Neuro: the patient is calm, moderately cooperative, confused, oriented 4*, no sedation intact

brain stem reflexes, perrla with GCS=13/15, four score 16/16, follow simple commands, respond
to questions, and grasps simple idea. intact sensory perception, move right upper extremities
against gravity 3/5 and left upper extremity 4/5, and contracture on the lower extremities with
motor power of 3/5.
Rep: The patient is on room air on nasal cannula of 1L , with spo2 of 99% and RR:
16breath/min. The patient has productive cough with minimal whitish secretion, good bilateral
airway entry and wheezes and crackles on the bilateral lungs. Chest x ray 2/2 showed good
pulmonary expansion and limited pleural effusion on the left side, suputm culture showed
MDRO, the patient was placed under contact isolation.
Cardia the patient scope shows a paced rhythm, HR-80bpm, BP: 160/82mmhg, s1 s2 heard , week
lower pulses , no cyanosis, capillary refill of less than 3 sec , bilateral lower edema of grade2. on
1000ml nacl 0.45% r=40ml/hr and 500ml D5W rate=20ml/hr via central venous catheter in the right
internal jugular running well. patient with no inotropes and haprien5000ui subq bid . on2/2 ( CBC: rbc:
2.87, hgb is 8.2, Hct is 26.3), on 2/1 troponin was 85ng/l, CKMB 8. On 2/2 at 10 pm the patient BP was
188/70 on multiple reading, amlocard was given 5mg PRN and resident Daniel informed. The patient
stayed hypertensive at 4:30 of 180mmHg , residient informed, no action taken.

Gastro: the patient is on soft diet well tolerated with no nausea or vomiting under aspiration
precaution. Soft and distended abdomen ,positive bowel movement, bowel sounds active on all
quadrant upon auscultation, no pain. H .gt q 6hrs on act rapid insulin subq middle scale and Lantus.

Uro patient voids via foley patient has good urine output 250ml/hr that is clear, no, no discomfort, no
tender or distended bladder. creatinine level is 3.76.

Integumentary. Patient has warm, dry skin, central line is running well and patent with no redness and
clean. patient has ecchymosis all over the body + skin sloughing in both upper limbs +dvt. Pressure ulcer
stage 2 on the right trochanter, dermatitis on the gential area, with redness in his back. For the
blanchable redness on bilateral buttocks Medi honey was applied. For Laceration on bue and right thigh
sliver derma. Mepilex heal for prevention and positioning q 2hrs.

A:

Plan:

Maintain blood pressure within acceptable range of less than 150 and avoid hypotension

Assess the patient po intake and advance diet as the patient.

Aspiration precaution keep the HOB elevated during po intake.

Monitor the cardiac rhythm and rate.

Monitor the respiratory function, sputum, the lung sound , and the airway entry.

monitor urinary output, HGT q6hrs,positioning Q2hours, pressure injury and fall precautions
Monitor the neurological function, loc and brain reflexes.

Assess the motor power of the extremities.

Follow up on the lab result and radiology

Monitor the tolerance to feeding and diarrhea.

Give oxygen by nasal cannula 1L.

Medication administration

Seizure precaution and continue convulex.

Assess the CVC for patency, clean dressing with no oozing to changed on 6/2

Dvt prophylaxis

The plan is to continue monitoring the patient and when is hemodynamically stable with stable BP and
cardiac status, improved level of consciousness and respiratory function and lab value the patient will be
transferred to a regular floor.

The plan is to transfer the patient to a regular floor if he stayed hemodynamically stable with stable BP
and cardiac status with improved LOC and neurological function with lab value and radiology test within
acceptable results , tolerating po intake with no aspiration.