START_OF_RECORD=1||||1|||| O: 58 YEAR OLD FEMALE ADMITTED IN TRANSFER FROM [**Hospital 1**] FOR MENTAL STATUS CHANGES POST FALL AT HOME AND CONTINUED HYPOTENSION AT [**Hospital 1**] REQUIRING DOPAMINE; PMH: CAD, S/P MI [**1994**]; LCX PTCA; 3V CABG WITH MVR; CMP; AFIB- AV NODE ABLATION; PERM PACER- DDD MODE; PULM HTN; PVD; NIDDM; HPI: 2 WEEK HISTORY LEG WEAKNESS; [**04-18**] FOUND BY HUSBAND ON FLOOR- AWAKE, BUT MENTAL STATUS CHANGES; TO [**Hospital 1**] ER- TO THEIR ICU; HEAD CT- NEG FOR BLEED; VQ SCAN- NEG FOR PE; ECHO- GLOBAL HYPOKINESIS; EF EST 20%; R/O FOR MI; DIGOXIN TOXIC WITH HYPERKALEMIA- KAYEXALATE, DEXTROSE, INSULIN; RENAL INSUFFICIENCY- BUN 54, CR 2.8; INR 7 ( ON COUMADIN AT HOME); [**04-19**] AT [**Last Name (un) **]- 2 FFP, 2 UNITS PRBC, VITAMIN K; REFERRED TO [**Hospital1 2**]. ARRIVED IN TRANSFER APPROX. 2130; IN NO MAJOR DISTRESS; DOPAMINE TAPER, THEN DC; NS FLUID BOLUS GIVEN WITH IMPROVEMENT IN BP RANGE; SEE FLOW SHEET SECTION FOR CLINICAL INFORMATION; A: NO HEMODYNAMIC COMPROMISE SINCE TRANSFER; TOLERATING DOPAMINE DC; P: TREND BP RANGE; OBSERVE FOR PRECIPITOUS HYPOTENSION. ||||END_OF_RECORD START_OF_RECORD=1||||2|||| O: BUN NOW 50; CR 2.1- URINE OUTPUT IMPROVING SLIGHTLY POST FLUID CHALLENGE; K 3.9; A: CONTINUED RENAL INSUFFICIENCY/ RENAL FAILURE. P: FOR REPEAT BUN,CR,K; CONTINUE I&O. ||||END_OF_RECORD START_OF_RECORD=1||||3|||| O: INR 2.0; PT 17.5; PTT 32.3; IV HEPARIN BEGUN AT 1100 UNITS POST BOLUS; 5 MG COUMADIN GIVEN. A: ANTICOAGULATION BEGUN FOR HISTORY OF MECHANICAK VALVE, HISTORY OF AFIB; P: MAINTAIN IV HEPARIN PER PROTOCOL; FOR AM PT, PTT. ||||END_OF_RECORD START_OF_RECORD=1||||4|||| 58 YR OLD ADMITTED TO [**Last Name (un) **] HOSPIATAL P FALL C MENTAL STATUS CHANGES REQUIRING DOPAMINE . CT SCAN NEG . R/O MI , VQ SCAN NEG, HYPERKALEMIA RX C KAYEXALATE PMH MI [**94**], 3 VCABG C MVR,ON COUMADIN, EF 20% ,AV NODE ABLATION FOR A FIB, DDD PERM PACER , PULM HYPERTENSION ,PVD, NIDDM ,2 WKS LEG WEAKNESS TRANS TO [**Hospital1 2**] [**04-19**] .DOPAMINE WEANED TO OFF . PLAN TO RESTART CARDIAC MEDS ,ADVANCE ACTIVITY, TRANS TO FLOOR. CV PACED R. NO ECTOPY . BP STABLE OFF DOPAMINE,OOB TOL WELL . DIG RESTARTED . HEPARIN DECREASED TO 900 U FOR PTT 119 . COUMADIN HAS BEEN RESTARTED . LEGS EDEMATOUS RESP RALES IN BASES ,EXERTIONAL WHEEZES . DOE. SAT 94 TO 96 ON 3LNP GI PASSING LOOSE BR STOOL .APPETITE POOR .NOT REQUIRING SSRI FOR BP GU CL YEL VIA FOLEY 50 CC HR ,LASIX GIVEN . K 3.8 NO RX AT THIS TIME NEURO AOX 3 MAE . SKIN RED RASH GROIN, NYSTATIN POWDER ORDERED APPROACHING BASELIN CARDIAC FX MONITOR BP C DIURESIS FOLLOW K ||||END_OF_RECORD START_OF_RECORD=1||||5|||| ccu nsg admission note: 12 am-- pt is a 57yo f who is followed at [**Hospital1 **] by dr [**Last Name (STitle) 3**]. she arrived a&ox3 via amb from [**Hospital1 4**] ew for further eval/monitoring. today pt was at home and states that her legs felt weak and she fell to the ground striking her head on the kitchen floor. pt states that she did not have loc. 911 was called and pt taken to [**Hospital 4**] hosp. she sustained a lac to the back of her head that was sutured. she did rec tet [**Name6 (MD) 5**] per rn. per report she has been a&ox3. she had labs drawn which showed inr to be 24, hct 25.4, na 132, k 5.1, dig 2.4 w/elevated bun/creat. she had head ct done which was reported to be neg. she was also noted to have bp that dropped to 70's--pt cont'd a&ox3, she was started on dopa up to 8mcg, she was given 1 unit ffp. she was transfered to ccu for further monitoring. pt states that for the past few weeks she hasn't been feeling well. states that she has been having swelling in her abd that has caused her to lose her appetite. she has not been eating/drinking that well, also notes decreased u/o over the past few weeks. she has also had increased swelling to her lower ext which she states makes it harder to amb. she did fall 1 noc ago but did not sustain any injury at that time. she has been having problems w/loose stools for the past few weeks as well and states that she has had several tests done on stool which have been neg, she was taking imodium for diarrhea but it has not been working and has started a new med which she can't recall. states that she has been having her inr followed and has been taking coumadin as instructed. she has only noted bleeding from hemrroids. ros-- neuro--a&ox3, mae, skin w&d, c/o pain to back of head. head w/sutures, no bleeding from site at this time resp--ls w/crackles at bases, cta in upper lobes, sat on 5l 98%, rr 16 not labored, no c/o sob cardiac--hr 70's av paced, arrived on 7mcg of dopa, bp 90-100/40's, no c/o cp gi--abd obese, firm/distened, (+)bs, did pass sm amt of brown stool, no c/o abd pain at this time gu--pt states no void since 3pm, feels like she has to void, foley placed for 50cc dark yellow urine skin--area of ecchymosis to r shoulder/upper arm, does also have other areas of bruising to arms/legs, skin to back/buttocks intact access--arrived w/2 #22 iv's to r arm, #18 ac placed and bloods resent social--pt married, lives in [**Location 6**], husband did not come to [**Hospital1 **] w/pt, he is aware that she is here ||||END_OF_RECORD START_OF_RECORD=1||||6|||| nsg note cont'd: pmh: cad--s/p mi '[**94**] s/p cabg/mvr '[**97**] s/p pacemaker-ddd s/p aflutter/afib htn dm high chol pvd--claudication depression uterine bleeding pre-renal azotemia all: ceclor meds: aldactone---asa atenolol---lipitor coreg---coumadin dig---enalapril gemptbrozil---lasix ativan---micro-k trazadone---zoloft amiodarone s: "i have a headache" o: neuro--pt remains a&ox3, asking for tylenol for c/o headache from lac, scant amt of bleeding noted on pad behind head resp--ls w/crackles at bases, conts w/out any c/o diff breathing, sat on 5l 98-100%, rr 18-20 not labored cardiac--hr conts av paced, conts on 8mcg of dopamine, no adjustments made, bp 90-101/50, repeat inr on arrival 5.7, will re-check labs this am gi--abd obese, (+)bs, has been on/off bed pan 2-3 times w/out any results, does have sm amt of old blood on rectum which pt states are from hemrroids gu--foley patent, draining approx 30-40cc/hr, team aware, will recheck bun/creat this am skin--conts w/areas of ecchymosis to arms/r shoulder, does have petachae to lower ext a: alt co d/t heart failure p: cont dopamine for bp control, wean as tol monitor fluid status, ?needs swan follow labs, monitor for bleeding ||||END_OF_RECORD START_OF_RECORD=1||||7|||| S-"When can I go home?" O-Neuro alert and oriented x3, pleasant but uncomfortable most of day. c/o headache treated with tylenol #3 q6hrs with relief. Received versed .5mg IVB during PA catheter placement. Asking appropiate questions about POC and hopefull to feel better to go home soon. CV-remained hypotensive all day unable to wean dopamine. At 8:30am SBP 80 and dopamine gtt increased to 9.5mg/kg. PA catheter placed under fluro with opening # PA 70/38 PWP 40 with V waves to 50, CVP 28 with V waves to 38, CO/CI/SVR 7.5/3.5/437. Started Dobutamine at 5mcg/kg without change in VS/PAD, increased to 7.5--10mcg/kg by 6pm. Epsiode of hypotension with gtts disconnected transiently. Presently at 6pm Dopamine at 12mcg/kg and Dobutamine at 10mcg/kg with PAP 58/27 CVP 29. Aline placed LRA with MAPS borderline 56-63. HR 70 AV paced with occ PVC's. Received 1 unit FFP for INR 7.0 decreased to 3.3 and received 2nd unit during PA insertion. Resp-rr 20-24 LS rales 1/3 up bilaterally O2 sats 95-98% on 5l np. GU-foley draining 20-30cc/hr concentrated urine. GI-abd remains distended +acsites tender to touch. No diarrhea, NPO until after PA catheter. Tolerated well. C/o burning from lying flat for PA catheter. HCT 24.7 received 1 unit PRBC. Skin-lac on back of head cleansed, no drainage from site. Eccymosis on right shoulder/arm. Social- husband and daughter into visit. ||||END_OF_RECORD START_OF_RECORD=1||||8|||| nsg progress note 7p-7a: neuro--a&ox3, c/o's of being uncomfortable w/back pain, turning s-s throughout the noc, given trazadone for sleep and then asking for ativan, given 1mg w/gd effect resp--ls w/crackles at bases, cta in upper lobes, conts on 5l w/sat 93-99%, rr 20's, states that she does have some sob but no different than how she felt when admitted, abg wnl cardiac--hr av paced at 70's w/occ pvc, pa# 63-70/27-30, cvp 28-31, unable to wedge d/t overwedging, conts on doubutamine/dopamine, gtts titrated throughout the noc, dobutamine as high as 15mcg, co 6.9-9.1, ci 3.22-4.25, svr 272-359, team aware that co increasing & svr decreasing, so dobutamine titrated down, now at 8.0mcg, dopamine up to 18mcg w/bp 85-101/40's w/map 58-60, team aware of increased dopamine, did rec 40mg iv lasix w/min response initially of 80cc, rec'd 2nd unit of prbc's for hct of 23, inr 2.7 gi--abd conts firm/distended, (+)bs, states that she has sensation that she has to move bowels but no stool tonight, asking for supp to help move bowels, gu--foley to gravity, hematuria initially but clearing up during noc, u/o 60-120cc/hr, conts to have discomfort w/cath, lido jelly applied around cath site w/temporary relief of discomfort, also started pyridium skin--conts w/bruising, c/o pain to buttocks, pt has ecchymosis to coccyx, no breakdown noted, states that she did fall and land on buttocks prior to admission, turning s-s to get comfortable, 1st step to get put on bed ||||END_OF_RECORD START_OF_RECORD=1||||9|||| S-"I wish they could find out whats wrong with me." O-Neuro alert and oriented x3, more talkative today. c/o anxiety from all the testing and asked for ativan x2. Received ativan .5mg IVB x2. ALso c/o slight headache, not as bad as yesterday, received tyelnol #3 x2 with relief. PEARL head lac sutures intact/ no drainage. CV-Hemodynamics remain unclear. CVP remains elevated at 28-30 and no change in PAD/PWP despite dopamine/dobutamine. O2 sat run done this am revealed CVP 65, VIP CVP 73, PA 72, PWP 93, Art 97%. Stat echo to r/o A or V shunt which was negative. Echo revealed severe TR unable to quantify severity of MR [**Last Name (Titles) 7**]/t MVR, LVEF <20%. Hemodynamics FICK CO/CI/SVR 10.1/4.72/230 c/w TD CO 5.17 (although waveform appeared dampened). MAPs low 54-62 on dobutamine/dopamine and plan to wean over to neo gtt. By 3pm dobutamine weaned off and dopamine wened down to 8mcg/kg SBP dropped to 70's and neo added. BY 5pm dopamine off but requiring 320mcg of Neo and so Dopamine restarted at 5mcg/kg. MAPs now 75-78. PLan to check hemodynamics at 8pm. Resp-rr 18-24 O2 sats 91-98% depending on sleeping when sats drop to 91%. LS rales at bases, no cough.ABG 91/42/7.36/25/-1. Occ periods of SOB possibly related to anxiety. When flying flat face does become cyanotic fairly quickly. ID-Afebrile temp 97-98% WBC 7.6 Plan for diagnotic paracentesis this eve. Plan to send blood cultures this eve also. GI- HCt remained low despite 2u PRBC 24.2 received 2 more units PRBC each over 4 hours. HCT to be check at 8pm. CAT scan of abd completed without contrast, revealed ascitis with gall stones no bleeding noted on preliminary assessment. Occ periods of nausea relief spont. Had feelings of having a BM but unable to, until about 5pm when she had 2 episodes of melanotic stools, 2nd stool about 100cc strongly OB+. NPO except clear liquids. Plan for NGT/lavage this eve and possibly EGD if neccesary. Abd is tense with ascitis. GU-foley draining moderate amt 50-100cc/hr clear amber/orange urine. At 4pm pt noted that she had wet the bed and found pt with a moderate amt of urine leak around foley. Noted urine darker with small clots. Manual lavage with 500cc NS and removed ~6 large sized clots. Replaced foley with #20fr 3way foley and started GU irrigation at 200cc/hr to keep urine free from clots with good results. Urine color cherry colored. Skin-petechiae over most of upper extremities still present. Eccymosis right shoulder/arm. Social-husband in visiting and spoke with MDs about POC. ||||END_OF_RECORD START_OF_RECORD=1||||10|||| O: afeb. HR 70 paced. BP 104-115/50's. remains on neo at 320mcq and dopa at 5mcq. PAP 60's/27-30, wedge 28, CVP 27-29. C.O. 6.1/2.8/616 , SVR down to 538 at 0600. mixed venous PAsat down to 53-55 off dobutamine gtt. HO aware. no intervention. remains off dobut. - LS crackles bases. sats 92-94% on 5lNC. dyspneic with turing, movement. resolves with rest. - u/o averaging 100cc/hr. GU irrigant inc. to 300cc in eve d/t clots in foley, currently urine is clear and orange d/t pyridium. GU irrigant at 200cc/hr at 0600. - repeat HCT 32 at 2100. am pnd. no stool. - ABD u/s done at bedside and paracentesis was performed. ~ 400cc clear liq. asicits fluid taken off. sent for cx. - following that procedure and allowing for rest, team placed NGT. found coffee grounds that cleared after ~ 300cc. NGT removed. pt. med. with total .75mg versed IV for both procedures. tol. well. - also given trazadone and po ativan for sleep and able to sleep well for ~ 6hours. woke alert, approp. A: SVR improved on neo. PA sat down improved u/o. hematuria resolved with irrigation PAP's unchanged asicitis removed via guided U/S. coffee grounds lavaged. P: follow hemodynamics, PAP's. ? wean neo as tol. monitor Sats, C.O. and SVR. follow u/o and GU irrigation. ||||END_OF_RECORD START_OF_RECORD=1||||11|||| NEURO: A&O X3. MAE. COOPERATIVE. RESP: O2->3L NP. O2 SATS 93->89%. O2 INCREASED TO 4L NP. O2 SATS 94- 100%. ABG 7.4/40/100/26 O2 SAT 97%. RR 15-19. BS CLEAR BUT DIMINISHED AT BASES. CARDIAC: HR 71 AVP. BP 91-102/45-52. PAD 29->23, CVP 31->24, W 17 ON DOPA 7.9MCG/KG. CO PENDING. GI: TOL. CLEAR LIXS WELL. ABD. DISTENDED WITH ASCITES. BS HYPOACTIVE. NO STOOL DESPITE BEING PLACED ON BEDPAN 6-8 TIMES. GU: 3 WAY FOLEY IN PLACE & DRAINING ORANGE COLOR URINE D/T PYRIDIUM. GU [**Last Name (un) 8**]. STOPPED AT 2130 & NO CLOTS SEEN. URINE DOES APPEAR TO HAVE INCREASED SEDIMENT. U/O 100-200CC/HR. GIVEN LASIX 80MG IV X1. ID: AFEBRILE. ENDOCRINE: BS 112. AM LABS PENDING. ||||END_OF_RECORD START_OF_RECORD=1||||12|||| NEURO: A&O X3. RESP: O2->2L NP. O2 SATS 92-95%. RR 15-22. BS CLEAR BUT DIMINISHED AT BASES. ABG 7.43/41/76/28 WITH O2 SAT 96%. MIXED VENOUS O2 61. CARDIAC: HR 71 AVP. BP 100-108/49-57. PAD 25-31, CVP 26-30, & CO 5.8/2.71/497 ON DOPA 9MCG/KG. GI: ADB. WITH ASCITES. BS HYPOACTIVE. 3 SM. STOOLS (LOOSE BLACK),G+. GU: FOLEY CATHETER->CD DRAINING ORANGE COLOR URINE D/T PYRIDIUM. C/O BURNING WITH CATHETER & WANTS IT REMOVED TODAY. U/O 80-360CC/ HR. ID: AFEBRILE. ENDOCRINE: BS 129. NO INSULIN REQUIRED. LABS: WBC 7.4, HCT 29.6, & PLAT CT 150K. CHEMISTRIES PENDING. ||||END_OF_RECORD START_OF_RECORD=1||||13|||| S- " CAN I GET UP TO THE WHEELCHAIR...CAN I GET UP TO A CHAIR.." O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- PT REMAINS WITH BP- 100-120/40-60. HR- 70'S AV PACED. NO VEA- LYTES WNL AFTER EARLIER REPLACEMENT. REMAINS DOPA DEPENDANT ON 7 MCG/KG- WITH ANY INTERRUPTION IN GTT- BP DROPS TO 70-80'S/ CO/CI/SVR REMAINS AT BASELINE WITH 5.5/2.5/450 HOLDING EVENING CAPTOPRIL FOR SEVERELY LOW SVR, LABILE BP OFF/DOPA DEPENDANCE. INCREASED ACTIVITY TO DANGLE ON EDGE OF BED X 15-20 MINUTES - TOLERATED WELL, BUT VERY EXHAUSTED AFTERWARD- ENCOURAGED TO REST/PACE ACTIVITIES. RESP- CRACKLES AT BASE- O2 SATS- 92% ON 2 L AFTER ACTIVITY- INCREASED TO 4 L NP WITH IMPROVED O2 SATS. DIURESING TO 80 LASIX - 100-200/HOUR. I/O (-) 1300CC AS OF 10PM.. TACHYPNIC WITH ANY EXERTION, BUT COMFORTABLE CURRENTLY RESTING. ID- AFBRILE. NO SIGN INFECTION. GI- GIVEN MOM - NO RESULTS AS OF YET, NO CALL FOR BEDPAN THIS SHIFT- NO FURTHER DIARRHEA.EATING SMALL AMTS SHERBET/TEA/CRACKERS. MUCH ABDOMINAL DISTENSION/ACSITES. GU- GOOD U.O- VIA FOLEY CATHTER- URINE ORANGE S/P PYRIDIUM. NO SIGN CLOTS/NEED FOR IRRIGANT. SKIN- REDDENED COCCYX- ENCOURAGED TO TILT ON SIDE- COMPLETELY NOT COMFORTABLE IN THIS POSITION, MOVING BACK TO MIDDLE OF BED. TURNED WITH 2 ASSIST. SEE ABOVE FOR INCREASE ACTIVITY. HEME- REMAINS OFF HEPARIN/COUMADIN WITH ELEVATED INR- NO REPEAT INR/COAGS CHECKED. MS- PT ASKING TO GET OOB- RESTLESS, EXPLAINED NEED FOR PA LINE, REASON FOR CERTAIN MEDS/TREAMENT PLAN ETC. APPEARS TO UNDERSTAND AND MORE COMFORTABLE AFTER MOVING AROUND AND EXPLAINING NEED FOR DECREASED MOBILITY WITH PA LINE, LABILE BP/ DOPA GTT. HUSBAND IN TO VISIT FOR COUPLE OF HOURS. Patient upset learning about death of son A/P - PT WITH HEART FAILURE/LABILE BP/LOW SVR CURRENTLY TOLERATING DIURESIS/DOPA THERAPY. CONTINUE TO AGGRESSIVELY DIURESE- GOAL (-) 1-2 LITERS/DAY. WATCH GI FOR ANY NEED FOR MORE MOM/LAXATIVES. SKIN CARE/COMFORT. CLOSELY WATCH LYTES/REPLETE AS NEEDED. CONSIDER ADDING VERY LOW DOSE CAPTOPRIL ONCE BP LESS LABILE/SVR NOT AS LOW. PA LINE D/C ONCE MEDS ARE OPTIMIZED. ||||END_OF_RECORD START_OF_RECORD=1||||14|||| S: " Can I get out of bed? " O: pt. slept through night well, woke ~ 0400, wanting to get OOB to commode. explained to pt. reason she is not ready or strong enough to get OOB at this time. refused bedpan. passing gas. no VEA. BP 92-119/50's. PAP's unchanged: 60's/27-30, CVP 25-27. C.O. 5.9/2.7/569. - u/o 80-100/hr. neg. 1.3L at 12am. neg. 400cc at 0600. no lasix tonight. LS crackles at bases. denies SOB. RR 16-20 when asleep, up to 20's with any activity. sats 95-97% on 4lnc. A: stable hemodynam. with no change from diuresis. P: continue dopa at 9mcq., wean per team. continue diuresis, monitor lytes, HCT. continue stool softener, laxative prn. ||||END_OF_RECORD START_OF_RECORD=1||||15|||| CCU NPN: PLEASE SEE FLOWSHEET FOR OBJECTIVE DATA. CARDIAC: DOPA WEANED TO 5MCG/KG/MIN MAINTAINING MAPS GREATER THAN 60. ALSO ABLE TO GIVE CAPTOPRIL 6.25 AT 11 AND 6PM. IN ADDITION ALSO DIURESED WITH 80MG LASIX AND CURRENTLY NEGATIVE BY 1500CC. SWAN NUMBERS PA 60/30 PCWP 30 CVP 39 CO/CI 6.9/3.22 K 3.4 THIS AM AND REPLEATED WITH 60 IV AND REPEAT LABS PENDING. RESP: 4L NP CRACKLES 1/2 UP BILATERALLY SATS MID 90'S. GI: POOR APETITE,NUTRITION CONSULT OBTAINED. Requesting [**Doctor Last Name 9**] beer NO STOOL. GU: URINE CONTAINS A LOT OF SEDIMENT.GOOD RESPONSE TO LASIX. HEME: INR 2.5 THIS AM. HCT 29.7 STABLE,REPEAT SENT THIS EVENING. ID: AFEBRILE SOCIAL: HUSBAND IN VISITING ||||END_OF_RECORD START_OF_RECORD=1||||16|||| npn 7p-7a: ccu nsg progress note: neuro--a&ox3, sleeping throughout the noc after getting trazadone/ativan, easily arrousable when needed, mae, skin w&d resp--ls cont w/crackles at bases, cta in upper lobes, conts on 4l nc w/sats 95-99%, rr 12-18, not labored, appears in nad cardiac--hr av paced at 70's, occ pvc noted, conts on dopa,initially on 5mcg w/maps 55-58, dopa increased to 6mcg w/increase in maps to 60, prior to getting captopril dose rate increased up to 7mcg w/maps up to 65-70, dopa weaned back down to 5mcg this am w/maps 60, pa numbers 58-65/30, cvp 26-30, unable to wedge, am co/ci---5.6/2.62, svr 564---this was drawn while on 6mcg of dopa, repeat hct from eve 27, team aware, no orders for transfusion at this time, will follow am hct, dr [**Last Name (STitle) 3**] in to talk w/pt this eve about condition and her need for ?heart transplant gi--abd firm/distended, (+)bs, still feels as though she has to have bm but conts to just pass gas, tol po's w/out diff gu--foley to gravity, draining orange urine, no clots noted, sediment present, given lasix 80mg at 6:45pm w/gd diuresis, cont'd w/gd u/o through noc of aprox 60-70cc/hr ||||END_OF_RECORD START_OF_RECORD=1||||17|||| CCU NPN: PLEASE SEE FLOWSHEET FOR OBJECTIVE DATA. CARDIAC: TITRATED DOPA NOW TO 4MCG/KG/MIN WITH MAP'S GREATER THAN 60. SWAN D/CED AND TRIPLE LUMEN PLACED THROUGH CORDIS AND MONITORING CVP. CAPTOPRIL INCREASED TO 12.5 MG TID. VOLUME:LASIX NOW BEING ORDERED AS 80MG BID WITH GREAT DIURESES TODAY,CURRENTLY NEG BY 1800CC. WT ALSO DOWN TO 88.6. HEME: HCT STABLE,INR 2.4 NO PLANS FOR HEPARIN AT THIS TIME. STOOL IS GUIAC POSITIVE GI:APPETITE HAS IMPROVED SLIGHTLY. NOW DRINKING SHAKES. HAS HAD TWO STOOLS SECOND MORE FORMED THAN FIRST.STILL HAS THE SENSATION OFTEN OF HAVING TO MOVE BOWELS,MOSTLY JUST FLATUS. ASCITES REMAINS GU: GREAT RESPONSE TO LASIX. URINE CONT TO HAVE SEDIMENT. LYTES: K REPLETED WITH 80 MEQ KCL,MAG REPLTED WITH 1 GM AND PHOS BEING REPLETED WITH NEUTROPHOS TID. SKIN: SKIN TEARS ON LEFT ARM CLEANSED AND LEFT OPEN TO AIR. BUTTOCKS IS RED AND STARTED ON DESTIN. PLAN: DR [**Last Name (STitle) 10**] IN TO TALK WITH PT REGARDING TRANSPLANT THIS EVENING. ||||END_OF_RECORD START_OF_RECORD=1||||18|||| npn 7p-7a: ccu nsg progress note: s: "i guess i have to make the decision about the transplant" o: cardiologist in speaking w/pt re:heart transplant which pt states she has to talk to her family about and make a decision. pt wants family to be able to talk to md's about transplant. pt a&ox3, given trazadone/ativan for sleep. did sleep through the noc, occ waking up. ls w/crackles at bases, no c/o sob, 4l on sat 97-98%, rr 18-20. conts on dopa initially on 4mcg but maps <60 when pt asleep, dopa increased to 6mcg then 7mcg w/maps >60. able to tol captopril 12.5mg. dopa again being weaned, at this time to 6mcg. abd firm/distended, (+)bs, lg soft, g(+)stool, (+)flatus. foley to gravity, draining lg amt of orange urine w/sediment, conts to c/o pain at cath, urine foul smelling, spec sent for ua/c&s. a: heart failure p: cont dopa, wean as tol monitor/asses cardiac status f/u w/cardiology re: heart transplant---have them meet w/family to up date them on status ||||END_OF_RECORD START_OF_RECORD=1||||19|||| s: i feel good today o: pls see carevue flowsheet for complete vs/data/events id: afeb. ua+. started on cipro. cv: hr 70s av paced. k and mg repleted. bp 90-105/50-60 via rad aline. dopa weaned to off. pt tol captopril at 12.5mg tid. hct cont at 27-28. no plans to transfuse unless<25. resp: cxs at bases up [**Date range (1) 11**]. sat 94% on 2lnc. no sob. gi: tol diet. no n/v. had sev loose stools. ob neg, brown. gu: good repsonse to lasix. aldactone added. foley changed. ms: ox3. cooperative. oob to ch for most of day. transfered with 1-2 assist. social: husband and dtr visited. dr [**Last Name (STitle) 3**] took husband and son's ph #s and planned to speak w/ then this afternoon. a: off dopa p: follow bp, i/o. act as tol. PT to see pt in am. support to pt and family. ||||END_OF_RECORD START_OF_RECORD=1||||20|||| npn 7p-7a: ccu nsg progress note: s:"i want to sit in the chair" o: pt in good spirits this eve, a&ox3, mae, skin w&d, oob to chair w/1 assist, steady gait, given trazadone/ativan for sleep, slept throughout the noc. no c/o sob, attempted to take o2 off w/sat to 88-89% although no c/o sob, 2l on w/sat up to 97%, ls w/crackles at bilat bases, cont on bid lasix. briefly talked about heart transplant stating that she didn't think that she wanted to have it done but that she would have to talk to her family about it more. no c/o cp, hr conts av paced at 70's, no ectopy, conts off dopamine w/maps 60-70, maps did drop to 50's for approx 1hr after getting captopril but came back up on own w/out any dopa. pt has tlcl that was placed over cordis which will have to be changed to just tlcl if pt goes to floor today. abd conts distended, soft, (+)bs, sm stool. foley initially leaking after given lasix, balloon inflated more and no further leaking. conts on cipro for uti, did c/o pain at urethra which resloved after lido jelly placed there. per pt dr [**Last Name (STitle) 3**] has husband/sons phone #s to call and update them on talk about heart transplant a: alt co d/t heart failure p: monitor/asses cardiac status--cont captopril, keep off dopa follow resp status, attempt to wean o2 as tol, ?cont to diuresis follow labs, replete lytes as indicated, follow hct, ? transfuse ||||END_OF_RECORD START_OF_RECORD=1||||21|||| S: "When is this bladder pain going to stop? this is worse than the swan" O: For complete VS see CCU flow sheet. ID: Pt afebrile. Urine + for UTI. She remains on cipro. CV: Pt has maintained stable BP off dopamine. HR 70s A-V paced. BP has ranged 88-130/50-60s. BP lower after captopril. She was replaced with 80 meq KCL today. She was restarted in heparin at 10am with ss written on low end. PTT was 63.4 and heparin was decreased from 900 to 700u/hr. PTT due 11pm. RESP: RR in 20s. She continues to have BB rales. On 2L 02 sats are 97-98%. She c/o of some nasal discomfort and with nasal prongs off she is sating 91-04%. She has no c/o of sob. GU: Pt c/o of bladder spasm. When she has spasm she feels as if she needs to move her bowels. She will be started on ditropan tonight. On commode she does leak urine into bedpan. She received standing lasix 100mg IV dose and diuresed well. She is now >1 liter neg for the day. HEME: Crit at 4p was stable at 28.2. GI: Pt onto commode ~14 times. She put out small amt soft G+ brown stool. She has poor apetite, but is taking nutritious shakes. ENDO: Finger sticks have not required ss reg coverage. ACTIVITY: Pt seen by PT today and walked. She has been very active, up to commode and back to chair frequently. She seems unsure of what the goal of this admission is and will need support with poor prognosis. Family in to visit and supportive. A: Restarted on heparin/bladder spasm P: Start ditropan. Support pt. Keep careful I & O. Continue PT. ||||END_OF_RECORD START_OF_RECORD=1||||22|||| NSG NOTE: CARDIAC: REMAINS OFF DOPAMINE WITH STABLE BP. AVPACED @ RATE 71. NO VEA NOTED. CAPTOPRIL DOSE INCREASED FROM 12.5 TO 25 MG,GIVEN AT MN. BP DROP 1/2 AFTER RECEIVING DOSE TO 75/40,88/46. HOUSE STAFF [**First Name8 (NamePattern2) 12**] [**Last Name (NamePattern1) 13**] AWARE. U/O DROP OFF SLIGHTLY,PT MENTATING,DENIES C/O AT THIS TIME. BP BACK UP AFTER OBSERVING FOR 1 HR,WITHOUT INTERVENTION TO MAP'S > 60. U/O IMPROVED GREATLY > 100CC/HR. CON'T TO RECEIVING IV HEPARIN. MD'S PREFER TO HAVE PT ON MORE OF SUBTHERAPEUTIC LEVEL (SEE PROTOCOL). PTT OVERNOC 61.4. RATE DECREASED FROM 700U TO 500U. CVP 24-26. RESP: O2 AT 2L NP WITH SATS 96%. DENIES SOB EVEN WITH EXERTION. HAS RALES 1/3 UP BILAT. RR-REG. ID: AFEBRILE. REMAINS ON CIPRO FOR UTI. GU: CON'T TO HAVE PERIODS OF BLADDER SPASMS. PT STARTED ON DITROPAN WITH SOME IMPROVEMENT. HAD HEMATURIA ON EVE SHIFT ? RELATED TO HEPARIN ADM. HEPARIN DOWN TO 500U/HR WITH IMPROVMENT IN HEMATURIA. RECEIVED 2 DOSES LASIX 80MG AND 40MG WITH GOOD RESPONCE. GI: HAD 2 SM BROWN SOFT STOOLS. CON'T TO C/O HEMMOROIDS PAIN. TUCKS ORDERED AND APPLIED WITH GOOD RELIEF. TOL DIET. DENIES N/V. ABD UNCHG. NEURO: A&O PLEASANT,COMPLIENT. COMFORT: C/O GENERALIZED ACHES AND PAINS. RECEIVED 1 TAB TYLENOL #3 WITH GOOD EFFECT. SKIN: UNCHG. HAD HEMATOMA'S R SHOULDER AND ON ARMS R AND L. ACTIVITY: OOB UP TO CH. TOL WELL. SEEN AND EVALUATED BY PT. REQUIERS STRENGTH AND ENDURANCE TRAINING. CAN PIVOT WELL FROM CH TO COMMODE WITH ASSIST OF 1. LABS: K+ 4.8 BS 125 PTT 61.4 DISPOSITION: TEAM HAS BEGUN TRANSPLANT DISCUSSION WITH PT AND FAMILY. PT DOES" NOT WANT TO FACE THAT" AND WANTS TO DELAY HER DECISION. A: STABLE ON INCREASING DOSE CAPTOPRIL. P: [**Hospital 14**] REHAB/PT TEAM TO CON'T TRANSPLANT DISCUSSION. CAPTOPRIL/CON'T DIURESIS. FOLLOW HCT NOW THAT PT IS ON HEPARIN AM LABS/PTT P: ||||END_OF_RECORD START_OF_RECORD=1||||23|||| S-"There is no way I am having a heart transplant, I need to go home and think about it-go on the internet..." O-Neuro alert and oriented x3, very pleasant and talkative today. Asked for a ativan in the afternoon for "nerves". CV-VSS no orthostatic VS changes when OOB commode/chair. Tolerating captopril 25mg TID despite SBP dipping to 80 after doses. Asymptomatic. Heparin at 500u/hr PTT 46. Off for 2 hours for RIJ line d/c'd and restarted at 1645. Last CVP 23. Resp- LS rales 1/3 up bilaterally. O2 off most of the day with O2 sats 90-93%. Encouraged to use IS and take deep breathe. ID afebrile 98.8po on cipro GU-foley draining amber urine no clots but occ blood tinged. C/o intermittant bladder spasm relieved with ditpropan. Received lasix 80mg IV BID with additional 40mg IVB at 2pm with good results. K 3.4 received additional 40meq po along with 40meq BID. GI-freq small soft BM OB- on the commode. Received immodium x1. Appetite improved. Needs to be limited po liquid intake otherwise would take in >2000cc. HCt remains low 26.4 recheck 26.8 at 3pm. SKin-occiput sutures removed by HO. Activity-OOB commode and chair [**Last Name (un) 15**] toelrated well. A few times pt up to the commode on her own. Wanting to take a walk. A/P-Improved VS on captopril/lasix ?change lasix to po dosing with prn IVB. Increase KCL po dose. FOllow HCT on Heparin. INcrease activity as tol. ||||END_OF_RECORD START_OF_RECORD=1||||24|||| CCU NURSING PROGRESS NOTE 7P-7A S-"JESUS I DON'T WANT TO LAY IN THE BED. I WANT TO SLEEP IN THE OTTOMAN CHAIR TONIGHT." NEURO: ALERT, ORIENTED X3, COOPERATIVE AND PLEASANT. CV: HR 70'S AV PACED. NO VEA NOTED. BP 90-110'S/50'S. BP DROPPED TO 80/40 AFTER CAPTOPRIL. PT DENIED C/O DIZZINESS. RECEIVED STANDING LASIX AND KCL DOSE AS ORDERED. BILAT LE EDEMA. CON'T ON HEPARIN AT 500 UNITS/HR. AM PTT PENDING. PULM: LS CLEAR, RIGHT BASE CRACKLES. O2 SATS 95-97% R/A. PT DENIES SOB. ENCOURAGED TO DEEP BREATHE. GI/GU: ABD ASCITES. +BS. FREQ SM BM'S OVERNIGHT ON COMMODE. FOLEY DRAINING CLEAR URINE, OCC BLOOD TINGED. PT C/O BLADDER SPASMS, SOME RELIEF WITH DITROPAN. ASKING TO HAVE FOLEY REMOVED. ENCOURAGED PT TO KEEP FOLEY IN OVERNIGHT. U/O APPROX 50-100 CC/HR (EXCEPT FOR SHORT TIME FOLLOWING CAPTOPRIL AND LOW BP, HO AWARE). ID: AFEBRILE. CON'T PO CIPRO. ACT: REMAINED IN CHAIR OVERNIGHT FOR PT COMFORT. PT STATES MUCH MORE COMFORTABLE IN CHAIR. UP TO COMMODE WITH MINIMAL ASSIST. COMFORT: GIVEN TYLENOL #3 X2 FOR C/O HEADACHE. SKIN: OCCIPUT INTACT AT LACERATION SITE. BRUISING ON RIGHT ARM AND SHOULDER. ACCESS: PERIPHERAL IV X1 PLAN: HEMODYNAMICALLY STABLE. INCREASE ACTIVITY AS TOLERATED. PT HAS BEEN CALLED OUT TO FLOOR. TRANSFER TO FLOOR WHEN BED AVAILABLE. ||||END_OF_RECORD START_OF_RECORD=1||||25|||| S-"I would like to go home tomorrow." O-Neuro alert and oriented x3, pleasant and cooperative anxious to go home Monday. Initial plan for milrinone x3 days. CV-VSS remains on milrinone at .288mcg/kg with symptomatic improvement of fatigue and SOB. SBP 83-105/60 Resp- LS clear without O2 no SOB noted with activity ID afebrile GU-voiding qs remains negative since MN GI appetite good , ate [**Last Name (un) 16**] sandwich Activity-OOB in room ad lib and walked in hallway ~200yards tolerated well without SOB A/P-stable day called out to floor with [**Last Name (un) 17**] dose of milrinone. ||||END_OF_RECORD START_OF_RECORD=1||||26|||| S-"I have more energy after walking. Dr. [**Last Name (STitle) 18**] is driving me crazy" O-Neuro alert and oriented x3, pleasant and cooperative. Feels better today. CV-Remains on IV heparin at 700u/hr PTT pnd. SBP dipping to 70's after captopril asymptomatic. Changed over to zestril 10mg po QD first dose at 1600. Also increased aldactone to 50mg QD. Resp-BBR O2 off sats 93% no cough ID afebrile GU-foley draining qs occ leakage esp after IV lasix. GI- appetite good, freq small soft BM's OB- HCT stable Activity-OOB with walker and assist. Walked approx 20 feet and had to sit down for 3 minutes and then walked another 20 feet back to the room. Tolerated well amd felt really good after. A/P-stable tolerating increase activity with meds adjustment. ||||END_OF_RECORD START_OF_RECORD=1||||27|||| CCU NURSING TRANSFER ACCEPT NOTE 58 YO FEMALE READMITTED TO CCU TODAY S/P CATH WITH PA LINE ON MILRINONE. PT WITH PMH MI '[**94**], CABG X3 '[**94**], REDO '[**97**], DDD PACER '[**97**], AFLUTTER S/P ABLATION '[**98**], AFIB S/P CARDIOVERSION, ECHO EF <20%, DM, PVD, DEPRESSION, CHF, HTN, AND ^CHOL. PT HAD ATTEMPT AT CATH FOR MILRINONE TRIAL, UNABLE TO PASS CATHETER R/T PVD. HAD RIGHT GROIN PA LINE PLACED. STARTED ON MILRINONE AND ADMITTED TO CCU FOR CLOSE MONITORING. NEURO: PT ALERT, ORIENTED X3, COOPERATIVE. MOVES ALL EXTREMETIES. CV: HR 71 AVP. BP 72-80/30'S. MILRINONE AT .35MCG/KG.MIN. LASIX STARTED AND INCREASED TO 4 MG/HR. PAP'S 60/23 MEAN 34-36. CVP 15-18. PCWP IN CATH LAB 30. MIXED VENOUS SAT 67 THIS AFTERNOON. CO 6.8 CI 3.18. PER MD'S PT TO BE STARTED ON NIPRIDE, MD'S AWARE SBP 70-80!!!! DOPPLER PT/DP. PULM: LS BIBAS. CRACKLES. SATS 92% R/A. 98% 2LNC. DENIES SOB. GI/GU: ABD DISTENDED, +BS X4. TOLERATING LIQUIDS WELL. FOLEY DRAINING CLEAR YELLOW URINE, TITRATING LASIX TO >100CC/HR. ACCESS: RIGHT GROIN PA LINE. RIGHT GROIN FEMORAL SHEATH DC'D BY FELLOW THIS AFTERNOON. NO BLEEDING/HEMATOMA NOTED. PIV X1 COMFORT: C/O BACK PAIN AND BILAT LEG PAIN. GIVEN PERCOCET AND REPOSITIONED WITH EFFECT. SOCIAL: HUSBAND IN TO VISIT THIS AFTERNOON. PLAN: CON'T MONITOR PA PRESSURES. ON MILRNONE. TITRATE LASIX TO DESIRED EFFECT. NIPRIDE FOR AFTERLOAD REDUCTION IF PT TOLERATES. RESUME HEPARIN. ||||END_OF_RECORD START_OF_RECORD=1||||28|||| S: "My left leg hurts. This has just been so long". O: For complete VS see CCU flow sheet. CV: Pt remains on milrinone at .35mic/kilo with sats staying at 67%m much improved from cath lab. C/O 5.6/67. Nipride was begun at low dose but BP did not tolerate. HR has been in 70s A-V paced and bp in low 80s. Heparin was begun at 7pm with PTT due at 1am. L groin remains dry wit no ooze or hematoma. RESP: O2 sat 98% on 2L NP. Lungs sound clear. RENAL: Despite increasing doses of lasix u/o has been low ~10-40cc/hr. Drip is presently on 20mg/hr. GI: Pt has poor apetite and took only liquids tonight.Her abdomen is very large. HEME: Dr [**Last Name (STitle) 19**] wants pt to have 2u PRBCs tonight. As she may be heart transplant candidate she needs irradiated, leukocyte poor RBCs. MS: Pt tearful and uncomfortable. She received 2 percocettes with fair results. Frequent position changes help. A: Improved c/o on milrinone P: Continue monitoring for change. Tranfuse 2 u PRBCs when ready. Increase lasix as needed. ||||END_OF_RECORD START_OF_RECORD=1||||29|||| S-"I am so uncomfortable I need to get OOB" O-Neuro alert and oriented x3, found very uncomfortable and sobbing at midnight. c/o back ache and right leg cramping from not being able to move it around. Treatedw ith tylenol #3 x2 and ativan 1mg po with good relief and slept well the rest of the night. CV-Milrinone at .375mcg/kg/min, hypotensive SBP 65 with MAP 35-45 HO notifed and milrinone decreased to .25mcg/kg/min and added dopamine 10mcg/kg to get SBP>90/MAP >60. Hemodynamics PA 54/18-70/21 after blood. Heparin at 1250u/hr PTT 99.8/INR 1.7/PT 16.0 Right fem sheath/PA cath no bleeding at site Resp-LS BBR O2 2l NP 90-95% ID afebrile GU-foley draining minimal amounts of urine despite lasix gtt at 20mg/hr. d/c'd gtt at 1:30am. With hypotension hourly urine 0-10cc/hr. BUN/CR 49/2.0 GI +ascites abd firm with hypoactive BS. Repeat HCT 29 last eve. Received 1 unit PRBC over 5 hours tolerated well. HCT pnd 7:30am. Mouth dry. Taking sips of water. Skin-very dry/red A/P-hypotension on milrinone. Oliguria with hypotension. ||||END_OF_RECORD START_OF_RECORD=1||||30|||| CCU NURSING PROGRESS NOTE 7A-7P NEURO: PT LETHARGIC BUT AROUSABLE. WAS AWAKE AND VERY ANXIOUS WHILE MD'S WORKING WITH HER, GIVEN TYLENOL #3 FOR BACK DISCOMFORT AND ATIVAN FOR ANXIETY. PT AROUSABLE TO VERBAL STIMULI, FOLLOWING COMMANDS APPRPOPRIATELY. CV: HR 70 AV PACED. BP 86-110/20-50'S. MILRINONE DC'D THIS AM R/T HYPOTENSION. DOPAMINE INCREASED TO KEEP MAPS >60, NOW UP TO 14 MCG/KG/MIN. SVO2 INITIALLY 60 OFF MILRINONE WITH CO 5.5 CI 3.09. HAS SINCE ^63 WITH ^U/O. PAP'S 68-78/17-29. CVP 17-25. UNABLE TO WEDGE GROIN PA LINE. HO AWARE. IV HEPARIN ADJUSTED PER PTT SS, NOW AT 700 UNITS/HR. HCT 26.9 S/P 1 UNIT RBC'S LAST NIGHT. RECEIVING 2ND UNIT RBC'S THIS AFTERNOON. DIG LEVEL 2.2 TODAY, RECHECK IN AM AND HOLD DIG TOMORROW. CORTISOL STIM TEST PERFORMED TODAY, RESULTS PENDING. PULM: LS CLEAR, BIBASILAR CRACKLES. O2 SAT 92-96% ON 2LNC. SATS LOW 90'S WHEN SLEEPING. GI/GU: ABD DISTENED, HYPOACTIVE BS. POOR PO INTAKE TODAY, SIPS WATER ONLY. FOLEY INITIALLY WITH POOR U/O. HAS SINCE INCREASED ONCE MILRINONE DC'D AND DOPA INCREASED. URINE IS NOW BLOOD TINGED, PT NOTED TO WINCE IN PAIN WHEN CATHETER MANIPULATED. HO MADE AWARE. NO INTERVENTION AT THIS TIME. BUN 52 CRT 2.1 ID: TEMP SPIKE 101.0 PAN CULTURED (BLOOD CULTURES X2 VIA LINES, UA AND URINE CULTURE) CXR DONE. GIVEN TYLENOL. SPOKE WITH MD'S, REPORTED TO GIVE RBC'S WITH TEMP. PLAN: MONITOR PAP'S AND BP, TITRATE DOPA TO MAINTAIN MAPS >60. ? WILL START DOBUTAMINE THIS EVENING TO ^CO. START ABX FOR TEMP SPIKE TODAY. OBSERVE FOR DECREASED U/O AND SIGNS/SYMPTOMS POOR PERFUSION. ||||END_OF_RECORD START_OF_RECORD=1||||31|||| S-"I'm just so uncomfortable" O-Neuro alert and oriented x3, c/o back ache received tylenol #3 x2 and ativan 1mg po for sleep. Slept most of night. CV-At 2130 restarted milrinone at .35mcg/kg after 50mcg/kg IVB over 10 minutes. Initial drop in SBP 83 but stable >90 most of night. Unable to wean dopamine much, 14mcg/kg to 11.4mcg/kg. Goal keep SBP >90. PAD 18-24 with CO/CI/SVR 9.9/5.56/356 after start of milrinone last eve. Recheck this am still pnd. Heparin at 700u/hr PTT 67. Resp- rr 16-24 O2 sats 90-95% LS BBR ID febrile 101.8R tylenol x1 98.8po this am. Started on abx. GU-foley draining 50-100cc/hr before milrinone. Started lasix gtt at 2mg/hr after 120mcg IVB and has had an excellant diuresis 150-300cc/hr. K 4.0 Imtermittant hematuria. GI-Appetite fair taking po liquids well. HCT 28 after 2nd unit of PRBC. Type and cross for 2u PRBC. NO BM's h/o melana on heparin in the past. Skin-dry using ucerin cream with some improvement. Open incision from old CABG last year LUL wet-dry dressing area is much improved with + granulation. A/P-Follow hemodynamics closely q 8hrs. Keep SBP >90 Follow electrolytes with diuresis h/o losing K+. ?restart zaroxylyn and aldactone. ||||END_OF_RECORD START_OF_RECORD=1||||32|||| Nursing Progress Note 7a-7p: Neuro: Pt alert and oriented x3. Pt stated that she thought she was going home today. Notified team that pt not understanding severity of illness. Moving all extremites spontaneously. CV: AV paved HR 71-73 no ectopy. Weaned dopamine gtt to 4mcg. SBP 97-130. Pt denies CP. PAD's 20-32. C.O. 7.8 CI 4.38 SVR 903. CVP 12. Hep gtt conts at 700u/hr PTT 62.0 no change per hep ss protocol. Milrinone gtt conts at 0.350mg/kg. K+ and mg repleted per prn order. HCT 28.4 per team transfuse <27.0. Heart Failure team to evaluate patient for transplant. Pt awaiting meeting with her husband present. PULM: NC 2.0 Sats 95%. Pt denies SOB. LS with bibasilary crackles. No peripheral edema noted. GI: Abd with +ascites. Hypoactive BS. Pt with abd discomfort rec'd tylenol 650mg po with effect. Pt with improved appetite, pt ate cottage ch and fruit plate. Pt taking sips of gingerale and water. No stool this shift. Pt asking for the bed pans many times w/o results. GU: Foley cath patent draining amber urine pt is on ditropan. u/o>70cc/hr until 4pm. 4-6p decreased to 10cc/hr with stable BP, H.O. notified. Conts on lasix gtt at 2mg/hr await further orders. ID: t max 99.3 po. Pt conts on abx. SKIN: LUE CABG site clean edges with red center. wet to dry dsg apiled. Heels pink, elevated off bed intermittently. Buttocks pink, turned prn. PAIN: Intermittent c/o back pain. Pt turned and given tylenol with effect. LINES: R groin PA line. R radial a-line. PROPH: hep gtt. DISPO: Full code SOCIAL: Family visiting throughout the day. A: Low grade temp with improving SVR on low dose dopamine and milrinone. P: Follow hemodynamics. Check PTT in am. Await lasix order for low u/o. follow temp curve. cont abx. replete electrolytes prn. Provide support. ||||END_OF_RECORD START_OF_RECORD=1||||33|||| S-" I'm in the church in [**Location 20**]" O-Neuro alert and oriented x1-2. Startedpicking at O2 and tape on arms and attempted to pull at foley catheter. Reoriented quickly but still continued to pick. Had received ativan 1mg and tyelnol #3 x2 as usual at bedtime. Finally fell asleep by 1:30AM. Desats to 88% on RA. CV-Hypotensive SBP 73 on dopamine 4mcg/kg increased back to 8mcg/kg with good response. BP 85-106/42-65. Hemodynamics PAP 53-61/20-24 CVP 15-18 with CO/CI/SVR 9.3/5.22/353. Heparin at 700u/hr PTT pnd 5am. Resp-LS BBR O2 2l np with O2 sats 90-95% but quickly desats to 85-88% off O2. ID afebrile on abx GU-Foley draining 10cc/hr and received lasix 120mg IVB and increased lasix gtt to 3-4mg/hr with good response ~1000cc. Received KCL 40meqIV GI-+BS taking po liquids well. Mouth dry Skin- open incision on upper left thigh closing up nicely with wet-dry dressing changes. Social- no call from family during the night. A/P-possibly change femoral PA catheter to neck? Freq orientation check. Have PT see pt while in bed to prevent deconditioning. ||||END_OF_RECORD START_OF_RECORD=1||||34|||| Nursing Progress Note 7a-7p: Neuro: Pt withdrawn and lethargic today. Pt dozing most of morning. Pt conts on zoloft and trazadone for depresssion. Pt requires frequent reminding of current situation. Pt conts ask if she is leaving today or tomorrow. Pt asks if she can get OOB and go to the bathroom following explaination of lines and meds. Team aware. Await Psych consult confirmation from Dr. [**Last Name (STitle) 19**]. Await PT eval. CV: AV paced 71-73. Pt denies CP. SBP 92-109 on dopamine gtt at 8mcg/kg/min. Do not wean Dopamine gtt per Dr. [**Last Name (STitle) 19**]. Milrinone gtt at 0.35mcg/kg/min. R groin PA line resited to RIJ this evening due to temp spike w/o source 48hrs ago and decrease mobility due to line.....AWAIT CXR for placement verification. R groin venous sheath pulled...monitor site. Pt tolerated procedure well after receiving 1mg po ativan. BP dropped transiently to SBP 80's. *PAD's 22-35. CVP 19. C.O./C.I./SVR 9.8/5.51/327. *Hep gtt off please turn on w/o bolus at 8pm per Resident. K+ 4.2 HCT 28.5 Transfusing <28.0. *Dig level 1.70 dig po conts to be on hold. Pt conts on lasix gtt at 4mg/hr with u/o 100cc/hr a/o. Wt 68.3kg(68.7). -1074 since mn -5872 LOS. Plan is to cont diuresis. Aldactone 25mg po restarted. PULM: NC 2.0 Sats 95-96%. Pt denies SOB. Pt able to lay flat. LS with crackles bibasilary. trace peripheral edema. GI: Abd soft distended with ascites. Pt refused meals. Denies n/v. Fruit plate in frig for pt. No stool tihs shift. ?LBM. Pt taking sips of water/tea. Oral mucosa is dry. ID: t max 99.4 Pt conts on abx iv. BC pending. SKIN: heels and buttocks red. Cream and repositoned. LUE old CABG site w-dry dsg. PROPH: Hep gtt. DISPO: Full Code SOCIAL: husband in to visit. A: afebrile with low SVR on milrinone and lasix gtt. P: Await CXR for swan placement. Re-start hep gtt at 8pm. Follow numbers with diuresis. Encourage po's. Follow mental status. Provide support. ||||END_OF_RECORD START_OF_RECORD=1||||35|||| S- " I WANT TO GO HOME- I WANT TO GET THESE THINGS OUT OF ME... I NEED TO CALL MY HUSBAND....I DON'T WANT TO HAVE THEM TAKE ME AWAY IN THE MIDDLE OF THE NIGHT AND PUT IN A (NEW) HEART....." O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- PT REMAIN WITH BORDELINE LOW BP- 90/50- AS HIGH AS 110'S/ MILRINONE 0.35 MCG/HEPARIN 700U RESTARTED AT 8PM AFTER RT IJ PA LINE INSERTED. PAD- 24-32 WITH PCW- 18-26. CO/CI/SVR- 7.1/3.99/451 RESP- CX AT BASE BILATERALLY- 02 SATS WNL ON 2-4L NP- DROPPING TO HIGH 80'S OFF O2. REQURING FREQUENT REINFORCEMENT TO KEEP ON O2. REMAINS ON LASIX GTT 4 MG/HOUR. FAIR TO GOOD RESPONSE- 60-100CC/HOUR. SUCTIONING FOR MINIMAL PLUGGY THICK SECRETONS. I/O (-) 1400 AS OF 7AM. ID- AFEBRILE- CONTINUES ON ANTIBX- GU- GOOD UO- NO DIURESIS THIS SHIFT- (-) 1400/HOUR GI- NO PO INTAKE THIS SHIFT- ATTEMPTED BEDPAN X [**11-29**]. NO RESULTS. SOFT DISTENDED ABD. MS- TRAZADONE/ZOLOFT QHS- HELD OFF ATIVAN D/T INCREASED SOMNOLENCE UP TILL AROUND 11PM. REQUIRING REPEAT ORIENTATION AS TO PLACE, REASON FOR ADMISSION TO ICU ETC. BY 3 AM, APPEARING MORE LUCID, LESS CONFUSED. SPENT OVER 45 MINUTES ENCOURAGING PT - EXPLAINING COURSE OF CARE. ASKING TO GET OUT OF BED, AFRAID WE ARE DOING THINGS WITHOUT HER KNOWING IT, WILL SEND HER TO THE OR TO GET A NEW HEART WITHOUT HER PERMISSION, ETC. ASKING TO SPEAK TO HUSBAND, DR [**Last Name (STitle) **], DR [**Last Name (STitle) 21**]. ENCOURAGED TO WAIT UNTIL THE DAYTIME FOR SUCH CALLS. PT ESCALATING BY 5 AM AND WANTING TO GET OOB, GO FOR WALK, PULL OUT LINES ETC. CALLED PT'S HUSBAND, BUT NO ANSWER. MUCH MUCH ENCOURAGEMENT AND LIMIT SETTING. HOLDING OFF ON ATIVAN D/T APPARENT CONFUSION/SOMNOLENCE FROM DRUG. PT IS CONVINCED WE WANT TO HOLD HER PRISONER. A/P- PT WITH CHF/LOW EF STATE DOPA/MILRINONE DEPENDANT CURRENTLY HEMODYNAMICALLY STABLE WITH GOOD DIURESIS/ I/O. ALTERED COPING SKILLS CONTINUE TO CLOSELY MONITOR HEMODYNAMICS- MEETING WITH TEAM/ATTENDINGS TO DISCUSS OVERALL PLAN OF CARE WITH STAFF/PT/FAMILY. PT IS ADAMENT CURRENTLY TO GO HOME, NOT HAVE ANY HEART TRANSPLANT ETC. CONTINUE TO SUPPORT/SET LIMITS TO ENSURE PT SAFETY. ALLOW PT TO MAKE DECISIONS RE: OWN CARE AS LONG AS NOT ENDANGERING TO PT. CONTINUE TO DIURESE WITH LASIX GTT. PSYCH CONSULT TODAY TO EVALUATE ESP IN SETTING OF POSSIBLE TRANSPLANT W/U. LIMIT SETTING/CONTRACT. ||||END_OF_RECORD START_OF_RECORD=1||||36|||| ERROR: PT NOT SUCTIONED AT ALL AS MENTIONED IN RESP SECTION OF OBJECTIVE DATA. ||||END_OF_RECORD START_OF_RECORD=1||||37|||| S: "I think I feel a little better" O: For complete VS see CCU flow sheet. ID: PT remains afebrile today. CV: Per Dr. [**Last Name (STitle) 22**] pt has remained on the same meds today: dopamine 8 mic/kilo, milrinone .35 mic/kilo and heparin at 700u/hr. Her CO at 2pm was 6.1/ 3.43 with SVR 511. She was started on enalapril 2.5 at 5pm and has tolerated it without drop in BP. HR has been in 70s AV paced with no ectopy, and BP stable in 90s/30-40s with PS 50-60s/ 20-26 with RA 17. She was K+ replaced with repeat K+ 4.0 and received 2amp mgso4. Her digoxin .125 was restarted this am. RESP: Pt frequently takes off 02 and sat then drops to 88-93%. On 4L NP sats are 96-99%. She continues to have BBR. RENAL: Pt on insulin drip at 4mg most of the day. It was increased to 6u at 5pm and u/o has picked up. She is 200cc neg for the day. GI: Pt has very poor apetite. She did eat 2 eggs and is drinking nutricious frappes. She was up to the commode ~10 times today. After suppository she had large G+ stool. SKIN: Wet to dry dsg done to small open area on L thigh. Area appears to be healing and is clean. MS: Pt seen by psych today. They suggested increasing zoloft which has been done. Pt up in chair the whole day and has been more comfortable and appropriate. A: Stable c/o on stable presures P: Continue with above meds over the weekend. Support pt and family. Keep careful I & O. Check K+ and replace for less than 4.0 ||||END_OF_RECORD START_OF_RECORD=1||||38|||| No