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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 ASSESSMENT: A 73 years old Covid-19 survivor with developed complications. His medications were managing his BP, BUN, Cr and Albumin. Impaired skin integrity related to stage III pressure ulcer. Risk for aspiration related to PEG tube feeding. Potential for unintentional weight loss related to enteral nutrition (PEG feeding). He was easily tired and had a hypophonic voice (weak and breathy). Impaired urinary elimination is related to muscle weakness in his lower extremities. PLAN: Continue current medications. Check vital signs every 4 hours. Check lab results. The patient will be in a Semi-fowler position during the shift; the mouth will be clean and free from any debris or mucous build-up. Normal gastric residual will be observed, and no complaints of GI upset for tolerance of continuous enteral feeding. Follow up with the Speech Language Pathologist to do a modified barium swallow (MBS) when the patient can tolerate sitting longer to advance in the oral diet to get proper nutrition. The condition of wound edges and surrounding tissue will be assessed; change dressing every three days or prn. Nasolaryngoscopy was done last January 26; continue to follow up with the physician. Follow up PT/OT to help mobilize the patient. Indwelling Catheter: Input and Output will be normal, with no catheter complications. INTERVENTION: Assessed vital signs and checked lab results. (1500 hrs) Performed head-to-toe assessment. (1500 hrs) Scheduled medications were given. PEG tube was flushed 30 ml q3h. Assessed for the head of the bed placement every shift. Provided mouth and lip care to the patient q4h. Monitored gastric residuals and complaints of GI upset. (1500 hrs) Informed the patient that SLP will assess him, explain the procedure to the patient (requires Geri chair), and answer any questions. (1500 hrs) Assessed condition of wound edges and surrounding tissue, odour, and drainage (1530 hrs) Talk about finding outpatient voice therapy as needed or considering surgical procedures if there is no long-term recovery. (1530 hrs) Monitored input and output, ACCO of urine, and possible catheter complications. (1545 hrs) EVALUATION: Normal vital signs- blood pressure within his range. The head of the bed remained in Semi-Fowler position during the shift. No signs of aspiration. Normal gastric residual was observed, and no complaints of GI upset. Wound Assessment: dry, no drainage, intact periwound edges and dressing. SLP report: patient tolerated upright seating in X-ray Geri chair- ready for MSBA booked for Thursday, February 10 (@10:30 AM) Urine Cha.: pale yellow colour, normal consistency and odour, I/O is normal, and no observed complications of the catheter. Date and Time: February 08, 2022, 1600 hrs 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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