lidocaine Doxazosin mesylate 8 mg PO bedtime SCH Glycerin 1 Supp PR daily PRN- constipation Ipratropium bromide 2 puff inhaler q4hr/prn Lactated Ringer’s 1000 ml @75 lm/hr IV q13h 20M SCH Lactulose 30 ml PO BID PRN – bowel movement Lansoprazole 30 mg PO daily SCH Multivitamin Centrum 1 tab PO daily SCH Ondansetron HCI 4 mg IV q6hr PRN Polyethylene glycol 17 g daily SCH Quetiapine fumarate 12.5 mg PO QID/PRN Salbutamol sulfate 2 puffs Inhale q4h/PRN- SOB Sennosides 2 tabs PO/Tube, bedtime/PRN- constipation Sodium bicarbonate 500 mg tube PRN- declogging tube Tinzaparin sodium 4500-unit subcut daily SCH Vitamin D 1000-unit PO daily SCH OBJECTIVE: Height: 1.71 m Weight: 68.3 kg Appears on his stated age. BMI: 24.3 (Normal weight) Vital Signs: Temperature: 36.9 degrees Celsius Pulse: (bilateral-radial)- 73 bpm, regular, 2+ (apical)- 72 bpm, regular, 2+ (bilateral-dorsal pedis): 74 bpm, 1+ Blood Pressure: 153/77 mmHg (right arm- supine) Range: 152-159/ 76-77 mmHg Respiration: 16 times per min. (non-labour, normal depth, eupnea, equal symmetry, no adventitious sounds auscultated in lungs, no cough, no sputum) Oxygen Saturation: 96% (room air) Pain Scale: 0 PQRSTUV: None I/0 – Intake: 1000 ml (PEG tube) Output: 650 mL (as of 1500hr) Last 48 hrs: BUN 18.9 mmol/L high, Cr 20.5 umol/L high, Albumin 29 L high Hair distribution: balding, symmetrical Skin: normal, warm, dry, elastic, smooth, normal colour appropriate with his ethnicity (low risk:15-18) Neurological: alert, awake, oriented to time, place, and person, arousable to speech and light touch, obeys command and able to respond to simple questions. No sensory and hearing deficits. Mood: appropriate, calm, relaxed, jokes around, cooperative, easily fatigued, but memory and judgments are intact. Speech: hypophonic voice (weak and breathy), clear and normal Diet/ Fluid: NPO, in PEG tube, rate: 85 ml/hr Oral Cavity: Mucous membrane and tongue are pink, no dentures Abdomen: soft and firm, nontender bowel sounds present in all four quadrants Hydration Status: skin turgor is normal, no tenting, no edema CSM arms and legs: no CSM deficits in arms, weak pulses in legs but has warm and normal colour Nail beds: pink, cap refill: less than 2 seconds Activity Order: Total Assistance Assistive Devices: Mechanical lift to Geri-chair Mobility concerns: muscle weakness, limited ROM Fall Risk: 0 ADLs: 1 person assist Urinary Continence: Diaper Incontinence Stool: Copious We need to do Nursing Care Plan. Please help me identify 1 actual diagnosis and 1 potential diagnosis for the patient using the NANDA and the information above. Identify 2 goals on each diagnosis (one short term and one long term goal). 4 goals in total

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