changes made to medical regime over this 4 hrs. Remains hemodynamically stable, is comfortable in the chair and would like to remain there, has been sleeping on and off. Up to commode x1, passed mucous and blood, sm amt. Given Mesalamine supp. Aloe Vesta oint applied to rectal area. UO good, is 400cc neg at 2200. A/P: cont close hemodynamic monitoring. ||||END_OF_RECORD START_OF_RECORD=1||||39|||| S:" I don't want to get in the bed, I'm more comfortable in the chair." O: Please see carevue for VS and objective data. CVS: Hemodynamically stable but Dopamine dependent with SBP trending down to the 70's when changing Dopamine bag. BP 70's-109/40-50's. IV Dopamine at 10mcg/kg/min. IV Milrinone at 0.35mcg/kg/min. CO/CI 6.3/3.54, unable to calculate SVR due to CVP port clotted. IV Heparin at 700u/hour with am PTT pnd. HR 60-70's 100% AV paced, no vea noted, K+ repletion as per flow. Resp: Po2 78 on 2l n/c, increased to 107 on 4 L n/c. Lungs with rales in bases only. IV Lasix titrated to maintain net u/o of 100cc/hour. Presently at 9mg/hour. GI;GU: Small sips taken with meds. Voiding qs as above via foley. OOB to commode x3 for very small amount of loose mucous, no stool. Neuro: Pt. A/A/Ox3, calm and cooperative this shift. Pt. states she is most comfortable in cardiac chair and requested to sleep in cardiac chair. Refused return to bed when encouraged. Slept on and off most of night. A: Stable, dependent on IV drips. P: Cont to assess hemodynamics, maintain drips as ordered. Titrate Lasix drip to maintain net u/o of 100cc neg. Follow up with am labs. Cont to assess mental status, safety measures. Comfort and emotional support to Pt. and family. ||||END_OF_RECORD START_OF_RECORD=1||||40|||| S: "I really do feel better today, though still no apetite." O: For complete VS see CCU flow sheet. ID: T-max 98.5 po. Flagyl d/c. CV: Pt continues on milrinone at .35 mic/kilo. HR has been in 70s av paced. BP has been stable in 90s to low 100s. By the afternoon dopamine was reduced to 8mic/kilo from 10mic/kilo with bp still in 90-low 100s. PAP has slowly been decreasing and is in 50-60/19-23s. Wedge was 18-19. Last c/o was lower at 5.5/ 3.09/ 611 on the 10 mic/kilo of dopamine. Her K+ today was 4.1. She continues on 700u heparin with stable PTT. RESP: Pt sating better with room air sats now 94-96% range and 98-100% on 4L NP. Lungs sound nearly clear with faint crackles at the bases. GU: Urine output has increased and she is now ~500cc neg for the day on 9mg lasix/hr. GI: Apetite very poor, despite attempts to get food that she likes. She is drinking the nutri-shakes though. No BM today. HEME: Crit 26 this am and she was transfused with unit of PRBCs this afternoon--completed at 6:30p. She had not problem with [**Name2 (NI) 23**]. SKIN: Dsg to small open area on L thigh changed. Looks clean. Salve applied to groin rash. MS: Pt stayed in chair for day. She will stand up ocassionally with minimal support, but tires easily and needs to sit. She requested and received 1mg po ativan this afternoon. She slept for a short time only after receiving it. A: Decreased dopamine. Decreased c/o. Increased u/o P: Continue to monitor hemodynamics. Decrease dopa as tolerated. Encourage po intake. ||||END_OF_RECORD START_OF_RECORD=1||||41|||| Neuro: Pt is A&O x3. Pt is frustrated with beigng in hosp. Pt able to move all extremeties well, Pt able to take small steps to camode, chair and bed. Cardiac: Pts rhythm is AV paced, HR in the 72, BP, pt is hypotensive. Attempt to keep SBP > 90. Pt has R IJ SWAN. PA pressures 60's-70's/20's, Wedge 16, CVP in high teens. Fick sent off in am. Pt on Dopa, initially on 8mcg, decreased to 7mcg, attempted to decrease to 6mcg, but pts BP decreased into the 80's. Pt on Milnerone at .35mcg, Pt on 700u/hr heparin; AM labs pending. Pt also has R rad al, and R IJ cordis. Resp: Pt is on 2L NC, decreased from 4L pt hving nose bleeds, and O2sat mid to high 90's on RA, therefore decreased O2, O2 sats on 2L are in high 90's. BS clear in upper lobes, and rales in lower lobes. Pt denies SOB. Question dx of pneumonia. GI: Pt has pos BS. ABD is greatly firm and distnded secondary to R heart failure. Pt has poor appetite, pt ate 2 packages of crackers last night, pt informed about fluid restriction, and importance of nutritional consumption. Pt up to camode x2. no BM GU: Pt on lasix drip at 9 mg/hr. Goal is to be -100cc q hr. Pt putting out adequate uring output. Skin: Pt has small breakdown on L upper thing, healing nicely, pt has wet to dry dsg, BID changed at 2100. Pt had protective lotion placed multiple times. Pt has much pain in rectup, pt given supposortory. Misc: Pt received 2mg MSO4 for severe R foot pain, med resolved pain. Pt slept for majority of night. No tmax. ||||END_OF_RECORD START_OF_RECORD=1||||42|||| S: "I definitely feel better" O: For complete VS see CCU flow sheet. ID: T-max 99.6po. Cont on ABX. CV: Pt remains on milrinone at .35mic/kilo. 2.5 enalapril given today and tolerated. Dopamine only decreased to 6.5mic/kilo with BP in low 90s/40s up to high 90s. HR stable in 70 av paced. K+ 3.7 in am and pt replaced with 40meq IV and repeat K+ was 4.1. PAP continue to decrease slightly, epecially right heart pressures: PAP 50/18-21, wedge 17, and RA [**09-11**]. Heparin continues at 700u/hr with just theraputic PTT. Pt overall feeling better. RESP: Pt now sating 95-98% on RA and 100% on 2L. Contd. rales up 1/4 on R and at bases on L. GU: Urine output excellent on 9mg lasix/hr. Pt 1400cc neg thus far today. GI: Pt continues to request commode ~ Q1 hour, despite not moving bowels. She did receive suppository and had very small hard stool. Apetite poor, though she will drink nutrashakes. SKIN: Rash on groin continues red and sore. Barrier cream applied frequently. Small wound on upper thigh appeared healed over this am and dry sterile dsg was applied. It should continue to be assessed to ensure it continue to heal appropriately. A: Stable on mirinone. Tolerated vasotec. Unable to wean dopa further P: Monitor I & O carefully. Increase lasix if necessary. Contue trying to wean dopamine. Comfort: Pt feeling stiff and achy. She received 1 tylenol #3. She spent day in chair. ||||END_OF_RECORD START_OF_RECORD=1||||43|||| Neuro: Pt is A&O x3 Pt, moves all extremeties well, pt OOB to cardiac chair and camode many times. Pt claims "I want to go home tomorrow." I spoke ot MD and he stated that he would talk to pt tomorrow. [**07-03**] Cardiac: Pt has cordis, swan, and R rad AL. Pt is AV paced at a rate of 71. Pts BP dopa dependant, Order written to maintain SBP of 80. Pts BP in 80's to 100's systolic, very low map. Pts PA pressures 50's/high teen's to low 20's. CVP 12-14, wedge 15-19. Pt on .35mcg Milrinone, currently on 6mcg of dopa, Order written to [**Last Name (un) 24**] dopa off and to maintain SBP of 80; dopa decreased to 4.5mcg from 6.5mcg, when urine output decreased to zero, despite lasix drip being increased to 12 from 9 mg/hr. When dopa increased to 6mcg urine output immediately increased. Pt kept on 12 mg of lasix to compensate for decreased urine output of 4-5 hours. Lasix may need to be decreased back to 9mg. Pt goal is -100cc/hr. Pt on 700u/hr heparin. AM labs pending, no CO or SVR avaliable to write in report. Resp: Pt on 2L O2 via NC. Pts O2 sat high 90's. BS clear in the upper lobes, rales in lower lobes bilaterally. Pt denies SOB. GI: Pt is on low salt and low cholester diet, however pt has no appetite. Abd is firm and distended secondary to ascites from R heart failure. No tap in near future. decreased BS. Pt is bowel obsessed, pt requests to go to camode multiple times a shift, unable to stool. 2 days ago pt given a supposotory and had large BM, since then pt has not eaten to produce stool. Pt con't to request and insist that she has to have a movement. Pt will drink neutri shakes, please encourage her to do so. GU: As explained above, pts goal of -100cc/hr, urine decreased to zero secondary to [**Last Name (un) 24**] of dopa, lasix increased to 12 mg from 9 mg without effect, dopa then increased again, immediately increasing urine output. Skin: Pt has small lesion on L thigh Wet to dry dsg, changed at 2300, appears to have signs of healing well. Pt has significant rash in peri area, barrier cream applied multiple times a shift. May need something stronger. ||||END_OF_RECORD START_OF_RECORD=1||||44|||| REMAINS STABLE w/ swan ganz catheter, off millrinone gtt, on dopamine gtt, heparin gtt, lasix gtt. ROS: CARDIAC: d/c'd millrinone w/ increased svr. Tolerating slow dopamine taper, decreased lasix gtt. Pain free. Swan remains in place. (see careview for data). Began vasotec, to monitor through night and repeat dose @ 6am, with numbers for rounds. Slow taper dopa if tolerates. Recheck ptt 11pm. She has very good activity tolerance w/ transfer to and from chair multiple times w/ only assistance required for management of lines. RESP: on room air w/ good sats. GI: taking good po intake...adequate nutrition. To commode, no stool. Distended abdomen r/t acites. GU/RENAL: excellent response to lasix gtt, requiring tapering gtt. Bun 30/cr 1.1 HEME: hct 26.7...for unit prbc tonight. ASSESS: stable, tolerating slow wean from dopa. PLAN: for unit prbc, recheck numbers this evening, monitor urine output, for PPD plant by intern ||||END_OF_RECORD START_OF_RECORD=1||||45|||| S- " I NEED TO GET OUT OF THIS CHAIR.." O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- VS REMAIN STABLE. HR- 70-'S AV PACED- NO VEA. BP- 88/42- 90/40- REMAINS OFF MILRINONE AND ON DOPA 5.5 MCG/KG. REPEAT CO/CI OFF MILRINONE- SIMILAR TO PREVIOUS- 5.3/2.98. UNABLE TO CALCULATE SVR B/C CVP PORT DAMPENED/UNABLE TO FLUSH. STARTED ENALAPRIL 2.5 MG BID. PAD- 20-24/ PCW- 20-22. HEPARIN GTT CONTINUES 800U- PTT- 60. OUT OF CHAIR TO COMMODE FREQUENTLY WITHOUT RESULTS. TOLERATING INCREASED ACTIVITY BUT REQUIRING MUCH ASSISTANCE WITH LINES. RESP- PT REMAINS ON ROOM AIR- O2 SATS MID 90'S. DIURESING WELL TO 8 MG/HOUR LASIX- I/O- -1400CC AS OF 12 AM. OVERALL (-) 15 LITERS FROM ADMISSION. GU- SEE ABOVE- UO- 75-120/HOUR. NO CHANGE WITH LASIX GTT DOSE. GI- ATTEMPTING COMMODE CHAIR- NO RESULTS. ID- AFEBRILE- HEME- HCT- 26.7 IN AM- SET UP AND TRANSFUSED WITH ONE U PRBC 12AM. MS- PT VERY ALERT AND AWAKE- OUT OF THE CHAIR TO COMMODE - NOT WANTING TO GET BACK TO BED UNTIL AROUND 2AM. CURRENTLY RESTING ON/OFF IN BED. A/P- PT S/P CV SHOCK/CHF CURRENTLY RESPONDING TO DIURESIS/MILRINONE TRIAL. CONTINUE LASIX/DOPA TO KEEP U.O > 100CC/HOUR. CONTINUE TO MAX RPP- ENALAPRIL AS ORDERED- CHECK CO/CI ON DOSE. CONSIDER REMOVING PA LINE TODAY TO ALLOW FOR INCREASED MOBILITY NOW THAT DIURESED WITH STABLE CO/CI MUCH SUPPORT. CONTINUE PRELIMINARY HEART TRANSPLANT W/U. ||||END_OF_RECORD START_OF_RECORD=1||||46|||| s: i haven't gone yet(bm) o: pls see carevue flowsheet for complete vs/data/events cv: hr 70s av paced. bp 82-98/45-50 via r rad aline. dopa weaned off this eve with drop in bp to 80s/ but well tol. co remains acceptable at 5.1/ci 2.87. (unable to do svr b/c cvp port in nonfunctional). enalapril at 2.5mg bid. pt rec'd an additional 2.5 this afternoon. pap: 50-60/23-25. heparin at 850u/hr. ptt 59.7. resp: basilar cxs. no sob. ra sat 94-98%. gu: foley to [**Last Name (un) 25**]. uop dropped from 100-120cc/hr to 40 then 10cc/hr as dopa was weaned , then dc'd. lasix gtt to be increased from 8 to 10mg/hr. currently 350cc neg from mn. gi: tol diet with fair intake. no n/v. feels she need to have a bm. on the commade at least once an hour without results despite mom x2. ms: a+ox3, cooperative. oob with min assist for lines, etc. visiting with friends this [**Name2 (NI) 26**], in good spirits. a: dopa off with fall in uop. p: follow co this eve. assess response to ^'d lasix gtt. ?need for more aggressive bowel meds. provide info and support to pt and family. ||||END_OF_RECORD START_OF_RECORD=1||||47|||| CCU NURSING PROGRESS NOTE 11p-7a NEURO: awake, a&ox3. Pt independently oob-> chair/commode. Tolerated well. RESP: LS clear. Sats 94-95% on room air. CARDIAC: BP 90's most of the shift. Will intermittently dip to mid 80's (of note, a-line is very positional). C.O. up to 9 and CI 5.06 this am. Remains off dopamine and milrinone. Tolerating po enalapril. Pt did receive additional dose of lasix preceded by 5mg po zaroxolyn with minimal results. Pt 176cc negative this am (however, noted pt voiding around foley cath-> therefore was dc'd this morning). GI: Tolerating cardiac diet. Taking good po's. Pt up to commode several times overnight with urge to void and stool, however only one lg black liquid stool mixed with urine. GU: foley with minimal urine output most of the shift, however as noted above, foley was leaking and appeared to be mostly out this am. Catheter has been dc'd. Pt instructed to save all urine in commode. ID: afebrile ||||END_OF_RECORD START_OF_RECORD=1||||48|||| ccu nursing progress note 7a-7p neuro: alert, oriented x3. pt becoming anxious at times through day. attempts made to calm pt with some success. cv: hr 70's av paced. bp 88-102/50-60's. pap's 48-56/24-28. svo2 66-69. most recent co 5.5 ci 3.09 off dopa and milrinone. tolerated enalapril 2.5 this am, dose remains same at present and given this evening. lasix changed to 90mg q 6hr, next dose to be given with zaroxolyn and then to zarox to be qam. heparin 850 units/hr turned off at 2:30 for paracentesis, to be restarted later this evening. pt to be seen by tranplant team in am, and to have tee at 11 am tomorrow. pulm: ls clear. sats 99% r/a. denies sob gi/gu: fair po intake. us guided paracentesis today removed 3700cc. pt voiding on commode approx 100cc/hr. access: pa line and right radial aline. plan: tee in am. cont transplant workup. to receive zarox and lasix this eve, then to start ? nitroglycerin iv. cont monitor pa pressures and diuresis. ||||END_OF_RECORD START_OF_RECORD=1||||49|||| npn 7p-7a ccu nsg progress note: s:"leave that side rail down" o: pt a&ox3, mae, skin w&d, color pale, does not have any c/o's throughout the noc, does get up to commode/chair several times during noc w/assistance. no c/o sob, no cp, ls cta, sats on ra 95-97%, rr 18-20, hr 70's av paced, bp 79-93/30-40, pa #'s 46-60/18-30, ntg gtt started at 2.5mcg, co/ci after being on ntg up to 6.6/3.71, am #'s pnd, hep gtt restarted at 11pm post paracentesis, am ptt pnd, conts to diuresis, given zaroxyln last pm prior to lasix, has been voiding w/out diff approx 100cc/hr, conts to tol enalapril 2.5mg w/out any change in bp, pt has been npo during noc for tee this am, also plan is for transplant team to see pt this am, abd soft, non tender to palpation, (+)bs, site where tap was done remains dry/intact, pt states that she does not change in abd since fluid removed a: chf/heart failure p: cont current treatment for heart failure f/u w/transplant team after eval today ?d/c swan or cont to monitor #'s cont diruesis ||||END_OF_RECORD START_OF_RECORD=1||||50|||| She remained stable ...stable v.s....stable filling pressures while awaiting TEE. Seen by Cardic Transplant surgeon. She initially agreed to the TEE, asking appropriate questions. She was npo after mn for TEE that never happened. She was irritated , speaking at length w/ the team regarding her wishes, concerns and direction regarding transplant vs. going home. primary MD to come today to consult w/ her and the team. Transfers independently bed to chair to commode etc. w/out difficulties. Good balance. No sob. On room air. Remains on tiny dose nitro. Heparin gtt. Taking po. Assess: stable. PlAN: per outcome of team discussion w/ primary. ||||END_OF_RECORD START_OF_RECORD=1||||51|||| S. "I JUST WANT TO GO HOME! - NO MORE TESTS!" O. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA CV: HR 70'S AV PACED, BP 70-87/30'S, RUNNING IN 70'S SYSTOLIC FOR SEVERAL HOURS AFTER RECEIVING ENALAPRIL 2.5MG AT 5:30 PM, ASSYMPTOMATIC, PA P'S 50'S/24-26 WHILE SITTING UPRIGHT, 69-76/36 WHEN LYING IN BED/RE-ZEROED, CO/CI AT 10P = 6.1/3.43 - UNABLE TO OBTAIN CVP - PORT CLOTTED OFF; RECEIVING LASIX QID - TOTAL 2.5 LITERS NEGATIVE TODAY; PTT ON HEPARIN 700U/HR = 42 - RECEIVED 1200U BOLUS AND INCREASED GTT TO 800U/HR AT 6 PM, PTT DUE AT MN RESP: SATS HIGH 90'S ON ROOM AIR, LUNGS CLEAR GI: TOLERATING CARDIAC DIET IN SMALL AMTS, NO STOOL GU: VOIDING WELL IN BEDPAN MS: A+O X 3, REQUESTED ATIVAN 1MG PO X 1, PT STATES SHE IS "HAVING A BAD DAY EMOTIONALLY" - "I'M READY TO GIVE UP - I DON'T WANT ANY MORE TESTS." "I DON'T WANT TO HAVE A TRANSPLANT!" - AFTER LONG DISCUSSION W/DR. [**Last Name (STitle) **]/RN, AGREED THAT GOALS OF CARE WILL BE TO FOCUS ON GETTING PT ON ORAL REGIMEN THAT SHE CAN GO HOME ON; PT TOLD THAT WOULD TAKE SEVERAL DAYS AT BEST; LATER IN EVENING PT CONTINUED TO NEED REINFORCEMENT THAT WE DID NOT WANT TO DO "MORE TESTS" ON HER AT THIS TIME AND THAT WE WILL NOT CONSIDER TRANSPLANT AT THIS TIME PER HER WISHES. SOCIAL: HUSBAND IN TO VISIT X 1HR THIS EVENING A: DROP IN BP AFTER ENALAPRIL 2.5MG - ASSYMPTOMATIC PAP'S REMAIN HIGH DESPITE CONTINUED DIURESIS EMOTIONALLY STRESSED W/LONG HOSPITALIZATION P: FOLLOW HEMODYNAMICS OVERNIGHT ON PRESENT MEDICAL REGIME ? D/C SWAN/A-LINE IF STABLE OVERNIGHT, PROVIDE EMOTIONAL SUPPORT, REINFORCE PLAN W/PATIENT, PRN. ||||END_OF_RECORD START_OF_RECORD=1||||52|||| O: SEE FLOW SHEET SECTION FOR CLINICAL INFORMATION: NEURO: ALERT, ORIENTED X 3; APPROPRIATE. PSYCHOSOCIAL: PLEASANT; AFFECT NOT DEPRESSED DURING NIGHT CV: AV PACED; BP RANGE REFLECTING VERY LOW DOSE IV NTG, PO VASOTEC, IV LASIX; PAD'S 24- 37 WHEN RESTING IN BED; PAD'S INVALID WHEN OOB TO CHAIR; ON IV HEPARIN AT 900 UNITS/HR PER PROTOCOL; RESP: O2 SAT 95,96 ON ROOM AIR. RENAL: OOB TO COMMODE- VOIDING QS POST LASIX. GI: TAKING SIPS OF CRANBERRY JUICE; MAINTAINING GOOD FLUID RESTRICTION; NO BOWEL MOVEMENT OVERNIGHT. ACTIVITY TOLERANCE: OOB TO CHAIR AND COMMODE- TOLERATED WELL WITHOUT FATIGUE OR SOB. A: NO ACUTE CARDIAC OR RESPIRATORY DECOMPENSATION THIS NIGHT; SPIRITS SOMEW HAT IMPROVED. P: AWAIT AM LABS, CO/CI; MAINTAIN IV NTG, IV HEPARIN; ATTEMPT AT INCREASING PO VASOTEC; FOR POSSIBLE TRANSFER TO PCU LATER THIS DAY. ||||END_OF_RECORD START_OF_RECORD=1||||53|||| 58 y.o. woman w/ cardiomyopathy admitted to hospital [**2000-05-30**]. (see past hx from admit note). Readmitted to CCu [**06-26**] from cath lab on milrinone gtt for PA monitoring while med management and evaluation for cardiac transplant. Swan and a-line out today, maximixed med management, for transfer to floor. CARDIAC: Pt not interested in cardiac transplant at this time. Being followed closely by Dr [**Last Name (STitle) 19**]. HR 72 AVP. B/P 78-80's SBP. Using mental status as guidline regarding med parameters, not b/p. pain free. On aggressive daily diuresis. Prn electrolyte replacements. On heparin gtt 900u/hr. RESP: room air w/ sats mid 90's. No sob. GI; taking po. ACTIVITY: needs asst w/ some bathing adl's, otherwise independent bed->chair->commode. tolerates well. PT following w/ exercises. WT [**07-05**] 59.2kg. peripheral lines #20x2 R arm. Aline d/c today w/ pressure dsg. R cordis and swan d/c today w/ dressing. SKIN: rash on back of legs ? etiology, has this skin, tearing easily w/ tape. Tape tears on R arm w/ tegraderm overlay. Neuro: intact, expressions of depression w/ several requests to go home. Followed by social service. SOCIAL; l/w husband who visits daily and involved in care. ASSESS; stable for transfer to cardiac floor PLAN; monitor volume status, electrolytes, discharge planning, check ptt 10pm tonight. ||||END_OF_RECORD START_OF_RECORD=1||||54|||| S: " I don't feel good " O: 58 yo female with severe CAD, EF 20% in hospital since [**05-31**] for treatment of progressive CHF, recently d/c'd from CCU after aggressive diuresis and inotropic support. Now re-admitted to CCU after progressive increase in creatinine and decrease in u/o. went to cath lab for right fem. swan showing RA 20, PA 80/30, W 35, MVO2 48%. PMH: CAD, CABG '[**94**], all grafts occluded. echo [**1990-04-27**] showing EF 20-25%, severe TR. baseline BP 70's -80's/ on floor. AV paced 70 creatinine up to 2.3(1.6) [**07-12**] with poor u/o despite >1liter fluid. foley placed on floor for only 30cc. decesion made to take to cath for swan. tolerated cath . opening pressures as above. started on dopa up to 10mcq with BP up to 90-110/. 