S: Pa ent is an 88 y/o Male who presented Lab Values/Diagnos c Tests

to the ER for acute metabolic

Conceptual Care Map
encephalopathy but later admi ed for AKI, 11/15 Na- 139
Student Name: Rachel Miller Pa ent: S. B.
NSTEMI, and COVID.

B: Pa ent has a past history of persistent A- Age: 88 y/o Gender: Male Admission Date: 11/10/23 WBC- 11.05 K- 4.5
b, Type 2 Diabetes, severe protein
CODE Status: DNR Allergies : NKA Braden Score: Diet: Thickened
RBC- 5.24 BUN-53
malnutri on, and falls. Pa ent has
developed Pleural E usions, Heart Failure, Liquid Diet, Cardiac, Consistent Carb Ac vity: SBA Hemo- 11.5 Creat- 1.10
and Aspira on Pneumonia since
hospitaliza on because of exacerba on of Weight: 51.5kg Height: 172.7cm Religion: Unknown IV Therapy: Le Forearm Hema-39 BG- 32, 43, 81
disease processes. Pa ent has a unwitnessed
fall. Plat-167 134, 256
A: Head: Le Parietal Scalp hematoma, Admi ng Diagnosis/Chief Complaint—> Acute Kidney Injury
normocephalic head, hard of hearing at Interdisciplinary Collabora on
baseline. A&O x1, confused. Respiratory:
Pleural E usions, rales bilaterally, aspira ng. Physicians, Nurses, Case Management,
Cardiac: A- b, no murmurs. GI: Normoac ve Patho Flow Diagram Speech Therapy, PT, OT
bowel sounds, at, non-distended, so , no
tenderness. GU: Brown urine, hematuria, Acute Kidney Injury Treatment/Procedures
UTI, AKI resolved. Muscular: SBA, slightly
US-Thoracentesis- 650mL from R Lung
unsteady, needs assistance. Vascular: Radial
pulses 2+ bilaterally, Right pedal pulse 2+, no CT-Chest- Pleural E usions
Pre-Renal
edema Skin: Dry, scaly, bruising, no rash or Post-Renal
jaundice, Le elbow contusion and bleeding Intra-Renal CT Abdomen Pelvis- L1 compression fracture,
from fall. prostate enlargement (don’t know when it
Causes could be: occurred, before or a er hospital fall?)
R: Prevent further complica ons from intravascular Causes could be:
disease processes. May need a consult for Causes could be: Obstructive causes
X-ray elbow- no fracture
volume depletion,
hospice care b/c the pa ent can’t be alone. blood clots, like renal/ureteral
hypotension, UA: Enterococcus Faecalis in Urine
glomerulonephritis calculi, tumors,
Medica ons sepsis, shock, over
and lupus nephritis, blood clots, or any Psych./Soc./Economic Data
diuresis, heart
necrosis, sepsis, urethral
Ampicillin-Sulbactam 1.5g in 0.9% NS failure, cirrhosis,
alcohol or drug obstruction, UTI No tobacco/drug/alcohol use, Lives with
bilateral renal
Aspirin 81mg once a day abuse, vasculitis, son who is a truck driver and can be gone
artery stenosis
acute tubular for 7 days at a me, has a home aid, lives in
Atorvasta n 20mg nightly necrosis
Caldwell, divorced, needs a consistent
Cholecalciferol (Vit. D3) 1,000 units caregiver.
This patient had post renal injury because of the UTI. It traveled from his bladder
Famo dine (Pepcid) 20mg once/day Risk Factors
Guaifenesin (Mucinex) 600mg Vitals: BP: 105/73 HR-84 R-16 O2: 94% Temp: 97.5F Age, Comorbidi es, Living Situa on
Metoprolol (Lopressor) 25mg BID
Discharge Teaching Needs
Mul vitamin w/ Folic Acid 1 tab/day Past Medical/Surgical History
Prevent further decline from disease
Tamsulosin (FLomax) 0.4mg daily Persistent A- b, Type 2 Diabetes Mellitus processes. May need a consult for hospice
Trazodone (Desyrel) 50mg nightly care b/c the pa ent can’t be alone.
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