60mg lasix IV -> 850cc responce. also started on nipride at .07mcq/kg/min. arrived to CCU at 2300 [**07-12**]. CCU: neuro: awake, cooperative. ativan 1mg po at 0200 for general anxiety with moderate effect. light sleeper. CV: HR 70-72 AV paced. BP on arrival 93/40. dopa at 10mcq, nipride .07mcq/kg/min and heparin 850u/hr. MVO2 72%, C.O. 7.1/4.1. u/o 350-400cc/hr with BP 94-99/30-40, therefore dopa decreased to 7.5mcq at 0145. BP down to 80-85/40 and u/o only 100cc in 1 hr. - dopa increased to 9.0mcq at 0315. heme: HCT 26.5 (7pm [**07-12**]) down from 28 in AM. tranfused one UPRBC 2400-0400. tol. well. resp: sats 96-97% on 4lnc. LS diminished bases. clear upper. denies SOB renal: plan renal U/S per resident. pt. had c/o right flank pain on floor. here, c/o general abd discomfort, some nausea which she states she has had before. also anxious, given ativan and able to sleep. skin: pink/red rash between legs, using myconizole cream. A: decompensated hear failure requiring ICU stay for inotropy and diuresis P: follow PAP's, u/o, lytes, HCT 2 hours after transfusion. titrate dopa for u/o 200cc/hr, nipride, heparin ||||END_OF_RECORD START_OF_RECORD=1||||55|||| n-quite somulent this am, flumazinal given-gradually more alert and appropriately interactive throughout the day, r-ra sats 98% breathing comfortably minimal biasilar crackles cv-av paced 70, Map's>60 on dopa at 8 mcg's, co/ci pa sats improved to 5-6/3-4/0-80 and has duireses 4liters since mn without lasix r fem pa line intact, iv hep at 850u/hr ptt 80 gi-poor po intake , primarily just po fluids gu-auto diuresing afebrile c/o sore back-slight red bottom-frequent re-position, 1 perc prn with fair response thus far a/p-improving heart failure with dopa, continue all current supports ||||END_OF_RECORD START_OF_RECORD=1||||56|||| O:CRYING @ X'S NOT SURE WHY-WITHDRAWN. SL CONFUSED-WONDERING WHEN SHE'S GOING TO GO BACK TO THE HOSPITAL. BRREATH SOUNDS-CLEAR. SATS UPPER 90'S. HEMODY STABLE. PAD'S LOW TEENS. DOPA & HEPARIN INFUSING AS ORDERED. EXCELLENT UO. AFEBRILE. AM LABS SENT. A:TIRED OF BEING IN HOSPITAL. RESPONDING TO DOPA GTT W EXCELLENT UO. P:?ATTEMPT TO GET PT HOME W ASSISTANCE. CONTIN DOPA GTT-MAINT ADEQ UO. ?DC PA/INTRODUCER-NEEDS CENTRAL ACCESS. SUPPORT AS NEEDED. ||||END_OF_RECORD START_OF_RECORD=1||||57|||| n-weepy, states she doesn't want to die and doesn't want to be here, alert and appropriately interactive but depressed and has had enough of the constraints of icu monitoring r-bbsds, cta, rr teens breathing comfortably sats>98% cv-av paced 71, bp 90/37 pads teens, co/ci 4-6/2-4 pa sats 60-70 added back enalapril, weaned dopa to 5 but bp 80's and uo decreased therefore increased to 6 and bp just above 90 uo 50/cc hr- attempting to wean dopa to stable dose to allow adequate uo/bp, r fem pa line intact- attempted picc today unsuccessful-plan to do with IR on monday gi-poor po intake-no stool-bowel meds given gu-qsuo via foley approx 50 cc/hr at presetn dopa of 6, creat had returned to 1.1 will follow afebrile husband in and updated a/p-dopa dependent, needs new central access, follow hemodynamic parameters and fluid volume balance ||||END_OF_RECORD START_OF_RECORD=1||||58|||| NEURO: A&O X3. DEPRESSED D/T LENGTHY HOSPITALIZATION. TEARY DURING BEGINNING OF SHIFT. DID NOT WANT TO HAVE HER LINE RE-SITED. GIVEN ATIVAN .5MG IV X1 PER HO. SLEPT WELL AFTER LINE CHANGE. RESP: O2 SATS 95-97% ON RM. AIR. BS CLEAR. RR 12-19. CARDIAC: HR 70-72 AVP. BP 84-98/23-46. PAD 12-20, CVP 11, CO 5.7/3.33. DOPA 6MCG/KG->8MCG/KG D/T HYPOTENSION & LOW U/O. R. FEMORAL SWAN D/C'D. RIJ TRIPLE LUMEN PLACED. CXR DONE, & PLACEMENT CONFIRMED. HEPARIN RESTARTED 3HRS AFTER LINE PLACEMENT, & INFUSING AT 850U/HR. HCT 35. GI: ABD. DISTENDED. BS HYPOACTIVE. NO STOOL. GU: FOLEY -> CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 65->20CC/HR. INCREASED TO 30-100CC/HR AFTER INCREASING DOPA. ID: T(MAX)98.7(PO). AM LABS PENDING. ||||END_OF_RECORD START_OF_RECORD=1||||59|||| Neuro: Pt is A&O to TPP, pt moves all extremeties well. Pt OOB to chair, and camode many times! Cardiac: Pt HR is AV paced, BP in 80's. Tolerating well. Pt has a R IJ TL. Pt on 8mcg dopa, will go home on dopa, pt on 1400u/hr heparin. PTT theraputic. Resp: Pt on RA O2 sat in high 90's. BS clear. GI: Pt is on cardiac diet. Pt to camode many times, +BS pt has very hard pellets of blak stool, guiac pos. Pt may need to be disimpacted. Abd soft nt. GU: Pt has f/c adequate urine output with the 8mcg dopa. Misc: pt will be evaluated for picc, for home with dopamine. ||||END_OF_RECORD START_OF_RECORD=1||||60|||| PT IS ON 850U/HR HEPARIN NOT 1400U/HR. [**Doctor First Name 27**] ||||END_OF_RECORD START_OF_RECORD=1||||61|||| S: " My legs hurt " O: HR 70-72 AV paced. BP 84/40 at 2000, increasing to 91-109/37-61 through rest of night. dopa at 8mcq, heparin at 850u/hr. u/o 30-50/hr. c/o leg pain, stated good relief with one percocet. pt. c/o constipation. given colace. had large loose stool in eve, able to walk to bedside commode. then had uncontrolled diahrea ~ 12am, large amt. on floor, etc. assisted to commode. guiac pos. dark brown/black. up to commode twice since then but only passing gas or very small amt of stool. taking water and juice only. pt. requesting to stay up in cardiac chair through night. able to get up on own and to chair side commode with minimal assist. very steady on feet. no c/o dizziness. LS diminished. RA sat 96%. A: stable hemodynamics on dopa 8mcq diarhea s/p constipation P: hold stool softeners, follow lytes, VS. follow plan for dopa titration. ambulate in room as tolerated. ||||END_OF_RECORD START_OF_RECORD=1||||62|||| S/O: BP 88-104/30's, HR 71 AV paced. u/o 30-50/hr. (-) 250cc for 12am and currently ~ 70cc (-). Dopa at 8mcq and heparin at 850u/hr. pt. prefers to stay up in cardiac chair , more comfortable. also has had to use commode freq. so this makes it easier. - had 2 large loose brown stools in eve, discussed with HO and ordered immodium po for rx of diarrhea. given 2mg x1 and since then has only gone once for small amt. no c/o abd pain/cramps. passing gas. getting up on own, appears steady on feet. LS clear. RA sat 96%. asking questions about planned PICC line placement today and looking forward to going home this week hopefully A: stable rx for diarrhea P: PICC line today. immodium prn, dopa, heparin gtt as ordered. ||||END_OF_RECORD START_OF_RECORD=1||||63|||| pls see carevue flowsheet for complete vs/data/events s: no c/o cp, sob o: cv: hr 70s avpaced. k 3.6, 40meq given. bp 95-105/45-50. cont on dopa at 8mcg/min. tol well. enalapril cont at 2.5mg bid. no cp or sob. resp: ra sat 94-96%. rr 12-20, nonlabored. bs sl basilar cxs. gI: poor intake. no n/v. no bm this shift. gu: foley dc'd at noon. no void yet. act: to commode freq indep. amb approx 40yrds with walker and assist x1. tol well. ms: alert, cooperative. mae with purpose. hoping to go home later this week. dispo: full code. poss transfer to [**Wardname 28**]. plan picc or hickman placement(dr [**Last Name (STitle) **] to decide) when inr< 2.0(today 2.2). a: bp stable on dopa. p: follow uop, dtv. enc amb with assist. d/c planning. ||||END_OF_RECORD START_OF_RECORD=1||||64|||| s: i think i probably will say yes...i really have no other choices now. o: pls see carevue flowsheet for complete vs/data/events cv: hr 75 avpaced. bp 100-109/44-50. cont on dopa at 8mcg/min. tol enalapril up to 5mg bid. heparin infusing at 850u/hr. resp: bs dim at bases. sat 97-99% on ra. no sob. gu: voiding in commode. no diuresis. cr stable. wt 55.1. gi: fair po intake. no stool today. id: afeb. no abx. ms: pt spoke at length w/dr [**Last Name (STitle) **], dr [**Last Name (STitle) **], dr [**Last Name (STitle) 29**] today about prognosis and options. she appears to now understand that a transplant represents her best option for survival and that going home with iv dopa will be palliative and that she would not be expected to live more than a few months. she will speak further with her family and let dr [**Last Name (STitle) **] know her decision so plans can proceed for either option in the morning. a: bp stable. p: provide info and support to pt and family. cont to monitor rhythm, bp, uop. ||||END_OF_RECORD START_OF_RECORD=1||||65|||| Uneventful nite VSS. Remains on Dopamine @ 8mcg/k/min, Heparin @ 850u/hr. Slept well overnite in bed, rec'd 1 dose of 0.5mg Ativan for sleep after midnite w/ good effect. No c/o of CP or discomfort. see careview for details. ||||END_OF_RECORD START_OF_RECORD=1||||66|||| S-"I have agreed to go ahead with the transplant" O-Neuro alert and oriented x3, very pleasant and cooperative. c/o feeling tired and slept until 9am. Has agreed to have the heart tranplant work-up and Dr [**Last Name (STitle) 19**] team is coordinating the lab test and ultrasound (completed carotid and vascular ultraounds) Husband in this afternoon, somewhat supportive. CV-VSS remains on dopamine at 8mcg/kg/min with SBP 87-94/30's HR 70's AV paced. Resp-LS diminished, no O2 O2 sats 97%No SOB with minimal activity in room. ID-afebrile WBC 8.7 GU-voiding well in commode without assist. GI-Appetite good, no BM today. Activity-OOB room and chair most of the day. A/P-stable day,no c/o SOB. Have PT see pt QD to ambulate and do strengthing exercises. ||||END_OF_RECORD START_OF_RECORD=1||||67|||| Uneventful pm VSS. AVpaced 70. remains on DOPAMINE@8mcg/k/min, HEPARIN @ 850u/hr. am labs pending. Slept in bed overnite. Up to bedside commode. No voiced complaints. PLAN: con't to monitor VS. con't work up for heart transplant. offer emotional supports to pt + family. ||||END_OF_RECORD START_OF_RECORD=1||||68|||| S-"I can't believe this is all happening." O-Neuro alert and oriented x3, pleasant and cooperative. Asking appropiate questions about surgery. Feels sheis getting stir crazy and would like to go outside (weather permitting). Husband in and brought in steak that really picked her spirits up. CV-VSS dopamine remains at 8mcg/kg/min with stable BP 85-100/40. Resp-LS clear no SOB with activity. PFT's completed in lab. ID afebrile GU-voiding well on commode, weight remains stable at 55.1kg GI-appetite improved no BM today. Feels constipated after starting Fe. Activity- Physical therapy in and did some exercises with her and then went for walk in hallway. BP 78 after walking, although asymptomatic. No c/o chest pain or SOB. c/o general leg aching relieved with tylenol A/P-stable day. Encourage exercises in room. Possibly allow pt to go outside if weather OK over weekend. Goal keep weight stable at 55kg ||||END_OF_RECORD START_OF_RECORD=1||||69|||| S: " I want to go home " O: pt. teary eyed and upset in eve. feeling "stir crazy" and wanting to get out of room more. ambulated with walker around unit( with RN) and did well. felt better after. ativan .5po for sleep with good effect. dopa 8mcq. heparin 850u/hr. BP stable. voiding on commode. A/P: situational depression r/t hosp. ambulate more during day. ? assist outside with wheelchair. ||||END_OF_RECORD START_OF_RECORD=1||||70|||| bright spirits today, walking out of unit no s/sx card/resp compromise on heparin/dopa at constant doses eating/drinking/voiding independently husband in an updates continue all current supports-pre-heart transplant ||||END_OF_RECORD START_OF_RECORD=1||||71|||| NSG NOTE S:" I FEEL BETTER SITTING UP IN THE CHAIR" O: CARDIAC: 71,REMAINS AVPACED. SBP 89-117/40-78. CON'T ON DOPAMINE @ 8MCG/KG AND HEPARIN @ 850U/HR. DENIES CP. RESP: REMAINS ON RA STAS 99%. RR-REG 14-22 BS CL. DENIES SOB. GI: NO STOOL THIS SHIFT. C/O CONSTIPATION. DULCOLAX X2 TABS @ HS GIVEN. TOL PO'S DENIES N/V. ABD SOFT. GU: UP VOIDING ON COMMODE IN ADEQUATE AMT'S. SKIN: APPEARS GROIN RASH IS IMPROVING. SL REDDENED. DENIES DISCOMFORT. NEURO: IN GOOD SPIRITS. PLEASANT AND COOPERATIVE. ORIENTED X3 COMFORT: C/O BILAT FT PAIN D/T ACTIVITY. PERCOCET X2 TABS WITH GOOD EFFECT. ACTIVITY: OOB UP TO CH. AMBULATING UP TO COMMODE. TOL INCREASE ACTIVITY WELL. A: STABLE P: AWAITING W/U REGARDING HEART TRANSPLANT AM LABS SUPPORT WHEN NEEDED ||||END_OF_RECORD START_OF_RECORD=1||||72|||| S-"It felt good to take a shower" O-Neuro alert and oriented x3, very pleasant and cooperative. In very good spirits today. Took a shower and washed her hair and wore plain clothes all day. A friend of the pt came in today who had a heart transplant at [**Hospital 30**]. This friend was a great boost in her spirits and she asked good questions about the transplant. CV-VSS on dopamine at 8mcg/kg and heparin at 850u/hr PTT 59.9 Resp- LS clear O2 sats 97% on RA ID afebrile GU-voiding intermittantly on the commode weight stable GI-appetite good, no BM- having cramps Activity-OOB walking today in room and alittle in hallway. Alittle shaky but no SOB or pain. Did well in shower with supervision. Social-Friends into visit and husband in and brought pt pasta for dinner and clean clothes for Sunday. A/P-Stable day. Needs encouragement to do her exercises in her room. Follow HCT. ||||END_OF_RECORD START_OF_RECORD=1||||73|||| CCU NURSING PROGRESS NOTE 7P-7A NEURO: ALERT, ORIENTED X3, COOPERATIVE. GOOD SPIRITS. CV: HR 70'S AV PACED. BP 89-98/40'S. DENIES CP/PRESSURE. CON'T ON DOPA AT 8MCG/KG/MIN AND HEPARIN AT 850 UNITS/HR. WEIGHED THIS EVENING, ^59.5 (FROM 55.1) BILAT PEDAL EDEMA NOTED. PULM: LS CLEAR. DENIES SOB. GI/GU: ABD SOFT/DISTENDED. +BS. C/O CONSTIPATION. GIVEN MOM X1. NO BM THUS FAR. VOIDING VIA COMMODE. COMFORT: PERCOCET GIVEN FOR BILAT FOOT PAIN R/T ACTIVIT PLAN: CONT AWAIT RESULTS OF W/U RE: HEART TRANSPLANT. ? IF PT NEEDS TO RESUME LASIX. MONITOR LABS INCREASE ACTIVITY AS TOLERATED. SUPPORT AS NEEDED ||||END_OF_RECORD START_OF_RECORD=1||||74|||| S-"I spoke to the surgeon this evening" O-Neuro alert and oriented x3, slept until 11am felt she needed the extra rest. Was in very good spirits today. Surgeon from [**Hospital1 31**] in this eve to talk to pt. Pt felt much better talking to him this time c/w last time when she was not ready to talk about any surgery. c/o headache tyelnol 650mg po. CV-VSS on dopamine 8mcg/kg and heparin at 850u/hr. Noted HR increased this afternoon to 83-85NSR with PVC's. Resp-LS clear ID afebrile temp 99po GU-voiding intermittantly on commode. Weight stable at 55.5kg(55.1) GI-still c/o constipation took po dulcolax and might take ducolax PR this eve. Activity-OOB room and took walk this eve with husband around the unit. Still weak and requiring a walker c/o intermittant dizzines with walking. Social-husband in with clothes and dinner. A/P-Stable day, encourage pt to do exercises in room, OOB walking at least 3x/day. ||||END_OF_RECORD START_OF_RECORD=1||||75|||| NEURO: A&O X3. PLEASANT & COOPERATIVE. RESP: BS CLEAR. RR 11-23. CARDIAC: HR 82-88 SR WITH OCC. PVC'S. ~O5OO->HR 106-108 ST-ATRIAL BI- GEMINY. CONT. ON DOPA 8MCG/KG & HEPARIN 850U/HR. ABD US DONE- ? VENOUS MALFORMATION. GI: TOL. DIET WELL. ABD. SL. DISTENDED. BS+. BM X2 BLACK FORMED STOOL. GU: VOIDING QS CLEAR AMBER URINE. ID: T(MAX) 98.8(PO). PLAN: AWAITING HEART TRANSPLANT EVALUATION. ||||END_OF_RECORD START_OF_RECORD=1||||76|||| NSR C OCC PVC. BP 85 TO 98 SYS WHICH IS HER USUAL . LASIX 20 MG MIN RESPONSE . DOPAMINE CONTINUES AT 8 MIC. PTT 65. HEPARIN UNCHANGED . TRANSPLANT SX HAVE REQUESTED FEMOPAL ARTERIOGRAM C STENT IF NECESSARY.PT AGREES TO THIS . NPO P MIDNOC. HEPARIN WILL BE SHUT OFF IN XRAY . TRIPLE LUMEN NEEDED RESUTURING . AREA REDDENED . PT AMBULATING C PT . E/D FAIR. SEVERAL MED TO LG STOOLS GUIAC TRACE TO STRONGLY POS. HCT STABLE . ||||END_OF_RECORD START_OF_RECORD=1||||77|||| O: afeb. HR 80's SR. no VEA. BP 90-100/40. dopa 8mcq, heparin 850u/hr. ambulating around room with IV pump, tol. well. no dizziness. voiding on commode. requesting percocet for headache/leg pain with good effect. slept well through night. LS clear. RA sat 99-100% NPO after MN for fem. Agram. A/P: maintain NPO, ambulate TID , follow daily wts. , I/O. ||||END_OF_RECORD START_OF_RECORD=1||||78|||| S-"I hope this helps me" O-Neuro-alert and oriented x3, in good spirits today prior to arterial angiogram for BLE. Wants to go to [**Hospital1 31**] and wait for heart mostly because her room does not have a BR and it's too small. CV-VSS dopamine at 8mcg/kg with SBP 80-90/50 Heparin at 850u/hr PTT 51 Resp-LS clear no O2 no c/o SOB ID afbrile GU-voiding small amts in commode. Started .45NS at 50cc/hr before procedure and d/c'd it at 6pm. Plan to restart in am. GI-NPO/appetite good this eve. NO BM Skin- rash on abd, less itchy Activity-OOB chair most of the day. Needs to walk more! A/P-NPO after MN restart IVF at 50cc/hr at 8am. ||||END_OF_RECORD START_OF_RECORD=1||||79|||| NEURO: A&O X3. PLEASANT & COOPERATIVE. RESP: O2 SAT ON RM. AIR 99%. RR 13-22. BS CLEAR. CARDIAC: HR 86-94 SR-NO ECTOPY. BP 84-102/39-49. CONT. ON DOPA AT 8 MCG/KG & HEPARIN 850U/HR. PTT56.1. HEPARIN TO BE D/C'D IN AM PRIOR TO ANGIO. GI: TOL. DIET WELL. NPO AFTER MIDNOC FOR AGRAM. GU: VOIDING QS ON COMMODE. ID: AFEBRILE. AM LABS PENDING. PLAN: A GRAM THIS AM HEART TRANSPLANT ||||END_OF_RECORD START_OF_RECORD=1||||80|||| S I NEED A CIGARETTE .DO YOU THINK IT MATTERS NOW. O.RETURNED FROM CATH LAB 12 NOON. AORTIC BLOCKAGES BELOW RENAL ARTERIES NOT AMENABLE TO STENT. PT DEPRESSED AS THIS MIGHT DELAY OR EVEN PREVENT TRANSPLANT . CATH SITE L BRACHIAL MIN BLOODY STAIN ,SOFT , SL SWOLLEN . ARM BOARD TO BE DC 6PM. ULNA, RADIAL PULSE PRESENT BY DOPPLER . HEPARIN DRIP RESTASRTED 850 U 5PM S BOLLUS. TO RECEIVE 1500 CC 1/2 NS. LASIX 40MG GIVEN 5PM . BP 80 TO 90. CO DIZZYNESS P USING COMMODE . PLACEMENT OF LONG TERM LINE DISCUSSED C PT .IF SHE AGRESS LINE WILL BE PLACED BY IR TOMORROW .AWAITING DR [**Last Name (STitle) **] FOR CLARIFICATION OF PLAN. A AT RISK FOR FLUID OVERLOAD APPROPRIATELY DEPRESSED OVER CONDITION P MONITOR FLUID BALANCE ,NOT HO IF NO RESPONSE TO LASIX EMOTIONAL SUPPORT AS NEEDED ||||END_OF_RECORD START_OF_RECORD=1||||81|||| npn 7p-7a: ccu nsg progress note: s:"i'm doing fine" o: neuro--pt a&ox3, not talking much about results of yesterdays cath results of lower ext, sitting up in chair most of night, occ dozing off to sleep, moving w/out diff, did c/o pain to feet, given 1 percocet w/improvment in pain resp-ls cta, no c/o sob, ra sat 95-100%, rr 16-18, appears in nard cardiac--conts on dopa at 8mcg, hep initially at 850u/hr, ptt at 11pm 50.9, no bolus given & gtt increased up to 950u/hr, am ptt & labs pnd, no c/o cp, no dizziness tonight, bp 85-126/70's, pulses to l arm dopplerable, hand warm to touch, dsg to site w/sm old blood spot, no hematoma, ?what plan is today after dr[**Last Name (STitle) 32**] meeting at [**Hospital1 **] gi/gu--no issues, voiding w/out diff, has remained npo since mn for ?hickman placement ||||END_OF_RECORD START_OF_RECORD=1||||82|||| PT REJECTED FOR TRANSPLANT . CRYING AT TIMES . PLAN TO GO HOME ON DOPAMINE . TO XRAY FOR HICKMAN , NO T DONE DUE TO SEDATION ISSUES , WILL REATTEMPT TOMORROW . NPO P MIDNIGHT . DC HEPARIN 7AM . SEEN BY HOME NSG FOR PUMP SET UP . COUMADIN WILL BE STARTED P HICKMAN PLACED. HAS R BRACHIAL IV FOR USE IN XRAY TOMORROW . SEEN BY EPS FELLOW .PT IN FLUTTER.PACER INTERROGATED AND RESET .PRESENTLY IN AV PACED . BP STABLE ON 8 MIC DOPAMINE .HEPARIN STOPPED FOR PROCEDURE . RESTATED ON HEPARIN 3PM . TO HAVE FLU SHOT ,CONSENT IN CHART TO BE SIGNED . ||||END_OF_RECORD START_OF_RECORD=1||||83|||| npn 7p-7a: ccu nsg progress note: s:"i'm not getting the transplant" o: neruo-pt a&ox3, talking about her disappointment in not being a transplant candidate, mae, skin w&d, c/o pain to legs, med w/2 percocet, sleeping in chair most of night resp--ls cta, sat on ra 97%, no c/o sob/doe cardiac--hr av paced at 70's, no ectopy, pt states that she has not been feeling as tired or dizzy since pacer interogated and put back in av paced mode, bp 90-103/50, conts on dopa at 8mcg, hep at 950u/hr, plan for d/c of hep at 7am then to have hickman placed and start coumadin today gi/gu--voiding w/out diff, npo for hickman placment, (+)bs access--#20 iv in r ac to be used for meds while hickman being placed, to go for hickman this am, hep to be turned off at 7am social--pt talking about going home w/pump for dopa, her mother is to visit next week from fla, pt wants flu shot but would like to wait till after hickman placed ||||END_OF_RECORD START_OF_RECORD=1||||84|||| AWAKE AND ALERT VERBALIZING CONCERNS AND DISAPOINTMENT ABOUT TRANSPLANT DENIAL. ALSO VERY ANGRY ABOUT HICKMAN CATH PLACEMENT PROCEEDURE. CONT ON DOPA AT 8 MCG. BP STABLE CONT AV PACED NO VEA. LUNGS CLEAR. O2 SATS 98%. DENIES SOB. TAKING PO WELL. SMALL HARD STOOL. GIVEN MOM AND [**Name2 (NI) 33**]. WILL PROBABLY NEED DULCOLAX. ||||END_OF_RECORD START_OF_RECORD=1||||85|||| S. "I WANT TO GO HOME ON MONDAY!" O. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA CV: HR 70'S AVP, NO ECTOPY NOTED, DOPAMINE REMAINS AT 8MCGS/KG W/SBP REMAINING IN 90'S/ THROUGHOUT DAY; TOLERATING MEDS AS ORDERED HEPARIN AT 1050U/HR - PTT >150, OFF X 1 HR AND DOWN TO 800U/HR AT 2PM; COUMADIN 5 MG PO GIVEN, AMBULATING AD LIB IN ROOM RESP: RA SATS 98-100%, LUNGS CLEAR - DENIES SOB GI: TOLERATING CARIAC DIET IN SM AMTS - COLACE GIVEN -NO STOOL TODAY GU: VOIDING ON COMMODE, I/O'S ~ EVEN FOR DAY ID: TEMP MAX 98.1 PO SKIN: C/O DRY ITCHY SKIN, SLIGHTLY REDDENED ON UPPER BODY FROM SCRATCHING, EUCERIN CREAM APPLIED PRN BY PT, CLARITIN ORDERED X 1 SOCIAL: HUSBAND, OTHER FRIENDS IN TO VISIT OFF/ON THROUGHOUT DAY; TALKING ABOUT WANTING TO GET HOME ON MONDAY A: STABLE ON PRESENT MED REGIMEN - AWAITING DISCHARGE HOME ON IV DOPAMINE - ? MONDAY P: CONTINUE SUPPORTIVE CARE, MONITOR HR/RHYTHM, RECHECK PTT AT 8PM, DISCHARGE PLANNING/EMOTIONAL SUPPORT. ||||END_OF_RECORD START_OF_RECORD=1||||86|||| NPN 7P-7A: CCU NSG PROGRESS NOTE: S:"I AM GOING HOME ON MON!!!" O: NEURO--A&OX3, STATING THAT SHE IS ANXIOUS TO GO HOME ON MON, ASKING FOR PAIN MED FOR PAIN IN LEGS, GIVEN 2 PERCOCET W/GD EFFECT RESP--LS CTA, SAT ON RA 97-98%, RR 18 NOT LABORED, CARDIAC--HR 70'S AV PACED, NO ECTOPY, BP 91-94/50, CONTS ON DOPA AT 8MCG/HR, PTT SUBTHERAPEUTIC, PER PROTOCAL GIVEN 1200U BOLUS & GTT INCREASED TO 900U/HR, REPEAT PTT 89--WITH IN RANGE GI--TOL PO'S W/OUT DIFF, NO STOOL, REC'D COLACE/MOM GU--VOIDING W/OUT DIFF SOCIAL--STATING THAT SHE REALLY CAN'T WAIT TO GO HOME, AND MON IS WHEN SHE WANTS TO GO HOME ||||END_OF_RECORD START_OF_RECORD=1||||87|||| S. "WHAT'S MY INR - I WANT TO GET OUT OF HERE TOMORROW!" O. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA CV: HR 70'S AV PACED, NO VEA, BP 84-98/40-50'S TOLERATING ENALAPRIL, DOPAMINE REMAINS AT 8MCGS/KG VIA HICKMAN CATHETER, HEPARIN AT 900U/HR W/PTT 78.9 INR 1.5 ON COUMADIN 5MG QD RESP: RA SATS 97-98% W/CLEAR LUNGS GI: TOLERATING CARDIAC DIET IN SM AMTS, STOOL X 1 HARD ROWN, RECEIVING COLACE 2-3X/DAY GU: VOIDING WELL ON COMMODE, LASIX/ALDACTONE QD W/I/O'S ~ 500CC NEGATIVE TODAY; WEIGHT STABLE MS: A+O X 3, VISITING W/FAMILY MOST OF DAY, ANXIOUS TO GO HOME ASAP A: STABLE ON PRESENT MED REGIMEN - AWAITING DISCHARGE ON HOME DOPAMINE WHEN INR BECOMES THERAPEUTIC P: MONITOR HR, RHYTHM, BP CONTINUE MEDICAL REGIMEN, EMOTIONAL SUPPORT AND DISCHARGE PLANNING. ||||END_OF_RECORD START_OF_RECORD=1||||88|||| NEURO: AWAKE AND ALERT, SLEPT IN LONG NAPS DURING NOC. ANXIOUS FOR D/C HOME, CONCERNED ABOUT VNA CARING FOR HER AT HOME WITH DOPAMINE AND CODE STATUS. CV: BP STABLE ON 8 MCG/KG DOPA. TAKING ALL CARDIAC MEDS WITHOUT PROBLEM. HR 70'S AV PACED. NO VEA. DENIES CP. RESP: O2 SATS 99% ON RA LUNGS CLEAR. DENIES SOB. GI: SMALL STOOL GIVEN COLACE AND MOM, MAY NEED DULCOLAX OR PO LAXATIVE TODAY. APPETITE FAIR. GU: VOIDING CLEAR YELLOW URINE IN GOOD AMTS. OOB TO COMMODE. SKIN: SKIN ON UPPER TORSO REDENED AND ITCHY. GIVEN ALLEGRA PO FOR ITCHINESS WITH GOOD EFFECT.. NUMEROUS ECCHYMOTIC AREAS NOTED ON ARMS (PT. ON COUMADIN). HICKMAN CATH SITE CLEAN AND DRY. OOB TO COMMODE AND TO SIDE OF BED TO DO PRESCRIBED EXERCIZES BY PT. C/O PAIN IN LEGS, GIVEN 2 PERCOCET. ||||END_OF_RECORD START_OF_RECORD=1||||89|||| PT CONSIDERING CODE STATUS OF DNR.SEEN BY [**Hospital1 34**] NURSE FOR ARRANGEMENTS CONCERNING DOPAMINE PUMP.SHE SAY HUSBAND HAS GOOD UNDERSTANDING, MRS [**Known patient lastname 35**] FAIR .VNA NSG AGENCY HAS NOT ACCEPTED CASE.TO MEET [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 36**] NURSING AGENCY WEN 9AM .INR NOT AT GOAL ,MUST BE . 2.0. PT STATES SHE IS LESS DIZZY BUT TIRED . AMBULATED IN HALL X2 . BP 90 OR ABOVE . AV PACED R. BS CL. SAT 98 RM AIR . HICKMAN CATH DSD CHANGED D/I . VOIDING QS C PO LASIX . E/D FAIR . REQUESTED DULCOLAX SUPP . LIDOCAINE PATCH TO ABD FOR PAIN. ALLEGRA FOR ITCHING. STABLE .DC TO HOME PLAN PROGRESSING SLOW BUT STAEDY ||||END_OF_RECORD START_OF_RECORD=1||||90|||| Pt while asleep slightly pulled out her hickman, a CXR has been ordered. Hickman still flushes and has good blood return. Con't to work with [**Doctor First Name 37**] for txr home. ||||END_OF_RECORD START_OF_RECORD=1||||91|||| awake ,alert ,oriented x3.ambulates around room without difficulty.remains avp with stable bp,dopamine continues at 8 mcq/kg/min.was able to ambulate around unit and out in the hall,tolerated well.skin warm and dry,with multiple ecchymotic and reddened blotches on arms.remains avp at 72 without ectopy. heparin continues at 800 units/hr and coumadin dose has been increased tonight .breath sounds clear,with nonproductive cough,sp02 97% on ra,resp rate in the 20s.abd soft with positive bowel sounds.eating full diet and supplemental drinks.appears to be constipated,had stool softner,refused suppository,was given bisacodyl 10 mg po.remains on daily lasix,voiding clear yellow urine.hickman cath placement was verified by xray,dsg around insertion site was changed for small amount of old serrosanguinous drainage,ports were flushed with ns and heparin per protocol.seen and evaluated by dr [**Last Name (STitle) **].talked with [**Doctor First Name **] from case management about arrangements for home,questionable family meeting planned for tomorrow. visited by husband,multiple phone calls from family and friends. pt agrees to status of dnr. ||||END_OF_RECORD START_OF_RECORD=1||||92|||| hickman cath examined by interventional radiology,cath ok.dr [**Last Name (STitle) **] spoke with husband and pt family meeting in am. ||||END_OF_RECORD START_OF_RECORD=1||||93|||| S-"I'm going home on Thursday", "I hope to live until my daughter's wedding". O-Neuro alert and oriented x3, in good spirits and very talkative about POC and appears to be OK with it. Although getting mixed messages about how long she is expected to live. Her daughter's wedding has been moved up so she can attend this year. Moved her to a room in the unit with a bigger window and this made her very happy. Comfort- having increase pain in her right leg/foot asked for percocett x2 and slept most of the night in the bed with leg elevated. CV-VSS on dopamine at 8mcg/kg and heparin t 800u/hr. Started coumadin received 10mg po last evening. Resp- LS clear NPC ID afebrile GU-voiding infrequent moderate amts of urine in commode GI-appetite good LBM [**08-01**] Activity-OOB walking in hallway with minimal assist. Mentioned that she has approx 10 stairs to the bathroom in the house. Possible have P.T. work with pt on the stairs Wed/Thurs. Access-hichman catheter site scant amt of blood, dressing changed and retaped to prevent pulling while OOB. Social-friends into visit and son came into also this evening. Discharge planning- family meeting at 9am. Husband to arrive at 8am. Discussion about care at home. Hospice/VNA visits.. on dopamine gtt. A/P-stable night prepare pt/family for pt discharge to home ||||END_OF_RECORD START_OF_RECORD=1||||94|||| S IN RESPONSE TO QUESTION " ANY PROBLEMS WE [**Name2 (NI) 38**] DISCUSSED? ""NONE EXCEPT I'M DYING." OPT MET C HOSPICE AGENCY . PLAN FOR DAILY VISITS TO START. WILL ALSO HAVE HOME HEALTH AID AND PT. WALKER/COMMODE ORDERED . MEDICATIONS DISCUSSED C PT,PRESCRIPTIONS WRITTEN .OPERATION OF HOME PUMP REVIEWED C FAMILY .PT TO GO HOME C HUSBAND 930 AM . NO DIZZINESS, BUT FATIGUED. AMBULATED X2 IN HALL . E/D FAIR. LARGE AMT OF STOOL TRACE QUIAC. VOIDING QS. WT 54.8 . A READY FOR D/C HOME P HAVE BLOOD WORK RESULTS PRE D/C ||||END_OF_RECORD START_OF_RECORD=1||||95|||| S-"I am so exhausted after all the visitors" O-Neuro alert and oriented x3, anxious about going home. Tired after a busy day with family meeting and visitors (missed her nap) Voicing some concern about family expecting her to do more at home than she can, and having to entertain visitors at home. Also afraid about having the infusion pumps alarming and no one is around to help her. Awake at 1pm and made pt go to bed and rest. c/o headache and right foot ache received percocett 2tabs. CV- VSS on dopamine 8mcg/kg and heparin at 800u/hr PT/INR pnd 6am. Resp- LS clear no c/o SOB ID afebrile GI appetite good, LBM [**08-02**] GU-voiding intermittant moderate amounts dark amber urine Skin- c/o itching arms/legs. +rash on chest from adhesive tape. Activity- walking in room, did not want to walk in hallway-too tired. A/P-Stable night and ready to go HOME today. ||||END_OF_RECORD START_OF_RECORD=1||||96|||| CORRECTION: Pt on lasix drip not insulin drip. ||||END_OF_RECORD START_OF_RECORD=1||||97|||| addendum: u/o improved to 220-250cc/hr. BP dropping to 70/30 at 0500. pt. also sleeping heavily although does wake easily. dopa increased to 10mcq and BP up to 84-96/40. HCT 29. PTT 70. ||||END_OF_RECORD START_OF_RECORD=2||||1|||| resp note - pt. transferred from cat lab to ccu. Pt. intubated with #8et tube 22at the lip, placed on 7200 ventilator ac tv 700 rr 15 70% fio2 5peep Spo2 100% hr 80 at this time. ||||END_OF_RECORD START_OF_RECORD=2||||2|||| 74 YO WOMAN TRANSFERRED FROM [**Hospital 39**] HOSPITAL FOR CATH/ACUTE MI. PMH: CAD WITH NQWMI [**02-07**], HTN, SUBCLAVIAN STEAL WITH R SBP 40 POINTS LOWER THAN LEFT SBP. EF 50%. EPISODIC EXERTIONAL DYSPNEA AND ANGINA. HPI: PT IN USOH UNTIL [**05-20**] WHEN PRESENTED AT [**Hospital 39**] HOSPITAL WITH SEVERAL HOURS OF SEVERE ABD PAIN AND NAUSEA. POS RUQ TENDERNESS AND INC LFT'S AND LIPASE, ? GALLSTONE PANCREATITIS. PT STARTED ON ABX AND CONSIDERING ERCP. TROP POS AT 5.2 FOR NON-Q WAVE MI AND TRANSFERRED TO [**Hospital1 39**] ICU. AT 2A [**05-22**], PT HAD EPISODE OF FLASH PULM EDEMA REQUIRING INTUBATION, EKG SUPPOSEDLY SHOWED NEW ST DEPRESSIONS IN LAT LEADS. PT TRANSFERRED TO [**Hospital1 2**] FOR CATH. EKG REVEALED TO HAVE LIMB LEADS SWITCHED, NO NEW CHANGES. CATH SHOWED SEVERE LAD AND DIAG DISEASE WITH INC RIGHT HEART PRESSURES, PT BALLOONED AND TRANSFERRED TO CCU. CV: IABP INITIALLY ON 1:1. AUGMENTING 0-12, UNLOADING 0-6. TOL WEAN TO 1:2 BUT SWITCHED BACK TO 1:1 FOR NOC. RIGHT GROIN SITE WITH SOME OLD BLOOD, NO HEMATOMA PALPATED. PULSES DOPPLERABLE AND SOMETIMES PALPABLE, FEET WARM EXCEPT FOR COOL TOES. PA CATHETER IN RA BY CXR, PULLED AT 1600 BY HO. MAPS 68-80'S. HR 70'S-80'S SR NO VEA. HEP STARTED AT 1000U, AGGRESTAT CONT AT 25CC/HR. PROPOFOL STARTED AND TITRATED TO COMFORT. REC'D KCL, CALCIUM REPLETION. RESP: INTUABTED ON 55% 700 X 15, NO SPON BREATHS. SCANT YELLOW SPUTUM, SPEC SENT. LUNGS WITH CRACKLES BILAT BASES, OTHERWISE CLEAR. LASIX 20 MG GIVEN X1 AT 1400 WITH MOD OUTPUT SO FAR. NO ABG SENT BY NURSING B/C NO A-LINE. ID: T 103.4 RECTAL, TYLENOL GIVEN X1. LEVO, OXI AND FLAGYL ALL STARTED. PT PAN-CX'ED. GI: NGT TO LIS, DRAINING BILE, OB POS IN SMALL AMOUNTS. PROTONIX TO START. HYPOACTIVE BS, NO STOOL. NPO FOR NOW. ABD U/S DONE. HCT 27. GU: FOLEY DRAINING CLEAR URINE. US WITH FLUID IN DOUGLAS POUCH, GYN CONSULT MS: SEDATED ON PROPOFOL, SPOKE TO 3 SONS TODAY, ALL FEEL THEY HAVE HAD SITUATION ADEQUATELY EXPLAINED. A/P: STABLE POST CATH, FOLLOW TEMP ON TYLENOL. CONT WITH LYTE REPLETION, PT NEEDS PRBC TONIGHT. WILL REPEAT LASIX IV. WAITING FOR MAGNESIUM TO BE SENT FROM PHARMACY. FOLLOW SEDATION LEVEL. ||||END_OF_RECORD START_OF_RECORD=2||||3|||| PT. INITIALLY ON AC 700X15/5/40%. ABG DRAWN 128/30/7.52 RR DECREASED TO 12. PT. REMAINS SEDATED TOLERATING CURRENT SETTINGS. BS: DECREASED ANTERIORLY NO SXN'ING THIS SHIFT. ||||END_OF_RECORD START_OF_RECORD=2||||4|||| O:NEURO=SEDATED W PROPOFOL GTT-INCREASED FROM 12 TO 24MCG & REQUIRING PRN BOLUSES DUE TO INCREASED AGITATION. RESPONSIVE TO NOXIOUS STIM, BUT DOES NOT FOLLOW COMMANDS. SOFT RESTRAINTS BILATERALLY. PULM:VENTED. SETTINGS-AC, 700X12, 40% & +5. SATS UPPER 90'S. LAST ABG-119/36/7.47/27/2. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TAN SECRETIONS. CV=HEMODY STABLE. IABP R-FEM--EXCELLENT AUGMENTATION & SYST UNLOADING. #'S-AS 90-124, AD 122-134, BAEDP 44-78. IABP M 86-108. SETTING CHGED FROM 1:1 TO 1:2 @ 0600. PT/DP PULSES DOPPLERABLE. SM AMT OLD BL UNDER IABP DSG. GTTS-AGGRASTAT @ 0.118MCG. & HEPARIN @ 1200U (INCREASE FROM 1000U FOR SUBTHERAPUTIC PTT). GI=NGT TO LCS-BILIOUS. GU=LASIX 40MG @ 2000. I&O +.6L @ 2300 & +.28L @ 0500. HEME=TX W 1URBC FOR HCT 27.3-POST 29-AM 27.4 (SET UP FOR 2U). ID=T MAX 100 PO. LABS=K REPLACED W 40MEQ IV. AM LABS PENDING. A:NOT IABP DEPENDENT. CONTIN DECREASE IN HCT. P:MAINT ADEQ SEDATION TILL IABP OUT & READY TO WEAN/EXTUBATE. PULM TOILET. WEAN IABP W GOAL DC. DC AGGRASTAT @ 1000. FOLLOW I&O-?AUGMENT DIURESIS W LASIX. ?TX W RBC FOR HCT 27.4. CK AM LABS-RX AS INDICATED. SUPPORT AS NEEDED. ||||END_OF_RECORD START_OF_RECORD=2||||5|||| REVIEW OF SYSTEMS- NEURO- PATIENT SEDATED ON PROPOFOL DRIP AS PER FLOWSHEET. DOES OCCASIONALLY OPEN EYES TO PAINFUL STIMULI. GETS SLIGHTLY AGGITATED WHEN NEEDS TO BE SUCTIONED ONCE SUCTIONED SHE SETTLES BACK DOWN. RESP- REMAINS VENTED ON 40% FIO2, A/C OF 12, TV OF 700 AND PEEP OF 5. SATS IN THE HIGH 90'S. BREATHING 12 ON 12. SUCTIONED FOR THICK TAN SPUTUM. CARDIAC- HR IN THE 60-70'S NSR WITH RARE PVC. SBP 130-160'S. BALLOON PUMP DC'D AT 11AM. RIGHT FEM SITE WITH ACE PRESSURE DRESSING. SITE C AND D AND SOFT. DOPPLER PEDAL PULSES. HEPARIN AND AGGRESTAT DC'D TODAY PRIOR TO D/C OF BALLOON PUMP. CK SENT AT 1515 TODAY DUE TO NEW EKG CHANGES NOTED ON EKG THIS AM. RESULTS PENDING. CONTINUES TO BE DIURESED. RECEIVED 60MG IV LASIX. SHE IS PRESENTLY 373 NEG AFTER 2 U PRBC. STARTED ON CAPTOPRIL TODAY RECEIVED 12.5MG WITH SBP GOING FROM 150 TO 129. TO GET A 25MG DOSE THEN TO BE INCREASED TO 50MG TID. GI- NG CONTINUES TO DRAIN BROWN MATERIAL THAT IS GASTRO POS. ABD SOFT DISTENDED WITH POS BS. RECEIVED 2 U PRBC FOR HCT OF 27 THIS AM WITH OUT SIGNS OR SYMPTOMS OF REACTION. REPEAT HCT POST TRANSFUSION 38. SEEN BY GI TODAY. THEY FEEL SHE IS CLINICALLY IMPROVING WITH DECREASING LFT'S, LIPASE, AND WBC. ALSO FEVER CURVE IS DONE. SHE CONTINUES ON ANTIBIODICS. ABD U/S FROM YESTERDAY NEG FOR CHOLOCYSTITIS. SOCIAL- SONS IN VISITING TODAY. THEY WERE UPDATED BY CCU TEAM. GU- FOLEY PATENT DRAINING CLEAR YELLOW URINE. ||||END_OF_RECORD START_OF_RECORD=2||||6|||| resp note - pt. remaines intubated and mech ventilated, ac tv 700 rr 12 40% fio2 5 peep, tol ok at this time. ||||END_OF_RECORD START_OF_RECORD=2||||7|||| CARDIAC- CK DRAWN AT 1515 373. DR [**Last Name (STitle) 40**] AWARE. ||||END_OF_RECORD START_OF_RECORD=2||||8|||| npn 7p-7a: ccu nsg progress note: neuro--conts sedated on propofol, at times is able to open eyes to name being called and able to follow commands, other times just moves to painful stimuli and grimaces face to pain resp--ls coarse throughout, sxn'd for thick tan/white secretions, conts vented, no changes made during the noc, does not have an aline to follow abg's, sats 97-98%, rr 12, occ breaths over 2-4 breaths cardiac--hr 60-70 sr w/occ pvc's, bp 110-148/50, r groin site intact, no bleeding noted, (+)dopplerable pulses bilat, conts on captopril, bp does drop sl after getting dose gi--abd obese, (+)bs, (+)flatus, no stool, ngt to lis, draining brown material gu--foley to gravity, draining clear yellow urine id--spiked to 102.2r during noc, 2 add bld cx sent, given tylenol w/no change in temp, conts on ivab ||||END_OF_RECORD START_OF_RECORD=2||||9|||| NEURO: remains lightly sedated on Propofol gtt @ 36mcg/k/min. pt obeyed commands for family. opens eyes to stimuli. bilat arm restraints. CARDIAC: SR 60s. BP stable. repeat HCT this afternoon 35.3. dopplerable pedal pulses. R groin dsg removed, bandaid applied over old IABP site. ACCESS: 2 x #20g IVs in LLA. RESP: LS coarse. AC 700x12, Peep 5, 40%... ABG: 123/37/7.44/26. then rate decreased to 8 and pt overbreathing vent w/ RR 10-12. SX: for small to mod amts thick white secretions. GI/GU: foley patent clear yellow urine. approx 30cc/hr. Abd large/obese, distended. +BS. +Flatus. no stool. OGT patent, for bilious brown drainage. remained NPO today, OGT clamped for meds. PLAN: for CT of ABD this afternoon. con't to monitor vitals. con't to wean on vent ?plan extubation tomorrow? ||||END_OF_RECORD START_OF_RECORD=2||||10|||| Resp. care note: Pt stable through the shift. Resp. rate was decreased from 12 to 8bpm. pt suctioned for a small amount of thick secretions. plan is for patients to have CT scan of abd. sometime this evening. FOr further information please refer to carevue charting. ||||END_OF_RECORD START_OF_RECORD=2||||11|||| npn 7p-7a: ccu nsg progress note; neuro--conts sedated on propofol w/gd effect, pt is able to open eyes when name called and follow simple commands, sleeping on/off most of the noc resp--ls coarse throughout, sxn'd q1-2hrs for thick white secretions, pt noted to have increased coughing, sats 98-99%, occ overbreathing vent by 3-4 breaths cardiac--hr 60-70's sr, occ pvc's noted, bp 133-179/50, conts to rec lopressor/captopril/isordil, gi--abd obese, soft/distended, (+)bs, (+)flatus, abd ct done which showed ?gallstone, conts npo, is rec'ing meds via ngt gu--foley intact, draining lg amt of clear/yellow urine after given lasix id--conts febrile up to 101r, team aware, conts on ivab, cx's still pnd, ?source of fever access--pt has 2 peripheral iv's, is difficult access for blood draws, would benefit from picc line! ||||END_OF_RECORD START_OF_RECORD=2||||12|||| Pt. weaned via PSV down to 5/5/ Leak test positive. Pt. extubated onto 40% cool aerosol face tent. Spo2 97% RR 16, some mild stridor noted, dr [**Last Name (STitle) 41**] aware. however pt. has strong cough and is tolerating well at this point. ||||END_OF_RECORD START_OF_RECORD=2||||13|||| HPA: This pleasant 74y old woman went to [**Hospital 31**] Hosp [**05-20**] with sever abd pain and nausea. She had RUQ tenderness and elevated LFTs and lipase. However her troponin came back at 5.2 and she R/I for non-Q wave MI. At 2am [**05-22**] she developed flash pulmonary edema and required intubation. They saw new EKG changes (which were later shown to be improperly placed EKG leads.)She was transfered to [**Hospital1 2**] for cath and was found to have severe LAD and diag disease with collaterals. They attempted to open the diag and were unable to. They felt none of the lesions were acute and inserted an IABP. She had elevated filling pressures and have an had IABP inserted with plans for diuresis. She was transfered to CCU for further care. ALLERGIES: tomatoes, codiene PMH: CAD: NQWMI 13. HTN. EF 50%. Exertional angina and dyspnea. Subclavian steal syndrone with L BP ~40p higher than L. CCU COURSE: ID: Pt spiked to 103.4 on [**05-22**] and was fully cultured. She is on levofloxacin, ampicillin and flagyl. She spiked to 101R on eve [**05-23**]. T-max today was 100.8R. CV: Pt has remained painfree. Her IABP was d/c [**04-22**]. Her groin remains dry. Her HR has been in the 70-80s and her lopressor will go up to 50mg tonight. Her BP has been stable in the 120s-140s/40-50 taken on her R arm. Her captopril was increased to 75mg po at 6pm and she has tolerated it. She will go up to 100mg tid at 2am. RESP: She was extubated easily at 2pm [**05-25**] and is now sating 98% on 4L NP. She is still [**Last Name (un) 42**] up viscous sputume from the back of her throat. She has a strong cough. Her breathing feels comfortable. GU: She has been diureses--last time at 2am [**05-25**]. She is presently 2 liters neg today and 4.7 Liters neg LOS. GI: Pt has been NPO since she has been here. She had some G+ asp. She has had and ultrasound neg for cholecystitis and CT thant showed gallstones, but no obstruction at this time. He LFTs have gone down.Pt had small G- liquid stool. She has been taking liquids but apetite is still poor. ENDO: FS have been in normal range. However at 6p [**05-25**] she was 205 and received 2u reg insulin. HEME: Her crit had dropped to 27 on [**05-23**] and she received 2U PRBCs. Her crit has since been stable. Last crit on am of 8/28 was 36.6. MS: Pt is now alert and oriented times three and extremly pleasant. SHe was OOB to chair and while she can weight bare she does have difficulty taking steps. She needs to be seen by PT this weekend to see if she needs rehab. PLAN: CV: She will need stress test to see if another attempt at intervention is needed. Maximise medications. She may recieve stents to both L and R subclavian arteries. It has been discussed with her, but she wants more time to think about it. GI: Once she has recovered she will be evaluated for probable ERCP. REHAB: She should be seen by PT. She has been seen by case manager and if she needs rehab there is one very near her home. ||||END_OF_RECORD START_OF_RECORD=2||||14|||| npn 7p-11p: pt conts a&ox3, mae, skin w&d, talking/drinking fluids w/out diff, ls cta, sat on 4l 97-100%, rr 16-18, not labored, does not appear in any distress. hr 70's sr, no ectopy, bp 150-170/60's. pt to be transfered to floor. to go to [**Wardname 43**]. ||||END_OF_RECORD START_OF_RECORD=2||||15|||| Cardiac: CK elevating 932, Troponin decreasing to 5.7. ?CK pt remains afebrile.leak? PLAN: con't to cycle CK+MB/Troponin ||||END_OF_RECORD START_OF_RECORD=3||||1|||| Resp Care pt intubated in eu for airway protection..swelling of upper airway seem by eu physicians. 7.5 ett taped 23 lip. sxned for thick yellow tinged sputum. transferred to ccu and placed on ac mode 700x12x1.0/5 peep. abg,cxr pending. bilateral bs. ||||END_OF_RECORD START_OF_RECORD=3||||2|||| 67 YO FEMALE ADMITTED TO CCU FROM THE EW WITH ?LITHIUM TOXICITY. PMH:CHRONIC DEPRESSION. HYPOTHYROIDISM. CHRONIC RENAL INSUFFICIENCY. LITHIUM TOXICITY-[**1995-05-30**]. ALLERGIES:NKDA. SOCIAL:MARRIED-WO CHILDREN. UNEMPLOYED. HUSBAND CEO OF [**Company 44**]. SMOKER 30PK/YR. WO ETOH. PRESENT HX:PRESENTED TO EW [**05-22**] @ 1230 W LETHERGY, CONFUSION, & DEHYDRATION X5 DAYS. IN EW FOUND TO HAVE INCREASED CALCIUM/BUN/CREAT, ELEVATED LITHIUM LEVEL & BRADYCARDIA WO HYPOTENSION-AGGRESSIVELY RXED W IVF APPROX 7L & ATROPINE .5MG X1. PAN CULTURED-ABX LEVOQUIN X1. LP/CT HEAD/CXR DONE. INTUBATED FOR DECREASED MENTATION & AIRWAY PROTECTION. ADMITTED TO CCU [**05-22**] @2330. O:NEURO=UPON ADMISSION AGITATED-NOT RESPONDING TO VERBAL STIMULI. PROPOFOL STARTED & TITRATED TO ADEQ SEDATION. SOFT RESTRAINTS UPPER EXTREM. SIDERAILS UP. PULM=INTUBATED & VENTED. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TANNISH SECRETIONS. SATS ON 100%-100%. AFTER ALINE INSERTED-ABG SENT (SEE FLOW SHEET)-FIO2 DECREASED TO 50%. CV=BRADYCARDIC W HR @ X'S TO UPPER 30'S-BORDERLINE HYPOTENSIVE BY CUFF-IVF WIDE OPEN. EKG-CHB W JUNCTIONAL ESCAPE RHYTHM. CENTRAL LINE PLACED-RFEM-DOPA GTT STARTED A 5MCG/KG/MIN-SUBSEQUENTLY HR INCREASED TO UPPER 60'S/LOW 70'S W INCREASE IN BP. GI=OGT PLACED-BILIOUS MATERIAL-GUIAC NEG. FOLEY=MINIMAL UO. URINE SENT FOR LYTES. W STABLIZATION OF BP-LASIX 40MG GIVEN W ADEQ RESPONSE. ID=AFEBRILE. WO ABX-AWAITING CULTURES. LABS=UPON PLACEMENT OF ACCESS LINES-LABS SENT. CA ELEVATED-RXED W PAMIDRONATE IV. LITHIUM LEVEL SENT. ACCESS=PERIPHERAL LINES X2-#18 & 20. INTRODUCTER PLACED R-FEM. ALINE PLACED L-RADIAL. A:ELEVATED LITHIUM LEVEL UPON ARRIVAL TO EW-?CAUSE OF S/S. P:ADEQ SEDATION. ADJUST VENT AS INDICATED. PULM TOILET. CONTIN LOW DOSE DOPA-RATE MANAGEMENT. MAINT IVF-AUGMENT DIURESIS W LASIX AS NEEDED. FOLLOW CULTURES. RECK LITHIUM LEVEL-?DIALYSIS IF REMAINS ELEVATED. AM LABS. SUPPORT FAMILY AS NEEDED. ||||END_OF_RECORD START_OF_RECORD=3||||3|||| Patient is a 67 y.o. female admitted with lithium toxicity. Patientintubated in EW with 7.5 ETT for airway protection. Tube taped and secured at 23cm. Patient remains intubated and mechanically vented Vent checked and alarms functioning. Patient comfortable on vent. Settings: A/C 700*12 50% 5 peep. ABG 7.35/281/42/24/-2. Pa02 weaned to 50% with this gas. BS: clear and equal. Please see respiratory section of carevue for further data. Plan: Continue mechanical ventilation. Respiratory status stable on current settings. Wean as tolerated. ||||END_OF_RECORD START_OF_RECORD=3||||4|||| CCU NPN See carevue for subjective/objective data. Neuro: Remains sedated with Propofol--initially at 50mcg/kg/min but titrated down to 20mcg/kg/min as pt unresponsive to painful stimuli at 50mcg/kg/min. Currently pt opens eyes to painful stimuli, some non-purposeful movement of hands, legs noted with tactile stimuli. PERL, 3mm, brisk. CV/Pulm: VS per carevue. MP=SB-->NSR 33-78. Isolated PVC noted. BP low 100's, occas dips to high 80's with MAP >65 until 1715 when BP dropped to 71/42 with MAP of 51. Dopa increased to 10mcg/kg/min with BP gradually increasing--currently with BP of 91/52 with MAP 64. KPhos 6.8mM hung at 1630--to infuse over 6hrs via femoral line. Remains vented with ABG's per carevue. Only vent change was this AM when rate decreased from 12 to 10 with rpt ABG's good. BS coarse bil. Suct for thick yel sec, sm amts q4h in addition to suctioning done by RT. GI/GU: OGT->LCS drng bilious material in lg amts. BS positive. No BM, no flatus. U/O qs q1h with brisk diuresis after Lasix. ID: Afebrile. Started on Levo and Ceftaz. Cultures from ED pending. Integ: Abrasion R knee-->no drainage. No other open areas noted. Psychosocial: Husband in to visit. Emotional support given to pt and husband. Per husband they do not have children and rarely see their family. ||||END_OF_RECORD START_OF_RECORD=3||||5|||| RESPIRATORY CARE: PT WITH 7.5 ORAL ETT AT 23 LIP. CONTINUES ON A/C 10/700/.50/5 WITH NO RECENT ABG. LAST ABG STABLE. QUIET NIGHT FOR PT. [**First Name11 (Name Pattern1) 45**] [**Name7 (MD) 46**], RRT ||||END_OF_RECORD START_OF_RECORD=3||||6|||| NEURO: remains sedated on PROPOFOL 29mcg/k/min. nonpurposeful movement, opens eyes to noxious stimuli. bilat wrist restraints. CARDIAC: SB/SR 50-110s. no ectopy noted. BP labile overnite, titrating DOPAMINE 8-12mcg/k/min. Had cp, levines sign, better when bp stable. Aline dampening often overnite, able to palpate pulses. This morning, aline dampened and was unable to draw labs off line, site looking worse, pulse harder to palpate, HO notified. aline d/c'd. HO attempting to place new aline at this time. R femoral introducer intact. able to palpate radial pulse in old aline site since aline d/c'd. ID: Tmax 100.8. On Levo + Ceftaz Q24h. RESP: AC 700x10, 50% 5 peep. SX large amts thick yellow secretions. LS coarse. unable to obtain am abg until new aline inserted. GI/GU: autodiruresed overnite large amts clear yellow urine. Foley patent. +BS. OGT to low constant suction, for greenish bile. quiac neg. remains NPO. PLAN: attempt to wean off dopamine as tolerated. monitor hemodynamics. placement of new aline. ??place TLC over wire thru R femoral introducer site?? monitor temps. ||||END_OF_RECORD START_OF_RECORD=3||||7|||| RESPIRATORY CARE: PT. WITH 7.5 ORAL ETT AT 23 LIP. CONTINUES ON A/C 10/700/.50/5 WITH STABLE ABG. SX. THICK YELLOW SPUTUM. [**First Name11 (Name Pattern1) 45**] [**Name7 (MD) 46**], RRT ||||END_OF_RECORD START_OF_RECORD=3||||8|||| no changes today on heated system from [**Hospital1 47**]. ET tube found at 20 cm at lip. BBS clear and equal. ||||END_OF_RECORD START_OF_RECORD=3||||9|||| MICU Nursing Progress Note 7a-7p: Neuro: Pt conts to be sedated on propofol gtt currently at 45 mcg. Pt arouses to painful stimuli. Sedation weaned to assess pt's neuro status pt opening eyes spontaneously and not following commands. Pt kicking legs off bed and pulling arms towards ETT. CV: SB HR 36-53 no ectopy noted. Labile BP on dopamine gtt. Dopamine gtt weaned from 5mcg to 3.5mcg/kg/min. On 3.0mcg SBP in the 80's up to 100 on 3.5mcg/kg/min. Secondary to hypotension and bradycardia temp wire paced at the bedside under fluro in L fem by EP fellow. VVI paced rate 80 ma 7. Sensitivity ma 2. No improvement in BP s/p pacer wire placement, see carevue for objective data. CXR and EKG preformed to verify placement. BP transiently to 170's with sunctioning and position changes. K+ 3.4 repleted with total 80meq KCL via OGT. Repeat K+ 3.4 on blood gas. Ca 8.7 PULM: Mechanically ventilated on AC 700x10 Fi02 40% 5 peep. ABG on these settings 191/31/7.40/20. Pt sxn'd for thick yellow sputum. treating pt for pnx with levo and ceftax IV. No peripheral edema. noted. GI: Abd soft NT +BS. No stool this shift. Nepro TF currently at 20cc/hr goal rate 30cc/hr and then add promod per nutrition consult. Pt with minimal residuals. JP minimal out. GU: Foley cath patent draining cyu. BUN 37(43) Creat 2.3(2.6). +4701 LOS +3042 since mn. Fluid status goal is postitve per team. ID: temp max 99.0. BC pending. Conts on IV abx. SKIN: Buttocks intact. R knee abrasion. LINES: R fem introducer, await team to place TLC. L fem a-line and temp pacer wire 2 piv. PROPH: protonix iv and pneumoboots. DISPO: Full Code SOCIAL: Husband [**First Name8 (NamePattern2) 48**] [**Name2 (NI) 49**] in to visit. Team to contact other family members in [**Location (un) 50**]. A: Resolving lithium toxcity and hypercalcemia with ?septic etiology. Brady and hypotensive on dopamine gtt with temp pacing wire. P: Follow CV status, wean dopamine gtt as tolerated. EP following s/p temp pacing wire placement. Await orders to replete K and Mg. Cont current vent settings. Increase TF to goal. follow neuro status on sedation. ||||END_OF_RECORD START_OF_RECORD=3||||10|||| NEURO: CONT TO BE SEDATED ON PROPOFOL. WHEN LIGHTENING UP ON SEDATION PT. BECOMES AGITATED WITH LEGS KICKING UP IN AIR AND BITING ON ETT. NON-PURPOSEFUL MOVEMENT. MOVES EXTREMITIES ON BED. CV: BP STABLE ON DOPA OVERNIGHT. THIS AM PT. BECOMING SL. HYPOTENSIVE SYS 70-80'S WITH MAP57-63. DR [**Last Name (STitle) 51**] AWARE. DOPA INCREASED TO 5 MCG/KG/MIN. BP BETTER WITH INCREASED DOSE. RESP: CONT ON SAME VENT SETTINGS SEE VENT FLOWSHEET FOR DATA. ABG PENDING THIS AM. SUCTIONING FOR THICK WHITE - YELLOW SPUTUM. STRONG COUGH AND GAG. ORAL SUCTIONING FOR THICK MUCOUS. GI: ON TF NEPRO RATE 30 CC/HR WITH MIN RESIDUALS. HYPOACTIVE BS. NO STOOL OVERNIGHT. NO VOMITING. GU: URINE VIA FOLEY. CLEAR YELLOW IN GOOD AMTS. SKIN: INTACT EXCEPT FOR SMALL ABRASION. CLEANED WITH SOAP AND WATER. AND OPEN TO AIR. ||||END_OF_RECORD START_OF_RECORD=3||||11|||| CV: Remains on Dopamine, very dependent, range 6-10ug/kg, BP 90-120/, did drop to 65-70/ a couple times this AM, no precipitating events, each time responded to increased Dopa. Presently at 8ug/kg with BP holding more stable this afternoon. Remains V-paced with temp wire at rat of 78, increased today to 96 to see if it would help her pressure, did not, cont to have drops in pressure, turned rate back down to 78. MA increased from 7 to 10 by EP. Groin site D&I, no hematoma. K+ 3.3 this AM, given 40 mEqpo and 40mEq IV, repeat 4.2. Repleated with 2 GM MgSO4. RESP: Remains vented on AC 40% 700x10, 5 PEEP. Suctioned 2-3x for sm amt white thin secretions. LS Clear with a few scattered rhonchi. ID: afebrile, fully cultured today for survalence, cont to have septic picture with no clear ID source. Ordered for chest and abd CT today, barocat given, finished 2 bottles at 5:30PM. Remains on Levo and Ceftaz. GI: TF at goal, off for CT scan, formula will be changed to 3/4 str Nepro with promode at 30cc/hr. No stool today. Hypoactive BS. Neuro: sedated on 45ug of propofol, tried to decrease to 40ug, pt began moving legs around, bending. Did not follow commands, eyes opened spontaneously, did not track or focus. Soc: husband and son in , updated by RN and Sub I. ||||END_OF_RECORD START_OF_RECORD=3||||12|||| Respiratory Care: Brought pt to ct which was uneventfull. Placed on servo vent (same settings). [**First Name4 (NamePattern1) 52**] [**Last Name (NamePattern1) 53**] CRT ||||END_OF_RECORD START_OF_RECORD=3||||13|||| S/O: SEE VS/OBJECTIVE DATA PER CARE VUE. ID: T MAX 101.4, STARTED ON FLAGYL AND VANCO TO HAVE A WIDER COVERAGE OVER PRESUMED PNEUMONIA. DOWN TO CT SCAN WHICH WAS NEG EXCEPT FOR BILAT CONSOLIDATIONS WITH SMALL PLEURAL EFFUSIONS. NO GROWTH SO FAR FROM [**05-26**] CULTURES. CV: HR INITIALLY 78 VENT PACED, HAVING SOME INTRINSIC BEATS, TEAM DOWN TO ASSESS TEMP WIRE AND INCREASED RATE TO 100 WITH NO EFFECT ON BP, ALSO DECREASED RATE TO DETERMINE PT'S INTRINSIC RATE WHICH WAS IN THE 40'S, WITH RATE THAT LOW BP DROPPED TO LOW 80'S. PACER INCREASED UP TO 94. BP REMAINS VERY LABILE, ATTEMPTED TO WEAN DOPA BUT UNSUCCESSFUL, DOPA AT 12MCG/KG/MIN TO MAINTAIN SBP > 90. ALSO FLUID DEPENDENT, WHEN FLUID OFF FOR ANY TIME BP DROPS TO 80'S. TEMP WIRE VIA L GROIN REMAINS INTACT AND APPEARS TO BE SENSING AND PACING WELL. L GROIN WITH A LINE INTACT WITH GOOD WAVEFORM. RESP: ONLY VENT CHANGE MADE WAS TO DECREASE FIO2 TO 30%, CONTS TO HAVE GOOD SATS 99-100%. SUCTIONED X 3 FOR SMALL AMTS THIN CLEAR/WHITE SECRETIONS. LUNGS WITH SCATTERED COURSE AERATION. GI: ABD SOFT WITH GOOD BOWEL SOUNDS. NO BM. TUBE FEEDS RESUMED AT 30CC/HR TOL WELL, NO RESIDUALS. GU: HAS EXCELLENT URINE OUTPUT, UP TO 300CC/HR. URINE CLEAR, LIGHT YELLOW . MS: SHE IS OPENING HER EYES TONIGHT ON OWN AND TO VERBAL STIMULI. MOVES LOWER EXTREMS BUT NO MOVEMENT SEEN IN UPPER. SHE DOES NOT FOLLOW COMMANDS AND DOES NOT APPEAR TO TRACK. WRIST RESTRAINTS UNTIED. PROPOFOL CONTS AT 45MCG/KG/MIN. A: REMAINS VERY DOPA.IVF DEPENDENT ABLE TO DECREASE FIO2 TO 30% BILATERAL BASILAR PNEUMONIA NO CULTURE GROWTH/ADDED 2 IV ANTIBX P: ? EXTUBATE SOON WITH LITTLE SECRETIONS AND LOW FIO2 NEEDS CONT TO TITRATE DOPA AS TOL ||||END_OF_RECORD START_OF_RECORD=3||||14|||| Resp: No vent changes made, Sating 99% on 30%, Suctioned Q3-4hrs for thick white sputum. LS clear with bronchial BS at R base. CV: remains on Dopa, increased to 13ug/kg to keep BP 90's-110/, HR initially 93PMR, EP checking pacer found intrinsic rate to be 68-70 acelerated junctional, BP unchanged in this rhythm, left with pacer set at 50. Had few minutes of NSR ~5pm, BP shot up to 160/70. Attempted to wean Dopa quickly, BP dropped and pt went back into accelerated junctional rhythm requiring Dopamine back at 13ug/kg. K+ 3.2, repeated with 40mEq IV and 40mEq po. ID: Remains febrile, 101- 101.4 Rectal. Added vanco, flagyl to Levo ceftaz. BC from R groin line drawn on [**05-26**] came back with Gr(+) COCCI in pairs and clusters. Team placing TL, and will DC R groin line. Also needs RUA peripheral line DC'd. Cardiology planing to DC Pacing wire in AM if intrinsic rate remains stable. Neuro: eyes open, not following commands. Remains on Propofol decreased to 40ug from 45. Spoke with her psychiatrist, at baseline pt is A&Ox3, functional, has general anxiety, Bipolar-1. Agrees with holding psych meds at present. GI: tolerating TF at goal. No stool. BS active. FEN: UO brisk, keeping even with intake. IVF decreased to 100cc/hr so total intake with gtt is 100cc/hr. Repeated K, cont on neutrophos. A: Pt benefits from atrial kick. P: If requires pacer consider duel chamber pacer. cont to follow hemodynamics and titrate Dopa, cont AB, check culture results. Pul toilet. Remove groin lines ASAP. ||||END_OF_RECORD START_OF_RECORD=3||||15|||| O: SEE VS/OBJECTIVE DATA PER CARE VUE. ID: T MAX 102 RECTALLY, REC'ING TYLENOL, NO CHANGE MADE ANTIBX. R GROIN LINE DC'D. BC X 1 SENT FROM NEW TLC. CV: HR 55-70'S SR/JUNCTIONAL ESCAPE. BP VERY LABILE DEPENDING ON RHYTHM. WHEN IN SR BP INCREASED SIGNIFICANTLY AND ABLE TO DECREASE DOPA BUT WHEN CONVERTS TO JUNCTIONAL THEN BP PLUMMETS TO 60'S REQUIRING INCREASE IN DOPA BACK TO PREVIOUS DOSE. TEMP WIRE REMAINS INTACT VIA L GROIN BUT CURRENTLY NOT BEING USED. L GROIN D/I. RESP: NO VENT CHANGES MADE, CONTS AT 30%/700/AC10 PEEP 5. SUCTIONED FOR SMALL AMTS OF THIN WHITE SECRETIONS. LUNGS WITH SCATTERED COURSE AERATION. HAS MOD AMTS OF SECRETIONS IN MOUTH. GI: TOLERATING TUBE FEEDS WITH LOW RESIDUALS, NO BM. ABD SOFT WITH ACTIVE BOWEL SOUNDS. GU: CONTS TO HAVE EXCELLENT URINE OUTPUT, 200-300CC/HR. URINE LIGHT YELLOW/CLEAR MS: OPENS EYES SPONT, MOVES LOWER EXTREMS SPONTANEOUSLY AND TO PAINFUL STIMULI, DOES NOT FOLLOW COMMANDS. SHE IS NOT MOVING UPPER EXTREMS, EVEN TO PAINFUL STIMULI. DECREASED PROPOFOL. A: TEMP SPIKE GROWING GRAM (+) COCCI FROM BLOOD CULTURES CONTS TO HAVE LABILE BP DEPENDING UPON RHYTHM P: CONT TO TITRATE DOPA AS TOL FOLLOW TEMP ? RECULTURE IF SPIKES AGAIN ||||END_OF_RECORD START_OF_RECORD=3||||16|||| s: remains orally intubated. no attempts to verbalize o: pls see carevue flowsheet for complete vs/data/events id: t max 100.4r this shift. wbc 14.4.ceftaz dc'd. cont on flagyl, levo and vanco. cultures pend. with next fever spike will culture with fungal isolators as well. neuro: propofol weaned down overnoc and pt very alert this morning. able to follow simple commands. moving arms and legs weakly. req l leg immobilizer d/t fem aline/venous line and soft wrist restraints. propofol increased with some sm boluses for agitation, pt coughing, req freq sxn'ing for thin secretions, ^'d rr and moving arms, legs. propofol back up to 40mcg/kg/min. cv: cont in sr this shift. rate 58-65. occ pvc. no runs. fem venous pacing wire dc'd by cardiology fellow this am. k and mg repleted, will recheck this eve. weaning dopa slowly. now down to 7.5mcg/kg/min with bp 100-115/60 via l fem aline. this afternoon r rad aline placed by team. l fem a and v lines will be dc'd this afternoon with culture of tips. resp: changed to ps from ac this afternoon. currently on ps of 10. tv avg 400-450. rr 20s. sxn'd q 2hrs for thin clear to thick white secretions. bs occ coarse at base but otherwise cta. abg: 7.39/31/77/19/-4. sats 96-99% gi: tol tf nepro with promod at 30cc/hr. will change per nutrition to promote with fiber with goal to 50cc/hr. no stool since admit. given ducc supp but no stool in rectum. also given lactulose x1. colace ordered as well. abd is soft. +bs. gu: uop 150-250cc/hr. goal even for day but is currently 700cc-. ivf ^'d to 140cc/hr of 1/2ns. cvp 8-10. skin: intact. mouth with white patches. started nystatin s/s. social: husband visited and was updated by team. is encouraged by her progress today. a: sr, dopa dep, afeb p: follow rhythm and hemodynamics. wean dopa as hr and bp tol. d/c l fem lines. change tf. cont meds to produce bm. med for comfort/safety. support to pt and spouse. ||||END_OF_RECORD START_OF_RECORD=3||||17|||| Resp: Pt placed back on AC for high RR on PS, ABG stable. Suctioned for thin white secretions x3 this eve. Sats 97-99% on FIO2 30%. CV: Remains on Dopa, decreased to 6ug/kg. BP has remained 90's-low 100's/, IVF .45NS at 140cc/hr. If Dopa or fluid stops for any reason pt drops her pressure. Remains in NSR with rate 58-66. K+ 3.6, Mg 1.9 Neuro: alert, but looking dazed and following commands on 40ug of Propofol. Soft restraints on, pt comfortable and sleeping on and off. ID: AB increased for normal renal function. T 99.7 po. If respikes need BC with fungal isolator. GI: TF changed to Promote with fiber at 30cc/hr, to be advance to goal of 50cc/hr. Low residuals. Had 2 large BM's OB(-). First stool with formed stool mixed with loose, @nd stool loose, rectal bag placed. Nystatin to mouth for thrush. A: On decreased amount of Dopa, all groin line now out. P: cont to follow hemodynamics, cont pul toilet, follow lytes and repleat as needed. Sedate to comfort and safety. ||||END_OF_RECORD START_OF_RECORD=3||||18|||| S- OPENING EYES TO VERBAL STIMULATION; APPEARS TO HAVE SOME PURPOSEFUL RESPONSE(SQUEEZE HAND) TO REQUEST. O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- PT REMAINS AT BASELINE HEMODYNAMICS WITH HR- 55-60 SB/SR. BP WHILE SEDATED, ASLEEP- 85-90'S/ WHILE AWAKE- 118/. REMAINS ON DOPA GTT 6MCG/KG. NO SIGNIFICANT EPISODES OF LABILE HEMODYNAMICS THIS SHIFT. REPLETING K/MG WITH 40MEQ KCL/2 AMPS MGSO4. TO REPEAT LYTES IN AM WITH AM LABS. RESP-PT REMAINS ON VENTILATORY SUPPORT- 30/700/10 A/C. BREATHING OVER VENT WITH INCREASED AWAKENED STATE- BREATHING IN SYNCH WITH INCREASE IN PROPOFOL GTT/SEDATION. O2 SATS- HIGH 90'S. SX Q 2-3 HOUR FOR THICK WHITISH SPUTUM. ID- AFEBRILE- REMAINS ON ANTIBX X 3- FLAGYL/VANCO/LEVO. GI- ON TUBE FEEDS- PROMOTE 30/HOUR- D/C 12 AM- NPO AFTER 12 A FOR TEE TODAY. GU- GOOD UO- 100-225/HOUR VIA FOLEY CATH. IVF- 140CC/HOUR. ATTEMPTING TO MATCH I/O. CURRENTLY I/O (+). MS/NEURO- PT AWAKE, ABLE TO SQUEEZE HAND TO COMMAND- OVERBREATHING VENT, APPEARING ANXIOUS- GIVEN BOLUS PROPOFOL, INCREASE GTT SLIGHTLY AS WELL/ CURRENTLY, SEDATED, COMFORTABLE AND BREATHING IN SYNCH WITH VENT. A/P- PT S/P LITHIUM TOXICITY/SEPSIS- CURRENTLY LESS HEMODYNAMICALLY LABILE ON LESS DOPA; AFEBRILE. CONTINUE ANTIBX FOR SEPSIS AS ORDERED. DOPA AS NEEDED FOR MAP>60, HR>50'S. CLOSELY WATCH I/O AND FLUID BALANCE- CONTINUE IVF AS ORDERED. PLAN FOR TEE- COMFORT/SEDATION WHILE INTUBATED. RESUME TUBE FEEDS ONCE TEE COMPLETE. KEEP PT AND FAMILY AWARE OF PLAN OF CARE. ||||END_OF_RECORD START_OF_RECORD=3||||19|||| Patient remains intubated and mechanically vented. vent checked and alarms functioning. Settings: A/C 700*10 30% 5 peep. BS Coarse. Please see respiratory section of carevue for further data Plan: Patient in synch with vent. Will continue to mechanically ventilate. Wean as tolerated. ||||END_OF_RECORD START_OF_RECORD=3||||20|||| Resp Care remains ac mode 700x10x.3/5 peep. plateau 20. sxned sm to md [**First Name (Titles) 54**] [**Last Name (Titles) 55**] yellow. no weaning attempts today. refer to flow sheet. ||||END_OF_RECORD START_OF_RECORD=3||||21|||| n-appropriately arousable, sedatd with propofol infusion r-remains on ac no changes with stable oxygenation/ventilation/slight met acidosis, white sx's cv-sb 50's map's mainatained >60 with dopa at 6mcg's, new a-line placed in r radial but also positional-left radial attempts not successful, cvp- 8 ^ to 11 after ^ivf to 150cc/hr and 2uprbc's for hct 26 now ^35, k and calc repleted gi-tf's resumed at 30cc/hr goal 50, small amt liq stool, softly distended abdomen, protonix gu-upwards of 150-250cc uo/per hour and +2.4liters since 12mn afebrile on iv vanco/flagyl/levo skin intact/pnuemo-boots husband in and updated a/p-remains vent dependent and still requiring vasopressors with hr just 50, following fluid volume balance and increasing intravascular volume(underfilled via tee), infection surveillance/rx ongoing, continue all current supports ||||END_OF_RECORD START_OF_RECORD=3||||22|||| S- INTUBATED O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- VS REMAIN STABLE ON 6 MCG DOPA- BP- 100/40- 140/70; HR- 44-70 SB/SR, NO VEA. AWAIT AM LABS. RESP- REMAINS INTUBATED- 30/700/10 A/C- BREATHING IN SYNCH WITH VENT WHEN SEDATED. SUCTIONING FOR WHITISH SPUTUM- COARSE BREATH SOUNDS AS WELL AS BRONCHIAL. O2 SATS 99%- AWAIT RESULTS AM ABG. ID- AFEBRILE - REMAINS ON FLAGYL/LEVO/VANCO. GU- GOOD U.O- 180-300CC/HOUR VIA FOLEY CATHETER. REMAINS ON IVF 140CC/HOUR. GI- TUBE FEEDS- PROMOTE- INCREASED TO 50CC/HOUR GOAL- FOR MINIMAL RESIDUAL- NO STOOL THIS SHIFT. MS- PT AWAKE, SOME OVERBREATHING VENT- REQUIRING SOME PROPOFOL BOLUSES. REMAINS ON GTT 60 MCG/KG. APPEARS COMFORTABLE. A/P- PT WITH SEPSIS/RESP FAILURE/ACIDOSIS CURRENTLY HEMODYNAMICALLY STABLE ON DOPA/VENT SUPPORT. AFEBRILE ON CURRENT ANTIBX THERAPY/ CONTINUE ANTIBX AS ORDERED. DOPA FOR MAP>60 AS WELL AS IVF. REPLETE AM LYTES/TRANSFUSE AS NEEDED TO KEEP HCT >30. COMFORT/SEDATION WHILE INTUBATED/ KEEP [**Known patient lastname 56**] FAMILY AWARE OF PLAN OF CARE. ||||END_OF_RECORD START_OF_RECORD=3||||23|||| Resp Care remains vented/no changes made so far this shift...settings ac 700x10x.3/5 peep ,pip/plat wnl. sxned for thick white,occas slight yellow tinge. sedated. c/w vent support, no attempts at weaning today. ||||END_OF_RECORD START_OF_RECORD=3||||24|||| n-awake with open eyes but does not fc's, weaning propofol but recently becoming tachypneac and anxious appearing, asked team to consult psych to resume her meds including anxiolytics-her primary psych [**First Name9 (NamePattern2) 57**] [**Location (un) **] phoned and explained that she is extremely anxious at baseline r-weaned to psv 18/peep 5 fio2 30% rr 20-30's tv's 400-700- moderate amount whiteish sx's- abg pnd sats 98% cv-sb 50's, map's>60 off dopa, Na^/cl^ therefore changed ivf to 1/2ns at 150cc/hr- cvp ^today to 17 and has been making adequate uo except uo has decreased to qs since dopa off gi-tf at goal at 50cc/hr/stooling guaiac neg-hct dropped yesterday to 26-2uprbc's>33 this am now backdoen to 29 afebrile on vanco/levo/flagyl skin intact husband in and updated. Police came by to ask questions. a/p-tolerated pressor wean and weaning vent, following fluid/lytes balance and s/sx bleeding ||||END_OF_RECORD START_OF_RECORD=3||||25|||| Respiratory Care Note Patient remains intubated and ventilated on pressure support ventilation. Psv decreased from 18 to 16 due to PCO2 of 26 but she continues to have a high resp rate in spite of large doses of Prpafol. Sister called from [**Location 58**] ||||END_OF_RECORD START_OF_RECORD=3||||26|||| O:NEURO=SEDATED W PROPOFOL W MOD EFFECT. OPENS EYES TO STIMULI, BUT DOES NOT FOLLOW VERBAL COMMANDS. PULM=VENTED. ON CPAP/PS W FIO2 @ 30%M RR UPPER 20'S TO 30'S (REQUIRING >PROPOFOL TO CONTROL RESP RATE), TV 400'S, PRESS SUPPORT >FROM 18-16, & PEEP 5. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK WHITE SECRETIONS. CV=HEMODY STABLE. GI=OGT CHGED TO R-NGT DUE TO PT FORCING OGT OUT W TONGUE. TF @ GOAL W MINIMAL RESIDUALS. RECTAL BAG INPLACE-W SOFT LIQ STOOL & GAS. GU=FOLEY. ADEQ UO. ID=AFEBRILE. LABS=0000 HCT STABLE. AM LABS SENT. A:?ADDITION HALDOL/ATIVAN FOR ANXIETY. ?WEAN VENT W GOAL TO EXTUBATE. CONTIN PRESENT RX. ||||END_OF_RECORD START_OF_RECORD=3||||27|||| resp note - pt, remaines intubated and mech ventelated, placed on ac tv 700 rr 10 30% fio2 5 peep ; tol ok at this time. ||||END_OF_RECORD START_OF_RECORD=3||||28|||| ccu nursing progress note 7a-7p neuro: sedated on propofol at 50mcg/kg/min. opens eyes spontaneously and to stimuli, not following commands. Kernig negative cv: hr 44-50's sb, no vea noted. no junctional bradycardia noted. bp dropped this am 74 systolic. given 500cc bolus and dopamine started transiently, weaned off dopa quickly. bp remained 90/40's most of day. approx 5pm bp again dropped to 80/40. given 500cc ns bolus again with effect. repeat afternoon hct 29.1 (no change from am) pulm: pt tachypneic and with decreased tv's this am. abg revealed 68/28/7.40/18/-5. pt had been on ps overnight and switched back to ac for rest. remains on ac 700/10 peep 5 fio2 30%. tv 700's. abg 93/26/7.41/17/-5. pt appears much more comfortable. ls coarse throughout. sx q2-4hrs thin white secretions. sats 97-100%. gi/gu: abd soft, distended. +bs. tolerating tube feeds promote at 50cc/hr without residuals. sm amt liquid brown stool. foley draining approx 100cc/hr or >. id: con't abx for pneumonia. access: left radial aline positional and dampened. left ij triple lumen intact. f/e/n: repleted mg, ca, and kcl today. neutraphos increased. plan: wean vent as tolerated. con't monitor bp and hemodynamics. ?reason for hypotensioln ? if pt will need swan. team aware of transient hypotension. communication with husband [**Name (NI) 59**]. ||||END_OF_RECORD START_OF_RECORD=3||||29|||| Respiratory Care Note Patient remained overnight on a/c 700 x 10 30%. ABGS/ Sats are within normal limits.No changes made overnight,pt. appears comfortable on current settings. ||||END_OF_RECORD START_OF_RECORD=3||||30|||| O:NEURO=SEDATED W PROPOFOL GTT @ 50MCG W EFFECT. AROUSES TO STIMULI, BUT DOES NOT FOLLOW COMMANDS. SOFT RESTRAINTS. PULM=INTUBATED & VENTED X10 DAYS. SETTINGS-AC, 700X10, 30%, & +5. SATS MID TO UPPER 90'S. AM ABG-90/30/7.36/18/-6. SX-THICK TANNISH SECRETIONS. CV=PA-LINE PLACE RIJ. LSC TL DCED. RHYTHM-SB WO ECTOPY W RATE 40-50 (2 EPISODES OF RATE INTO LOW 30'S). BP 128/63 ON DOPA 4.7. PA-LINE 37/26-31, W 25, & CVP 13 W TD-5.15/2.51/1150 & FICK 8.3/4.05. GI=TF-PROMODE @ 50ML/HR-GOAL. RECTAL BAG INPLACE. GU=FOLEY. I&0=@2300-6L+ OVERALL. ID=AFEBRILE. LABS=2300 HCT-33.5, K-4.3, & BS-111. AM LABS PENDING. A:REQUIRING DOPA TO MAINT ADEQ BP. ?PA #'S-?SEPTIC. ?CAUSE OF SEVER SB. P:MAINT ADEQ SEDATION. ?ATTEMPT CPAP/PRESS SUPPORT. ?WEAN DOPA. ?PA #'S. ?NEED FOR PERM PACER. SUPPORT. CK AM LABS-RX AS INDICATED. ||||END_OF_RECORD START_OF_RECORD=3||||31|||| RESPIRATORY CARE Pt changed to PSV 15/5 with RR 12-16 in NARD. Bronch planned today. Vent checked alarms on. Humidifier full. SX scant clear white. ||||END_OF_RECORD START_OF_RECORD=3||||32|||| s: pt. remains intubated and sedated o: see flowsheet for all objective data. BP extremely labile from 70-150 depending on sedation/agitation issues. remains on dopamine which has been titrated to sbp >90. HR remains labile as well, 40 SB to 60's SR without VEA. lytes repleted remains hypocalcemic.Na cont to increase, IVF changed to D5W and recently rate increased. no more ringers. cont free H20 bolus down NGT afebrile on antibx, pan cultured today. urine clear. swan site D/I. remains vented and did well on 15 pressure support/5 peep. now back on AC 700 x 10 100% for bronch. minimal secretions obtained today, thick yellow sputum. lungs coarse. remains on propofol gtt which has had to be increased. pt. waking up, opening eyes to name but not following commands. MAE and very figidty in bed, trying to tongue out ETT. husband in all afternoon and pt. responded to his calling her but again not following commands. cont to have brown diarrhea via FIB dr. [**First Name (STitle) 60**] aware cont tube feeds with minimal aspirates which were held at 12 pm to give synthroid 2 hours later. cont to be held for bronch and will be restarted. pneumo boots on, pt. turned q2hr. ||||END_OF_RECORD START_OF_RECORD=3||||33|||| NEURO: CONT ON PROPOFOL GTT FOR SEDATION. OPENS EYES SPONTANEOUSLY AND TO PAIN. DOES NOT FOLLOW COMMANDS AND NO PURPOSEFUL MOVEMENT NOTED. CV: HR 40-60 SB-SR NO VEA NOTED. BP STABLE ON DOPAMINE GTT. SEE FLOWSHEET FOR OBJECTIVE DATA AND HEMODYNAMICS. CO/CI IMPROVED THIS AM FROM LAST NIGHT. CA++ LEVEL STILL LOW AND RPLACED WITH 2 GMS OF CALCIUM GLUC IV. LABS PENDING THIS AM, RESP: COARSE BREATH SOUNDS. SUCTIONING FOR MINIMAL SECRETIONS. VENT SETTINGS AC700X10 50% FIO2. ABG PENDING THIS AM. GI: ACTIVE BOWEL SOUNDS. FIB IN PLACE DRAINING GREEN COLORED STOOL. TF OFF. ? STARTING TPN TODAY. MINIMAL RESIDUALS WITH TF ON. GU: FOLEY TO GRAVITY. DRAINING CLEAR YELLOW URINE IN GOOD AMTS. SEE FLOWSHEET FOR I/O'S. SKIN: SKIN INTACT EXCEPT FOR SMALL ABRASION NOTED ON RIGHT KNEE. CLEANED WITH SOAP AND WATER AND LEFT OPEN TO AIR. ||||END_OF_RECORD START_OF_RECORD=3||||34|||| S REMAINS INTUBATED AND SEDATED O: SEE FLOWSHEET FOR OBJECTIVE DATA. PT. HAVING A FEW EPISODES OF GOING INTO JUNCTIONAL RHYTHM RATE IN 40'S WITH SUBSEQUENT SBP DROP TO 50-60 REQUIRING INCREASED DOPAMINE. ONE TRANSIENT EPISODE OF CHB RATE 30'S WITH SBP 60'S REQUIRING INCREASED DOPAMINE. HO AWARE. 12 LEAD DONE FOR JUNCTIONAL RHYTHM EPISODE, UNABLE TO CAPTURE TRANSIENT CHB. LYTES SENT AND PND. CALCIUM CONT TO BE REPLETED. PAD'S IN 20'S WITH PCW 20 AND CVP IN TEENS. D5W DECREASED TO 75CC/HR. CONT WITH FREE H20 BOLUSES WITH DECREASING NA. TUBE FEEDINGS RESTARTED, CURRENTLY ON PROMOTE WITH RATE 25CC/HR. TOLERATING SO FAR WITH MINIMAL ASPIRATES. SYNTHROID CHANGED TO IV DOSING. NO STOOL NOTED TODAY VIA FIB. BS HYPOACTIVE. PT. REMAINS ON ANTIBX, AFEBRILE. REMAINS INTUBATED NOW ON PRESSURE SUPPORT AND PEEP WITH STABLE ABG'S, CURRENTLY ON 15CM PRESSURE SUPPORT, 5 PEEP AND 40%. WITH TURNING RR TO 30'S WITH TV GOING TO 300 AND INCREASED MINUTE VOLUME TO 14. WITH PROPOFOL THAT IMPROVES. TV 400'S. CONT PROPOFOL, MORE AWAKE TODAY WITH SPONTANEOUS EYE OPENING BUT NOT FOLLOWING COMMANDS AND NO PURPOSEFUL MOVEMENT. INTERMITTENLY MOVING EXTREMITIES. PNEUMO BOOTS CONT. FAMILY IN, UPDATED ON CONDITION. CONT TO GET NYSTATIN SWISH/SWALLOW FOR ORAL THRUSH. A: TOLERATING PRESSURE SUPPORT P; CONT TO WEAN AS ABLE, FOLLOW RHYTHM, HEMODYNAMICS, LYTES, PULM STATUS, FOLLOW NEURO STATUS, INCREASE TUBE FEEDINGS AS TOL TO GOAL RATE OF 50CC/HR ||||END_OF_RECORD START_OF_RECORD=3||||35|||| Pt received intubated on vent setting P/S 15 peep 5 FiO2 40%. Tidal volumes 400-500 RR 14-23. Suctioned ETT for sm amt of yellow secretions. Breath sounds coarse. Will cont to follow closely. ||||END_OF_RECORD START_OF_RECORD=3||||36|||| NEURO: CONT ON PROPOFOL FOR SEDATION. OPENS EYES SPONTANEOUSLY, DOES NOT FOLLOW COMMANDS, NO PURPOSEFUL MOVEMENT. CV: SB-SR RATE 45-60. BP STABLE ON DOPAMINE 5 MCG/KG/MIN. RESP: SUCTIONING FOR THICK YELLOW SPUTUM. SEE VENT FLOWSHEET FOR SETTINGS. ABG'S PENDING THIS AM. COARSE BREATH SOUNDS THROUGHOUT LUNG FIELD. GI: CONT ON TF TOL WELL. RATE INCREASED TO 35 CC/HR. SMALL AMT OF DARK GREEN STOOL OVERNIGHT, FIB REPLACED AND NEW ONE INTACT. CONT ON FREE WATER BOLUSES. NA+ IMPROVING. GU: FOLEY TO GRAVITY, DRAINING CLEAR YELLOW URINE IN GOOD AMTS. SEE I/O SHEET FOR TOTALS. STABLE OVERNIGHT. ||||END_OF_RECORD START_OF_RECORD=3||||37|||| Respiratory Care Note Pt weaned to CPAP 5peep 12IPS. Pt tried on 10IPS but rate increased to 35-40 and Vt dropped to 200's. Pt placed back on 12IPS. Pt suctioned for mod amount of thick clear secretions. Plan to continue to try and wean patient ||||END_OF_RECORD START_OF_RECORD=3||||38|||| S: INTUBATED/ SEDATED O: SEE CAREVUE FOR ALL OBJECTIVE DATA CV: REMAINS DEPENDENT ON DOPAMINE, CURRENTLY 4MCG/KG W/ BP 95-110/60-70. REMAINS IN SB 46-60 NO VEA. PAD'S MID 20'S, CVP 14, SWAN TO BE PULLED AND TLC PLACED OVER A WIRE. RESP: PS WEANED TO 12, TOLERATED WELL, W/ ATTEMPT TO WEAN TO 10PS RR^30'S AND TV DOWN TO MID 200'S, CURRENTLY ON 10PS/5PEEP, TV 300-400 RR 20'S. LUNGS COARSE, SX Q2-3HRS FOR MOD AMTS THICK WHITE/YELLOW SECRETIONS. GI: TF ^ TO 45CC/HR W/ MINIMAL RESIDUALS. 4 LARGE THICK LIQ GREEN STOOLS. SPEC SENT FOR C DIFF. GU: FOLEY DRAINING LG AMTS CL YEL URINE. CURRENTLY ~ 1L NEG. ID: LOW GRADE TEMP, CONT ON ABX. SKIN: MOUTH W/ LG AMTS THRUSH, NYSTATIN SWISH AND ASWALLOW APPLIED, DIFFUSE FLAT PINK RASH ON BACK. SM HEALING ABRASION ON R KNEE. MS: CONTINUES ON PROPOFOL AT 55 MCG/KG. AROUSABLE TO VOICE, APPEARS COMFORTABLE. SOCIAL: HUSBAND IN MOST OF DAY. A: REMAINS DOPA DEPENDENT. LG AMT STOOL, LOW GRADE TEMP, P: MONITOR BP, CHANGE CORDIS TO TLC OVER WIRE. FOLLOW I/O, WEAN AS TOLERATED. ||||END_OF_RECORD START_OF_RECORD=3||||39|||| Pt received intubated on vent settings pressure support 12 peep 5 FiO2 40%. Tidal volumes 410-500 RR 15-21. Suctioned ETT for sm amt of white secretions. Breath sounds improve after suctioning. Abg PH 7.32 CO2 41 PO2 109. Cont to follow. ||||END_OF_RECORD START_OF_RECORD=3||||40|||| S: orally intubated and sedated O: Please see carevue for VS and objective data CVS: Hemodynamically stable. HR 40's-60's NSB/NSR, no junctional or CHB noted. No vea. K+ 3.9, am labs pnd. IV Dopamine at 4 mcg/kg/min. weaned to off with bp ranges 90-130/50-60. Maintaining MAPs 60-90. Swan catheter dc'd by team, attempted to change over to TLC, however cordis came out. Team unable to gain access for TLC, therefore 2 peripheral IV's in place for IV drips and medications., functioning well at present. Resp; Remains orally intubated and mechanically ventilated on PSV 12/5, 40%. TV 400-500. RR 14-22. ABG 109/41/7.32/22/-4. Lungs coarse. Suctioned q2-3 hours for small amount of thick, yellow to white sputum. CXR done after multiple attempts of subclavian and IJ for TLC as above, no pneumo present. ID: Tmax 99.2 po. On multiple antibxs. GI;GU: TF Promote with fiber, initially at 45cc/hour, increased to goal of 50cc/hour with residuals WNL. However, incontinent of green, loose liquid stool. Multiple rectal bags have not worked in the past. Attempted mushroom catheter without success. 30FR, 30cc balloon rectal catheter placed with good effect at present. Placed at 0400. Na up to 150 therefore Free H20 boluses restarted. Neuro: IV Propofol initially at 58.82mcg/kg, titrated down to 49 overnight for BP support and Pt. sedation level. Pt. opening eyes spont. and to verbal stimulation. Not following commands. Nonpurposeful movements of extremities, soft hands restraints remain in place. Turned q 2 hours, skin care provided. A: Hemodynamically stable off IV Dopamine. P: Cont to assess hemodynamics and rhythm. Maintain MAP of 60 or >. Cont. antibxs. May need further IV access. Mat reattempt to wean from vent. Cont. pulmonary toileting. IV Propofol as need. Follow up with am labs. Comfort and emotional support to Pt. and family. ||||END_OF_RECORD START_OF_RECORD=3||||41|||| Respiratory Care Note Pt currently on CPAP/PS 8PS 5Peep 30%. Pt tol settings well. RR 20-25 Vt400-500. Pt more awake today. Sxnd for thick white secretions today. ABG results from weans in flowsheets. Will continue to follow and wean as tolerated. ||||END_OF_RECORD START_OF_RECORD=3||||42|||| S; orally intubated O: see carevue for VS and objective data. CVS: Hemodynamically stable. HR 50-70's NSB/NSR, no vea. K+ 3.6, repleted with 40meq po KCL. am labs pnd. BP 100-130's/50-60. Resp; Remains intubated and mechanically ventilated. Tolerated PSV 8/5 30%, with RR low-mid 20's, TV 440-500. ABG 99/30/7.42/20/-3 98% . PSV increased to [**07-02**] overnight to rest Pt. TV 430-500. RR 18-24. am abg pnd. Lungs coarse, decreased left base. Suctioned q 2-3 hours for small amount thick, white sputum. GI:GU; TF Promote with fiber at goal of 50cc/hour, residuals high x1 at 0400, after MN meds and 250cc free H20 bolus. Held x2 hours with decreased residuals and restarted TF. Continues with loose, green stool, rectal foley in place 30FR, 30cc balloon, deflated q 4 hours. U/O via foley remains 150-285cc q/hour. I/O approx. even. D5W conts at 125cc/hour, free H2O boluses qid with Na 148, am pnd. Hct stable 28-30. ID: afebrile, on po Flagyl, Vanco and Levoq. dc'd after last doses 9/7. Neuro; Remains on IV Propofol at 35mcg/kg/min, Pt. more alert and restless this shift. Given 1mg IV Haldol at 2200 and 0400 with moderate effect. Opening eyes spont, lifting head off pillow. Looks at RN when spoken to, but does not nod head to simple questions. Inconsistently follows commands to squeeze hand or move extremites. Soft hand restraints remain in place. Skin: Intact without breakdown, buttocks red raw, rash remains the same on back. Skin care provided, turned q 2 hours. A: stable, tolerated slow PSV wean. P: Cont with pulmonary toileting, cont. PSV wean with decrease of Propofol on days. Follow up with am labs. Monitor hemodynamics. Comfort and emotional support to Pt. and family ||||END_OF_RECORD START_OF_RECORD=3||||43|||| Respiratory care note Remains on pressure support,increased from 8 to 10 overnight to rest;now back on 8. Tidal volumes are variable from 390-500,occas. up to 700. ABGS/Sats are within normal range. Plan is to continue with slow wean of psv today. ||||END_OF_RECORD START_OF_RECORD=3||||44|||| n-alert and fc's and softly speaks, mental status seems to be appropriate but still somewhat lethargic, propofol off since early am r-found ett to too far out-checked abg and found to be adequate therefore removed ett for extubation trial and she has been able to maintain oxygenation/ventilation adequately, weak cough, weak gag, requiring oral/pharangeal sx to clear, rr remains^20's-30's but remaining stable thus far cv-nsr, stable bp, no pressor requirement, na remains ^ ^'d free water to q 4hr and d5w at 125cc/hr, uo is brisk gi-tf's on hold until airway confirmed stable gu-auto diuresing afebrile on po flagyl hct stable >28 husband in and updated a/p-no s/sx resp compromise s/p extubation, continue all current supports ||||END_OF_RECORD START_OF_RECORD=3||||45|||| s. states that she feels confused when asked O. NEURO ALERT RESTLESS MAE FC PEARLA MOVING CONTINUOUSLY ABOUT THE BED ORIENTED ONLY TO PERSON CARDIAC HR SB-NSR BP STABLE SKIN W+D PP+2 RESP 40% FM LUNGS CTA WITH ALOT UPPER AIRWAY CONGESTION SX MOD AMT OF THICK YELLOW SPUTUM TO EXP WHEEZES GIVEN NEB TX WITH IMPROVEMENT ABG JUST PRIOR TO NEB 102/41/7.34/23/-3 GI CONT WITH LIQ STOOL FLAGYL D/C STOOLS NEG FOR C-DIFF ABD SNT BS+4 GU FOLEY U/O> 100CC QHR ID AFEBRILE WBC 9.9 OFF ANTIBX A. S/P SEPSIS WITH LONG INTUBATION +SMOKER P. VIGOROUS PULM TOLIET ||||END_OF_RECORD START_OF_RECORD=3||||46|||| ADD 1850P GIVEN 4OMG IV LASIX CRACKLES 1/4 UP BILAT IV STOPPED FREE BOLUS WATER STOPPED ||||END_OF_RECORD START_OF_RECORD=3||||47|||| ccu nursing progress note 7p-7a neuro: pt alert, oriented to name. follows simple commands. extremely restless overnight. given haldol x2 with little effect. cv: vss. tmax 99.6 ax. hr 60-80's sr. no vea noted. bp 110-130/60's. remains off pressors. pulm: ls clear, occ exp wheezes, diminished at bases. rr 24-30's tachypnic, asynchronous at times. receiving nebs prn. remains on cool neb mask at 40%. o2 sats 95-97%. am abg 90/43/7.42/29/2. no congestion/coughing noted. received lasix on evenings with ++++ diuresis. -2l thus far today. gi/gu: abd soft, distended. +bs. rectal bag draining liquid green stool. remains npo. ngt intact. foley draining lg amts clear yellow urine. skin: large rash on back. difficult to position in bed r/t restlessness overnight. labs: evening Ca 8.1. repleted with 1amp Ca gluconate. am labs pending. plan: con't pulm toilet. reasess nutrition status. communication with husband. stable s/p extubation yesterday. ||||END_OF_RECORD START_OF_RECORD=3||||48|||| NEURO--pt remains confused but pleasant. mae spont and to command . able to bear wt with max assist of 2 persons but knees buckle. her upper ext. at times are flaccid . she has received 150 mcg of synthroid po today. oriented x2. CARDIAC--when sleeping, hr decreased to 50 but only transiently. now hr 70-80's sr with occasional pvc. bp stable at 130-140/70's. RESP--lungs clear and decreased in bases. strong productive cough. sao2 97-99%. o2 at 4l nc GI--- ngt d/ced. tolerating cereal, jello, h2o and juice without signs of aspiration. denies nausea, vomiting. appetite good. incontinent of lgr amts of stool. abd soft and distended. GU---foley cath patent draining lgr amts of yellow urine. SKIN--rash covering entire back. team aware. per pt, it does not itch. COPING--husband in to visit. pt oob in chair x 4 hrs. tolerated well. max assist of 2. ID--temp 100.8 rectal. off all abx. A--stable. no episodes of bradycardia P-- con't to monitor. redirect and reorient as needed. maintain aspiration precautions ||||END_OF_RECORD START_OF_RECORD=3||||49|||| S: " Get me out of hear " " Get me my lithium! " O: pt. awake but confused. oriented to person only. yelling out, wanting to get out of bed and leave building. trying to get out of bed but not getting agitated. still able to follow conversation. voice very raspy and difficult to understand. Rx with haldol 2mg IV with good effect. able to sleep for ~ 4hours. wakes again, yelling for help and confused. Rx with haldol for total 2 doses of 2mg each. no restraints required. also asking for husband and needing reasurance and reminders of his whereabouts. u/o 100-200/hr. IVF D5W at 130/hr. Na in eve 151. AM pnd. - HR down to 47 when sleeping, up to 70's to 80 when awake. no VEA. BP 111-150's/50-70's. negative 1.7L at 12am. about even at 0600. taking water with straw. taking meds well. - no stool. Abd soft, NT. (+) BS. - LS diminished at bases. sats 94-97% on 4lNC. RR 20-26. - moving all extremeties well. trying to sit up. wants to get out of bed. A: acute confusion helped with haldol for short periods. Na remains high P: follow lytes, out of bed today. reorient as needed. contin. IVF per team. ||||END_OF_RECORD START_OF_RECORD=3||||50|||| SR TO SB NO ECT, BP STABLE. SAT 96 4L NP. PT CONFUSED ,YELLING OUT. WANTS TO GO HOME, BUT COOPERATIVE.OOB TO CHAIR ,VERY WEAK . TO BE SEEN BY PT. E/D FAIR C ASSIST . DRUG RASH OVER BACK . PASSING BR NEG SOFT STOOL . HUO 100CC /HR . ||||END_OF_RECORD START_OF_RECORD=4||||1|||| S- " WHERE AM I NOW?...CAN I EAT [**Last Name (un) 61**]?" O- SEE FLOWSHEET FOR OBJECTIVE DATA. PMH: PLEASE REFER TO MEDICAL TEAM NOTES FOR DETAILS R/T PMH/HPI. THIS IS A 67 YR OLD PT WITH A HX SIGNIFICANT FOR : AFIB CVA/TIA MI/CAD/RECENT LCX STENT/S/P AVR EF- 10% S/P CABG [**1959**], [**1973**] ENDOCARDITIS HPI: PT WAS ADMITTED TO [**Hospital 62**] FOR VFIB ARREST [**05-15**] AT WHICH TIME HE WAS TREATED WITH EP/ICD/PACER. HE HAD A CATH AND HAD A LCX STENT. PT WAS D/C TO HOME [**05-23**]. PT NOTED INCREASED FATIGUE, WEAKNESS AND WENT TO [**Hospital **] WITH FEVER OF 103 [**05-28**]. HE WAS TREATED WITH NEO/FLUID/VANCO/GENT AND HEPARINZED. HIS WC/LFT WERE ELEVATED WITH AN ULTRASOUND REVEALED DILATED DUCTS. PT WAS TRANSFERED TO THE [**Hospital 63**] CAMPUS FOR GI STUDIES- ERCP. CBD WAS FOUND TO BE DILATED, NO STONES; CYSTIC DUCT DID NOT FILL AND PANCREATIC DUCT WAS NML. SPECIMENS WERE SENT FROM THE BILE DUCT AND A STENT WAS PLACED IN THE DISTAL BILE DUCT. PT WAS SENT TO PACU POST PROCEDURE ON NEO 1 MCG/NEO- HE WAS AFEBRILE WITH A STABLE BP AND TRANSFERED TO CCU 9:30PM. CURRENT COURSE OF SYSTEM: CV- PT ARRIVED ON NEO 1 MCG/KG/MIN WITH BP- 120- ATTEMPTED TO D/C GTT- BUT BP -DROP TO 80-90/. RESTARTED ON 1 MCG AND SLOWLY DECREASED BY 0.4 MCG/KG/MIN- CURRENTLY ON 0.6 MCG/KG/MIN NEO WITH MAPS>60. LYTES WNL. RESP- LUNGS CLEAR- O2 SATS- HIGH 90'S ON 2 L NP. NO SIGN CHF. ID- AFEBRILE- STARTED ON CIPRO/FLAGYL/AMPI. D5NS 75CC/HOUR. GI- DENIES PAIN- NPO EXCEPT SOME ICE CHIPS. VERY ITCHY HANDS- GIVEN BENADRYL 25 QHS WITH RELIEF. MS- PT ALERT/ORIENTED X 3, VERY PLEASANT- COMFORTABLE EXCEPT FOR ITCHINESS. CALLED SON/DAUGHTER/FIANCE TO INFORM ABOUT TRANSFER TO CCU. APPEARS TO UNDERSTAND PLAN OF CARE. A/P- PT ADMITTED TO CCU FOR CHOLANGITIS/HYPOTENSION CURRENTLY HEMODYNAMICS STABLE ON NEO GTT/ AFEBRILE ON ANTIBX X 3. COMFORTABLE AFTER BENADRYL QHS. CONTINUE TO MONITOR HEMODYNAMICS- SLOWLY WEAN NEO AS TOLERATED. CONTINUE ANTIBX. NPO- CONSIDER ADVANCE OF DIET. KEEP PT AWARE OF PLAN OF CARE/PROGRESS. C/O ONCE HEMODYNAMICS STABILIZED OFF NEO/ALINE D/C. ||||END_OF_RECORD START_OF_RECORD=4||||2|||| please refer to page 2 written today for transfer back to [**Hospital **] for hpi/pmhx n-intact, anxious to get home, concerned about his business Genentech r-ra sats>96% breathing comfortably bbsds cv-av paced 60 recent aicd/ddd/l cx stent/ef 10%/s/p avr x 2 bp stable off neo, ivf maintenance continues d5ns at 75cc/hr 3 piv's intact gi-keeping diet clear liqs for today gu-uo>100cc/hr afebriel today on amp/flagyl/cipro a/p-hemodyamcially stable s/p biliary stent/sepsis continue all current supports ||||END_OF_RECORD START_OF_RECORD=5||||1|||| Respiratory Care: Pt intubated in ER for airway potection with #7.5 ETT 24 at lipps. x-ray taken and tube pulled back to 21 lipps. Pt ventalating and oxygenating well (see flow sheet for abg's). pt currently sedated and on full vent support. Vent settings are AC 600*12 40% 5 peep. These settings were weaned from rr 16 and fio2 100%. Will continue to follow and wean as tollerated. ||||END_OF_RECORD START_OF_RECORD=5||||2|||| 77 YO FEMALE ADMITTED FROM THE EW W RAPID AF, ?ACUTE MI, & UROSEPSIS. PMH:CAD W AMI [**1984-03-27**]-ECHO=EF 40%. APICAL HK. APEX AK. HTN. DM W RETINOPATHY. CVA [**76**]'. CHOLECYSTECTOMY [**79**]'. OBESITY. URINARY INCONTENENCE. MILD MENTAL RETARDATION VS DEMENTIA. ALLERGIES:NKDA. SOCIAL:RESIDES NH SINCE RECENT MI. WIDOWER WO CHILDREN. SISTER-?HEALTH CARE PROXY. LIVES IN [**Location 64**] PAST SMOKER. WO ETOH. PRESENT HX:[**05-27**] DECEASED MENTAL STATUS, LETHARGIC-NOT ABLE TO CUSTOMARY THINGS, HYPOTENSIVE, FEBRILE, & FOUL/CLOUDY URINE. TRANSPORTED TO EW. IN EW FOLEY PLACED, PAN CULTURED & ABX STARTED-LEVOGUIN, & NEG HEAD CT W INITAL PLAN TO ADMIT TO MICU W UROSEPSIS. WHILE IN EW DEVELOPED RAPID AF W HYPOTENSION-RXED W DOPA THEN LEVO-ATTEMPTED CARDIOVERSION X3 WO SUCCESS. LOADED & STARTED ON AMIODARONE. BOLUSED & STARTED ON HEPARIN. INTUBATED DUE TO DECREASED RESPONSIVENESS. ALINE PLACED R-FEM & TLC PLACED RSC.ADMITTED TO CCU. CCU COURSE:O:NEURO=SP INTUBATION-SLOWLY BECOMING RESTLESS-PROPOFOL STARTED W ADEQUATE EFFECT. SOFT RESTRAINTS BILATERALLY. RESPONDS TO NOXIOUS STIMULI W WDRAWL. PULM:INTUBATED & VENTED. SETTINGS ADJUSTED TO ABGS-SEE FLOW SHEET. BREATH SOUNDS=COURSE. SX MINIMAL SECRETIONS. SATS 100%. CV=REMAINS IN AF W VENTRICUALR RESPONSE 120'S. DOPA OFF. LEVO DECREASED W STABLE BP. HEPARIN @ 800U-PTT PENDING. AMIODARONE @ 30MG/HR. R-RADIAL ALINE PLACED & R-FEM ALINE DCED. GI=OGT PLACED. BILIOUS MATERIAL. ENDO=ELEVATED BS. INSULIN GTT STARTED. TITRATED TO OBTAIN BS IN LOW 200'S. GU=FOLEY. MINIMAL UO. UO VERY CLOUDY/SEDIMENT. ID=LOW GRAADE T. LABS=AM SENT. A:VENTED & SEDATED. REMAINS IN AF. TOLERATING LEVO WEAN. REQUIRING INSULIN GTT. P:?ATTEMPT TO WEAN PROPOFOL & VENT. PULM TOILET. ?RX AF-?REBOLUS W AMIODARONE & REATTEMPT CARDIOVERSION. CONTIN WEAN LEVO AS TOLERATED. MAINT THERAPUTIC PTT. FOLLOW BS-TITRATE AS INDICATED. ABX AS ORDERED. CK AM LABS-RX AS INDICATED. NEED TO ADDRESS CODE STATUS-HEALTH CARE PROXY. ||||END_OF_RECORD START_OF_RECORD=5||||3|||| Resp Care, 7a-7p Pt received on CMV 600/12/40%, 5 peep. No vent changes during shift. ABG on settings were: 7.38-33-169. BS remain CTA bilaterally. Pt suct for scant amounts of clear secretions. Plan is to continue vent support as necessary, wean as tolerated. ||||END_OF_RECORD START_OF_RECORD=5||||4|||| Remains stable intubated and ventilated, on pressors. Remains full code. Management continues for urosepsis, MI, Diabetes, rhythm disturbance. ROS: CARDIAC: Tolerating tapering Levofed doses. On and off to max 8 mcg/min throughout day. Has tolerated hours off at a time. Maintaining b/p > 100/. Currently off Levo w/ b/p 112/59. Hr 107 regular rhythm( has regular atrial ectopic stimuli). On dilt gtt, heparin gtt,(has had 2 theraputic ptt...next check in am), amiodarone gtt (beginning po amio tonight). Ck trending downward (needs ck 8pm) RESP: A/C-600cc-40%-5cm peep -12 br. Sx thick tan secretions, small amnts infrequently. ABG: 169-33-7.38-20--4. Strong cough. GI: no stool. ogt. no nutritional repletion. RENAL: bun 62/cr 1.1. urine output 60-70cc/hr throughout day. Cloudy. ID: afebrile. Improving gap. CO2 16. On abx.wbc 14.4. NEURO: propofol gtt. Turned off, pt awoke and very responsive. Not to commands, but alert and coughing. Resumed propofol w/ good sedative effects. Fluid/electrolytes: +1800cc past 24hrs. hypokalemia, receiving kcl repletion. Got 15mmKPhos today. Repleted calcium (4 amps), phosphorus, Endocrine: on insulin gtt w/ glu drop to 60's. Off gtt, on d5 1/2 ns, on sliding scale. SOCIAL; sister in to visit, spoke w/ physicians Dr. [**Last Name (STitle) 53**]. Remains full code. Assess: stable, improving sepsis Plan: lytes w/ck @ 8pm. wean levo as tol. monitor u.o. ||||END_OF_RECORD START_OF_RECORD=5||||5|||| Patient remains intubated and mechanically vented. Vent checked and alarms functioning. Settings: A/C 600*12 40% with 5 Peep. Please see respiratory section of carevue for further data. ||||END_OF_RECORD START_OF_RECORD=5||||6|||| O: TM 100.4R. down to 99.8R. continues on levoquin iv. - HR 97-105 regular rythym, no VEA. BP 95-123/50-60's. remains off levo gtt. started on po amio 400mg TID at 2100. IV amio d/c'ed at 2300. continues on dilt gtt at 7.5mg/hr. heparin at 800u/hr. - eve K+ 5.4, CK down to 1039/37% - resp: orally intubated on AC 600x12x.40. RR 12. no overbreathing. sats 100%. ABG 7.41/27/162. LS diminished. suctioned for thin white secretions. clear oral secretions. - GU: u/o 50-60/hr. (+) 2l for [**05-28**] and (+) 900 LOS. continues on IVF D5 [**09-28**] at 75/hr. FS 100-120. insulin gtt remains off. - neuro: opening eyes slightly to name, appearing uncomf., coughing, grimacing when stimulated. given small propofol boluses with good effect(1-2gtt) and remains on gtt at 28mcq. no purposeful movement. hands restrained lightly. - GI: oral GT, (+) audible placement. green bile liquid small amts in stomach. tol. meds. no stool. (+) BS. A: hemodynamically stable off levo. HR stable on po amio and off IV gtt amio u/o adaquate maintaining comfort on propofol gtt. FS stable P: follow BP/HR. follow plan for dilt gtt. contin. po amio., heparin. monitor neuro for change. titrate propfol for comfort. follow FS. ||||END_OF_RECORD START_OF_RECORD=5||||7|||| Resp Care attempting to wean this afternoon...pt with no ventilation/oxygenation issues...changed to psv mode..initially only requiring 10 ps...now requiring 20. also initially with white secretions...now with more yellow. ?not ready for extubation.. refer to flow sheet. ||||END_OF_RECORD START_OF_RECORD=5||||8|||| NEURO: PROPOFOL OFF 13:00, PT AWAKE,NODDING HEAD APPROPRIATELY,MOVING EXTREMETIES VERY LITTLE. ID: TM 100.2 R. CV: HEMODYNAMICALLY STABLE, W/ HR 100-110 OFF DILTIAZEM. BP 110-130/50-70. HEPARIN TO BE D/C AT 20:00. RESP: VENT CHANGED TO PS. ATTMEPT AT PS10/PEEP 5 -> RR 30'S AND LOW TV. PS ^ TO 15, AND TV 500'S RR 20. SX Q2HR FOR THICK TAN/WHITE SECRETIONS. LG AMTS ORAL SECRETIONS. GI: OGT CLAMPED. NO STOOL THIS SHIFT. GU: FOLEY DRAINING CL YEL URINE. 80-110CC/HR CURRENTLY ~ 600CC +, IVF HAS BEEN D/C. END: BS MID 200'S, COVERED PER RISS. SOCIAL: HAVE NOT HEARD FROM ANY FAMILY TODAY. ||||END_OF_RECORD START_OF_RECORD=5||||9|||| VENT CHANGED BACK TO A/C 600 X 12 .40 5P. PT'S RR UP, TEMP 100.8, APPEARS SOMEWHAT AGITATED, STILL THICK SECRETIONS. ||||END_OF_RECORD START_OF_RECORD=5||||10|||| PT CONTINUED ON CPAP TILL 9PM.ABG 174/26/7.42/17. RESP RATE 36. SX PT LG AMT THICK TAN .PLACED ON AC FOR NIGHT . ALREADY ON 10 MIC PROPOFOL BUT PT AROUSABLE.PT CONT IN ST.BP STABLE . NG CLAMPED.PASSING BR LIQUID STOOL . ||||END_OF_RECORD START_OF_RECORD=5||||11|||| CCU NURSING PROGRESS NOTE 11P-7A NEURO: Pt appeared anxious with rr in 30's at beginning of shift requiring increased propofol with good effect. Pt is presently sedated, but does arouse to tactile stimulation. Unable to follow commands at this time. RESP: LS coarse. Suctioned q2-3 hrs for mod amt thick tan secretions. Vented on AC 600x12 with 5 peep and 40%. stable gas. CARDIAC: Pt noted to be in afib with rate 90-130's at onset of shift (also in setting of Temp spike). Was started on diltiazem gtt at 5mg/hr which has been titrated up to 7mg/hr. Pt later noted to be in PAT with occas. APC's. Decision made by cardiology team to heparinize pt in case of need for cardioversion. Was bolused with 4500u and started on gtt at 1000u/hr. PTT due at 9am. Bp dipped into mid 70's at 5am-> rec'd 250cc NS bolus x1 with BP presently up to 90/40. (pt noted to be +255 this am with urine output ~25cc/hr overnight.) Pt remains on po amiodarone, however ? need for IV amiodarone vs cardioversion if pt continues to decompensate. ID: Temp spike to 102-> blood cxs sent from a-line and c-line; sputum cx and gs sent as well. Given tylenol x2 with labs trending downward. GI: NGT with minimal aspirates. Tolerating po meds given via NGT. Abd with hypoactive BS. skin: Lg ecchymotic area over buttocks-> area outlined. ? etiology. ||||END_OF_RECORD START_OF_RECORD=5||||12|||| Resp CAre remains vented/ac mode ,no changes today..600x12x.4/5 peep. pip/plat wnl. sxned thick yellow. no weaning d/t temp/sputum/fluid status. ||||END_OF_RECORD START_OF_RECORD=5||||13|||| NEURO: PT REMAINS ON PROPOFOL 10 MCG/KG/MIN W/ GOOD EFFECT. AROUSABLE TO VOICE, CV: HR 95-110 PAT W/ OCC PAC. BP LABILE THIS AM, DOWN TO 7O'S, GIVEN 250CC NS W/ GOOD EFFECT, MORE STABLE THIS AFTERNOON SBP LOW HUNDREDS. HEPARIN, LOPRESSOR, AND CAPTOPRIL HAS BEEN D/C. ECHO DONE, RESULTS PND. RESP: REMAINS VENTED W/ NO CHANGES MADE TODAY, SEE CAREVUE FOR ALL DATA. SX FOR MOD, LG AMTS THICK TAN SECRETIONS. ID: TM 101, DOWN TO 98.8 THIS AFTERNOON , STARTED ON VANCO AND CEFTAZ. GI: STARTED ON TF, PROMOTE W/ FIBER AT 10CC/HR. NO STOOL GU: FOLEY DRAINING CL YEL URINE, 20-50CC/HR. SOCIAL: SISTER IN TO VISIT, MET W/ CASEWORKER [**First Name5 (NamePattern1) 65**] [**Last Name (NamePattern1) 66**]. ||||END_OF_RECORD START_OF_RECORD=5||||14|||| Respiratory Care Note Respiratory status remains unchanged overnight,on full ventilation a/c mode. ABGs and sats are good;pt.is not overbreathing the vent. Breath sounds are coarse,suctioning thick yellow sputum. She appears comfortable on current settings. ||||END_OF_RECORD START_OF_RECORD=5||||15|||| npn 7p-7a: ccu nsg progress note: s/o: neuro--conts sedated on 10mcg of propofol, opens eyes when name is called, able to follow simple commands, able to squeeze w/hands and move feet, sleeping throughout the noc resp--ls coarse in upper lobes, decreased in lower lobes, sxn'd for mod amt thick tan secretions, remains vented a/c 600-12-peep 5, 40%, abg wnl cardiac--hr 100 pat, no ecotpy, bp 90-110/50's, conts on amio po gi--abd soft, non tender to palpation, (+)bs, tf's infusing up to 40cc/hr w/out residuals, rectal bag intact, no stool gu--foley draining cloudy yellow foul smelling urine, approx 30cc/hr skin--intact, buttocks cont w/ecchymotic area, turning s-s, pt would probably benefit from 1st step mattress id--tmax 99.6po, conts on ivab, pt has new aline a: septic p: cont ivab, monitor temp/labs monitor cvs follow resp status, suction as needed, wean as tol ||||END_OF_RECORD START_OF_RECORD=5||||16|||| 7A-7P CV: REMAINS HEMODYNAMICALLY STABLE W/ HR 100-110 ATRIAL TACHYCARDIA, BP 100-120/50-70. CONTINUES ON AMIODARONE RESP: NO VENT CHANGES MADE THIS SHIFT. SX Q2HR FOR MOD AMTS THICK TAN SECRETIONS. ID: TM 100.2 CONT ON ABX. GU: DIURESED W/ 80MG IV LASIX AT 10:00 W/ GOOD RESPONSE, CURRENTLY ~1L NEG. GI: TF ^ TO 50CC/HR W/ MINIMAL RESIDUALS, NO STOOL END: BS 260'S, COVERED PER RISS. MS: REMAINS ON PROPOFOL AT 10 MCG/KG, OPENS EYES TO STIMULI, FOLLOWS SIMPLE COMMANDSM, NODS HEAD. SKIN: INTACT, BRUISED AREA ON COCCYX SLIGHTLY IMPROVED. SOCIAL: HAVE NOT HEARD FROM FAMILY TODAY. A: HEMODYNAMICALLY STABLE, CONT W/ LOW GRADE TEMPS, FLUID OVERLOADED TOLERATING TF. P: CONT DIURESIS, ADD LOPRESSOR AND CAPTOPRIL AS BP PERMITS, MONITOR TEMP CURVE, CONT ABX. ||||END_OF_RECORD START_OF_RECORD=5||||17|||| nsg progress note 7p-7a: neuro--conts sedated on 10mcg propofol, opens eyes to name, is able to follow commands, sleeping most of night, ?wean propofol if pt is ready to be weaned from vent resp--ls coarse throughout, sxn'd for mod amt of thick tan secretions, sats 100%, no vent changes made, conts on a/c 600-12-peep 5, 40%, ? if plan to wean today cardiac--hr 90-100 pat, no ectopy, bp 100-120/40's, given lasix 80mg iv d/t fluid status (+), lg diuresis gi--abd soft, non tender to palpation, (+)bs, no stool, rec'd colace, conts on tf's at 50cc/hr, min residuals gu--foley draining clear yellow, foul smelling urine, lg amt of urine after lasix id--remains afeb, tmax 99.6po, conts on ivab ||||END_OF_RECORD START_OF_RECORD=5||||18|||| resp note - pt. remaines intubated, weaned to psv 10 peep 5 40% fio2, tol ok at this time. abg 7.44 - 33 - 127 - 23 - 99%. ||||END_OF_RECORD START_OF_RECORD=5||||19|||| SINUS R. RATE 90 TO 100 OFF DILTIAZEM GTT . BP STABLE C DIURESIS ,STARTED ON CAPTOPRIL . K, MG REPLETED WEANED ON CPAP 10/PEEP 5,FIO2 40%.RATE 15 TO 30 ABG 7.44/35/127/23. SX THCK TAN. GI TF 55CCHR/NO RESIDUALS, NO STOOL GU DIURESIS TAPERING OFF .2490CC NEURO ON 10 MIC PROPOFOL, OPENS EYES TO NAME . T MAX 100 .2 , STARTED ON OXACILLIN CHF IMPROVING, TOL WEAN MAY BE ABLE TO EXTUBATE TOMORROW ||||END_OF_RECORD START_OF_RECORD=5||||20|||| NEURO; PT. OPENS TO PAINFUL STIMULI, DOES NOT FOLLOW COMMANDS . REMAINS ON PROPOFOL FOR SEDATION. PT. WILL PULL HEAD AWAY AND MOVE FROM SIDE TO SIDE WHEN TAKING TEMP. CV: SR-ST NO VEA NOTED. BP STABLE. CONT ON AMIODORONE PO. RESP: PLACE ON AC OVERNIGHT TO REST IN ANTICIPATION OF POSSIBLE EXTUBATION TODAY. SUCTIONING FOR THICK YELLOW SPUTUM Q2-3 HRS. COARSE BREATH SOUNDS. GI: TF OFF AT 0600 FOR POSSIBLE EXTUBATION. ACTIVE BOWEL SOUNDS. FIB INATACT, NO STOOL OVERNIGHT. MIN. RESIDUALS WHILE TF ON. ? OF STARTING TPN TODAY. GU: FOLEY TO GRAVITY, DRAINING CLOUDY URINE. RESPONDED VERY WELL TO LASIX 80 MG GIVE LAST EVE. SEE FLOWSHEET FOR 1/O TALLY. SKIN: BUTTOCKS DARK PURPLE IN COLOR. NO OPEN AREAS NOTED IN THAT AREA. CLUSTERS OF BROWN "DOT-LIKE" DISCOLORATIONS NOTED ON RIGHT LOWER LEG. ||||END_OF_RECORD START_OF_RECORD=5||||21|||| DUE TO SECRETIONS AND CHF EXTUBATION HELD.PT ALSO HAD AFIB FOR 2 HR BEFORE RETURNING TO SR. TOL PS 10/5PEEP C SATS 98. SX THICK TAN .LASIX 80MG X2,DIURESED . K REPLTED TOL INCREASE CAPTOPRIL DOSE,ADDITION OF LOPRESSER.PROPOFOL DC, PT REMAINS CALM.OPENS EYES TO NAME, PULLS AWAY FROM NOXIOUS STIMULI. PLACED ON FIRST STEP AIR MATTRESS TF RESTARTED,BS COVERED C SSRI. ||||END_OF_RECORD START_OF_RECORD=5||||22|||| NEURO: RESPONDING TO NAME AND NODDING APPROPRIATELY TO QUESTIONS EARLIER IN SHIFT. ABLE TO COMMUNICATE THAT SHE IS COMFORTABLE BY NODDING HEAD WHEN ASKED. RESTARTED ON PROPOFOL AFTER PT BECOMING AGITATED WHEN TURNING PT. TRYING TO TONGUE OUT ETT. CONT TO PULL AWAY FROM NOXIOUS STIMULI. WILL OPEN EYES TO STIMULATION. CV: HR RHYTHM PAT RATE98-100. BP STABLE AT PRESENT. TRANSIENT HYPOTESIVE AFTER RECEIVING CAPTOPRIL DOSE AT MIDNOC. A-LINE DAMPENS FREQ AND IS POSITIONAL AT TIMES. RESP: REMAINS INTUBATED SUCTIONING Q2-3 HRS FOR THICK, YELLOW SPUTUM. SEE VENT FLOWSHEET FOR SETTINGS. RESTED OVERNIGHT ON AC 600X12 PEEP 5 FIO2 40%. CRACKLES NOTED AT BASES. GU: FOLEY TO GRAVITY. GIVEN 80 MG IV LASIX WITH GOOD DIURESIS. URINE YELLOW AND CLOUDY. GI: NO STOOL. TOL TF WELL WITH MIN RESIDUALS, + BOWEL SOUNDS. SKIN: SKIN DRY AND FLAKEY. PEELING SKIN NOTED ON BACK. BUTTOCKS PURPLE COLORED. RIGHT LOWER EXTREMITY HAS BROWN DISCOLORATION "DOT-LIKE". ||||END_OF_RECORD START_OF_RECORD=5||||23|||| PT APNEIC WITH WEANING ATTEMT DUE TO PH 7.60.PT PLACED ON SIMV 4. LASIX HELD. K ,MG REPLETED .ABG CORRECTED TO 7.47/41/7126/3I.WEANING ATTEMPTED AGAIN BUT TV ONLY 125. PROPOFOL HELD AT PRESENT IN PREPARATION FOR NEXT WEANING ATTEMPT . SECRESTIONS LESS TODATY BUT THICK WHITE . PT OPENS EYES TO NAME, PULLS AWAY FROM ORAL THERMOMETER.REMAINS IN SINUS RHYTHM, NO EPISODES AF.BP ON LOW SIDE POST CAPTOPRIL DOSE ,85 TO 95. LOPRESSER DOSE DELAYED, 4PM CAPTOPRIL DOSE HELD.TF ON HOLD FOR POTENTIAL WEAN PER HO .NO STOOL ,LACTULOSE GIVEN , HUO 20 TO 30 CC ||||END_OF_RECORD START_OF_RECORD=5||||24|||| RESPIRATORY CARE NOTE PT CURRENTLY ON CPAP 5PS 5PEEP 40%. PT TOL SETTINGS FAIRLY VT 200'S RR 26-30. PT SXND FOR MOD AMOUNTS OF THICK CLEAR SECRETIONS. BS REMAIN COARSE POST SXNING. ?KEEP PT ON THESE SETTINGS OR PUT BACK ON IMV RATE FOR NOC. WILL CONTINUE TO FOLLOW AND MAKE ADJUSTSMENTS WHEN NECESSARY. ||||END_OF_RECORD START_OF_RECORD=5||||25|||| Pt received intubated on vent settings P/S 10 peep 5 FiO2 40%. At 8pm switched to SIMV and pressure support. Tidal volume 600 Rate 4 P/S 10 peep 5 FiO2 40%. Suctioned ETT for mod amt of white secretions. Breath sounds coarse. RR 10-22. Will cont to follow closely. ||||END_OF_RECORD START_OF_RECORD=5||||26|||| O:NEURO=RESPONSIVE TO STIMULI-ON PROPOFOL @ 10MCG W GD EFFECT. COMFOTABLE. PULM=RESTED OVER NIGHT-SIMV/PS, 40%, 600X4, & [**02-04**] W SATS UPPER 90'S & AM ABG-100/48/7.43/33/6. BREATH SOUNDS=COURSE. SX-TANNISH SECRETIONS. CV=HEMODY STABLE. GI=TF DCED @ 0600. RECTAL BAG INPLACE. GU=FOLEY. I&O=@2300-APPROX .3L POS @ 0600. NEG 2.6L OVERALL. ID=AFEBRILE. LABS=AM HCT 26.8. A:COMFORTABLE NIGHT. P:DC PROPOFOL IN AM. WEAN W GAOL EXTUBATE. HOLD TF @ PRESENT. ?T&C & TX W RBC FOR HCT-26.8 BEFORE EXTUBATING. SUPPORT AS NEEDED. ||||END_OF_RECORD START_OF_RECORD=5||||27|||| CCU NURSING PROGRESS NOTE 7A-7P NEURO: Propofol dc'd this am. Pt has since been responsive. Eyes open; able to squeeze hands, answer simple yes/no questions by nodding head. RESP: LS coarse throughout. Suctioned q2-3 hrs for small-> mod amt thick white secretions. Attempted to wean to PSV 8/5 with borderline abg. Therefore, pt has been placed on PSV 10/5 all day with most recent ABG: 139/39/7.49. SPont Vt 180-320 rr 20. Plan to increase PSV as pt needs overnight rather than using SIMV. No plans to extubate at this time. CARDIAC: hemodynamically stable. HR 70-80's NSR. no ectopy noted. GI: Tube feeds have been on hold all day. Will keep NPO overnight in hopes if extubation tomorrow. +BS. Passing brown liquid stool via rectal bag. 2nd stool sample sent for c-diff today. 1st c-diff negative. GU: Foley draining cloudy yellow urine. Pt is 100cc negative at this time. ID: afebrile. WBC up to 18.1 (17). Central line dc'd and tip sent for cx. Conts on IV oxacillin and po cipro. ACCESS: #20 and #22 angios placed today. STATUS: full code. ||||END_OF_RECORD START_OF_RECORD=5||||28|||| Respiratory Care Note Pt currently on CPAP/PS 10ps 5 peep 40%. Pt tol settings fairly well. RR 20's Vt300-400. Plan to keep pt on CPAP over noc and adjust according to VT >350. Will follow as ordered. ||||END_OF_RECORD START_OF_RECORD=5||||29|||| Respiratory Care Note Patient remained all night on pressure support of 10, tolerated well. O2 sats are good/ABGs with metabolic alkalosis. Breath sounds are coarse, suctioned for mod. amounts of thick white sputum. Plan is to extubate later today. ||||END_OF_RECORD START_OF_RECORD=5||||30|||| O:NEURO=WO SEDATION. RESPONSIVE & APPROPRIATE. SOFT RESTRAINTS DUE TO ETT. PULM=CPAP & PS THROUGHOUT NIGHT. SETTINGS-40%, TV 400'S, RR 14-19, & [**02-04**]. SATS & ABGS-ACCEPTABLE. BREATH SOUNDS=COURSE. SX-SCANT THICK TANNISH SECRETIONS. CV=HEMODY STABLE. SR WO ECTOPY. GI=NPO. RECTAL BAG INPLACE. GU=FOLEY. MINIMAL UO, BUT O>I. ID=AFEBRILE. LABS=AM SENT. A:STABLE THROUGHOUT NIGHT. P:WEAN W GOAL EXTUBATION. ||||END_OF_RECORD START_OF_RECORD=5||||31|||| S. WHEN IS THIS GOING TO BE OVER? O. NEURO ALERT ANXIOUS APPEARING DIFFICULT TO ASSCESS LEVEL OF ORIENTATION ABLE TO FC MAE OD GLAUCOMA OS RL RESP EXTUBATED 1600 ABG ON 50% FM 149/43/7.44/30/5 LUNGS CTA TO RHONCI COARSE ALOT UPPER AIRWAY CONGESTION COUGHING NOT BRINGING UP SPUTUM CARDIAC HR 70-80'S NSR BP 100/-150/ HCT 28.8 SKIN W+D PP+2 GU FOLEY U/O MARGINALY 30CC QHR BUN 14 CR .5 GI ABD SNT BS+4 STOOL YELLOW LIQ SENT C-DIFF ID WBC 10.5 CONT ON OXACILLIN AND CIPRO AFEBRILE ENDOCRINE BS WNL A. STABLE POST EXTUBATION CONFUSION UROSEPSIS DM P. NEED VIGOROUS PULM TOLIET REORIENT FREQUENTLY ANTIBX AS ORDERED MONITOR BS ||||END_OF_RECORD START_OF_RECORD=5||||32|||| npn 7p-7a: ccu nsg progress note: neuro--off sedation, awake, oriented to self but not able to answer questions appropriately, asking to eat, moving ext resp--ls coarse throughout, prod cough but swallows secretions, 50% cool neb mask on but pt not compliant w/keeping it on, on ra sat 96-100%, rr 16-18 not labored, does not appear in any resp distress cardiac--hr 80's sr, no ecotpy, bp 100-120/40's gi--abd soft, non tender to palpation, (+)bs, rectal bag intact, draining mod amt of golden liq stool, cdiff pnd, tol min amt of po's, taking custard/jello w/pills gu--foley draining cloudy yellow urine id--remains afeb, conts on antibiotics dispo--probably will be ready to get called out to floor today ||||END_OF_RECORD START_OF_RECORD=5||||33|||| PT BUTTOCKS VERY RED, NOT BROKEN DOWN BUT APPEARING AS A PURPLE BRUISE. SEED BY HO, AND OUTLINED. ||||END_OF_RECORD START_OF_RECORD=6||||1|||| CCU NURSING ADMISSION NOTE 79 YO FEMALE BROUGHT TO [**Hospital1 2**] CATH LAB TODAY FROM OSH FOR ELECTIVE CARDIAC CATHERIZATION. PT ADMITTED TO OSH [**04-29**] WITH C/O CHEST PAIN. R/O'D MI. REPORTED TO HAVE +ETT AND SENT FOR CATH. PT FOUND TO HAVE 70% LM OCCLUSION, 60% LCX OCCLUSION, AND 80% RCA PROXIMAL. STENTS PLACED TO LCX AND LM. ONCE IN HOLDING ROOM PT VOMITED APPROX 400CC BRIGHT RED BLOOD WITH SIGNIFICANT DECREASED IN BP. IV HEPARIN, NTG, AND INTEGRELLIN DC'D AT THAT TIME AND PT GIVEN IVF. ADMITTED TO CCU FOR CLOSER MONITORING. PMH: S/P MI [**07-13**], S/P CABG [**07-13**] EF 30% GLOBAL HK HTN ^CHOL IDDM GERD CVA S/P TAH/BSO S/P APPY ROS: NEURO: PT ARRIVED TO CCU ALERT, ORIENTED X3, COOPERATIVE. DENIES H/A -DIZZINESS. CV: HR 70-90'S SR, LBBB. BP 180/90 ON ARRIVAL C/O MID-STERNAL EPIGASTRIC DISCOMFORT. EKG DONE. RESTARTED ON IV NTG. NO CHANGE IN CHEST DISCOMFORT. HO AWARE. BP DOWN TO 100-120/50'S. CURRENTLY NTG GTT OFF R/T LOW BP DUE TO SEDATION. PULM: LS CLEAR. O2 SATS 94-98% 3LNC. GI: PT HAD ENDOSCOPY THIS AFTERNOON. RECEIVED 10MG IV VERSED. 700CC BLOOD REMOVED FROM STOMACH. EPINEPHRINE APPLIED TO SPURTING LESION WITH EFFECT. PT VOMITED X2 S/P PROCEDURE. GIVEN COMPAZINE WITH LITTLE EFFECT. THEN GIVEN ATIVAN FOR NAUSEA WITH EFFECT. RECEIVED 2 UNITS RBC'S AFTER CATH. HCT S/P 2 UNITS BLOOD 33.9. ON PROTONIX GTT. NO STOOL NOTED. ABD SOFT, +BS. GU: FOLEY DRAINING APPROX 45CC/HR CLEAR YELLOW URINE. ENDO: 6P FS 340. GIVEN NPH AND REG AS ORDERED. ACCESS: RIGHT FEMORAL ALINE DC'D BY FELLOW. PERIPHERAL IV X2. PLAN: RECHECK HCT TONIGHT. MONITOR HEMODYNAMICS. TRANSFUSE RBC'S AS NEEDED. ||||END_OF_RECORD START_OF_RECORD=6||||2|||| NEURO: pt was still lightly sedated this evening s/p endoscopy sedation. Slept well overnite. slight disorientation noted when awake, but easily reoriented and then seemed oriented x3. mae. CARDIAC: no c/o chest pain or discomfort. LOPRESSOR 25mg given at hs.. then additional 12.5mg po given per HO after midnite. To recieve 50mg this morning and BID. NTG off. to con't plavix x 3 days post cath. asa daily. repeat HS HCT 32.7. am labs pending. R femoral cath site D+I, no bleeding or hematomas noted. +pulses palpated. R leg immobilizer on, to remove this morning. RESP: LS clear, dim bases. sats >96% on 3L n/c. no resp distress. GI/GU: foley patent, draining ~30cc/hr clear yellow urine. +BS. taking ice chips progressing to water this evening for meds. tolerated well. No c/o of nausea or vomiting. PLAN: con't to monitor for rebleeding. monitor for n/v. monitor hemodynamics and HCT.. keep pt comfortable. ?transfer to stepdown today if pt remains stable. ||||END_OF_RECORD START_OF_RECORD=6||||3|||| ccu nursing transfer note please see admission and written transfer note for details neuro: alert, oriented x3, cooperative. denies h/a. -dizziness cv: hr 60-80's sr. no vea. bp 120-140/60's. tolerating lopressor and captopril. pulm: ls clear. o2 sat 98% 2lnc. +productive cough thin white sputum gi/gu: abd soft, nt. +bs. tolerating po's well. no nausea, vomiting. guiac + stool x1 today. hct stable today. no further signs/symptoms bleeding. foley draining adequate urine. plan: hemodynamically stable. s/p stent x2 [**05-04**]. transfer to [**Wardname **]. increase activity as tolerated. ||||END_OF_RECORD START_OF_RECORD=7||||1|||| PMHX: stroke, middle cerebellar peduncle CVA [**2006**], hernia, GB removal, AAA repair, MI [**1994**]. no etoh, non smoker, no recreational drugs. HPI: 69yo Male admitted w/ Hx 1.5days of 'feeling sick', dizziness w/ spinning, and he fell down yesterday, was unable to get out of bed, lost control of bowels, and slurred speech since yesterday. Came to ED this afternoon and found to have RT cerebellar bleed extending into the 4th ventricle w/ increased vent size /edema in cerebellum. CCU stay: Admitted to CCU, Aline place in R radial, Ventricular shunt placed by neuro-surgery. Able to obtain ICP 6-7 originally w/ clear CSF, then had blood-tinged drainage that clotted in tubing requiring neuro-surg to clear, since unable to get accurate ICP which neuro-surg is aware of, con't to check neuro status q1h + PRN. Remains on Nipride gtt, titrating to keep SBP <140. No neuro complaints of headache/dizziness. NEURO: pupils 2-3mm bilat brisk reactions, pupils pinpoint w/ sedation during procedures. Rec'd total of 300mcg of Fentanyl and 1.5mg versed during the ventricular bolt placement. HOB 30'. Drain placed at 15cm above tragus originally then after Neuro-surg back to clear clotted drain, ordered to place drain at 20cm above tragus. ICP originally [**03-04**], but now ICP ranging from 11-30s, neuro-surg aware-to follow neuro status q1h and prn. obeys commands, opens eyes to verbal stimuli. [**First Name8 (NamePattern2) 67**] [**Last Name (un) 68**] grips. slight confusion noted at times. no c/o of headache or dizziness. +gag +cough. for MRI tonite. On droperidol 0.625mg IV q6h. CARDIAC: SB/SR 50-70s w/ occ PVCs noted. R radial aline, SBP 90-160s. Titrating NIPRIDE to keep SBP <<140s. +strong pulses. no c/o chest pain. RESP: was on NRB 100% during bolt placement, switched to n/c 3L w/ sats remaining >98%. congested non-productive cough. LS clear, dim bases. no resp distress. ID: afebrile. started on Kefzol 1gm q8h. GI/GU: foley patent, clear amber urine <30cc/hr. SICU resident notified, no action taken as yet. to con't to monitor. NPO. +BS. no BM. PLAN: cont' to monitor neuro status and ventricular drain. titrate Nipride to keep sbp <140. keep HO notified of any neuro changes. to MRI tonite. ||||END_OF_RECORD START_OF_RECORD=7||||2|||| Neuro: Pt remains sleepy, easily arousable to voice. Oriented to person, place (hospital), not time. Follows commands, answers most questions appropriately. mae, equal strength.pearl, This afternoon has started pulling at lines, twice pulling out a line despite being wrapped in kling and restrained. ventricular drain remains in place. Has not drained all day despite being flushed by neurosurgery x3 and line being patent. currently 20cm above tragus. not able to get icp tracing, neurosurgery aware. Cv: BP labile, especially early in shift. requiring frequent titration of nipride and addition of nitroglycerine. To begin on labetelol drip when available, not started earlier d/t ? allergies to betablockers. Currently Nitro at 100mcg/min and Nipride 1.5 mcg/kg w/ bp 120-130/50-60 (goal sbp <140). hr 80's sr w/ occ pvc's. Resp: sats 96-98% on 3lnp GI: npo, no stool. NS w/ 40 kcl infusing at 75cc/hr.erebellar GU: foley draining cl yel urine 30-40cc/hr. ID: afebrile SKIN: intact Lines: 2 PIV, to have A line replaced shortly. Social: Married, 6 children. Wife and son in today, spoke w/ MD. ||||END_OF_RECORD START_OF_RECORD=7||||3|||| see above admit note for HPI/PMHX: NEURO: pt remains agitated, needing bilat wrist restraints to keep pt from pulling out IV/alines. sitter at bedside. pt still able to 'rub/pull' IV out of arms this evening by resisting restraints repeatedly. pupils 2mm reactive. MAE, [**Last Name (un) 68**] grips.obeys commands. verbal in short sentences or words only when prompted. Ventricular drain intact, ICP waveform [**09-11**] tonite. draining small amt serosang CSF @ 20cm above tragus. HOB 30degrees. droperidol given tonite at 9pm with no effect (q6h prn dosing). no neuro complaints of headache or dizziness. CARDIAC: SB/SR 50-60s w/ occ PVCs. SBP 100-170s tonite, depending on agitation levels. Nipride was titrated to off. Remains on Labetelol titrating to keep SBP <160s. no c/o chest pain. +pulses. RESP: LS clear dim bases. congested productive cough at times. O2 3L n/c. no resp distress. GI/GU: foley intact, pt had pulled at foley a few times during day and evening, con't with amber coloured urine ~20-30cc/hr. HO aware. Abd soft. remains NPO. mouth swabs to wet mouth. no bm. PLAN: transfer to NEURO/SICU for further monitoring. titrate drips to keep SBP <160. monitor neuro status q1h. monitor ventricular drain. keep neuro and neurosurg aware of pt status. ||||END_OF_RECORD START_OF_RECORD=8||||1|||| hpi: pt admitted to hosp on [**2020-05-12**] following a clinic visit where he c/o sob, ruq pain, and possible r/o chf. pt admitted to ccu on [**05-14**] for increased aggitation, twitching, periods of unresponsiveness, arf illustrated by a creatnine of 4 (1.2 1 month ago), and elevated liver enzymes. pt of dr. [**First Name (STitle) 69**] [**Doctor Last Name 70**]. allergies: nkda meds: pt claims that he is compliant at home on meds, amiodarone 200mg po qd, dig .125mg po qd, colace 100mg po qd, methadone (methadone in house has been dc'd) his wife, [**First Name8 (NamePattern2) 71**] [**Last Name (NamePattern1) 72**] ([**Telephone/Fax (2) 73**]) confirms the story. pmh: dilated cardiomyopathy with an ef of 20%, l atrial and ventricular enlargement and r ventricular dysfunction, chf, severe mr +3/+4, nsvt, chronic renal insufficency, hepatitis c, pancretitis, etoh abuse, heroine abuse, and cocaine abuse. he has had difficulty urinating, and in the past had acute retention and was on foley drainage for several weeks in [**2019-07-29**]. he had TURP at [**Hospital 74**] hospital at that time. neuro: pt is a&o x3, however pt is aggitated and has periods of change of consecness, pt appears to be asleep and will awake abbruptly. pt is uncooperative. pt moves all extremeties well, when awake pt has gross twitching movements. cardiac: pt is in sr of 60's 70's, bp in 90's systolic over 30-40 mean of 50-60's. pt has +3 pulses in all 4 extremeties. resp: pts bs upon arrival to ccu were clear bilaterally, o2 sat in the 70-80's, pt placed on 70% face tent and o2 sat increased to 100%. pt is tachypenic in the 20's at rest and 30's when awake and aggitated. abg upon ccu admition is as follows 44, 37, 7.35, 21, -4, on ra. face tent placed post abg. gi: pts abd is soft nt upon palpation, hypoactive bowel sounds, pts last bm on [**05-13**], and ate a small amt of breakfast on [**05-14**]. gu: pt being evaluated for arf, pt refused f/c. pt claims "i only pee when i get my lasix." skin: intact psycho/social: pt had sister and daughter at bedside upon arrival, family seem to aggitate pt further, and are uncooperative with mc staff. daughter is mrs. [**First Name8 (NamePattern2) 75**] [**Last Name (NamePattern1) 76**], tel [**Telephone/Fax (2) 77**]. daughter claims that pt listens to mother, and mother will be able to "get him to do things." ||||END_OF_RECORD START_OF_RECORD=8||||2|||| pt agreed and concent signed by mother, for swan placement. pt aggitated and needed to be sedated. pt sedated with additional medication 1mg haldol and 1mg versed ivp. procedure started and unsuccessful, the carotid artery canulated. cardiology team decided to attempt again later. mrs. [**Known patient lastname 78**] [**Name (STitle) **] to be heavely sedated. ||||END_OF_RECORD START_OF_RECORD=8||||3|||| neuro: pt lethargic/sedated until around midnite, pt requesting food and drink.. took well.. then settled back to sleep. arousable, answering yes/no questions. mae. no sedation given this shift. cardiac: sr 60s, occasional pvc and mfpairs noted. aline inserted this evening to l radial. bp 90-100s. bp dropped to 70s during nite, t-berg and additional 250cc ns bolus given. 1 bolus of ns and ivf started prior to pts bp dropping. no c/o chest pain. no further attempts at central access overnite. pt as 1 peripheral iv. resp: pt sats 90-92 at beginning of evening on 3l n/c + 70% face tent, weaned off face tent and left on 3l n/c for sats this morning >98%. had been short of breath early in evening while lethargic, but once [**Known patient firstname 79**] woke up after midnite, breathing regular w/ no distress. gi/gu: voiding good amts urine in urinal, clear yellow. abd soft. +bs. taking po well. plan: cont' to monitor vitals, keep pt comfort, monitor neuro and resp status. ?another attempt at central access and swan placement today?? ||||END_OF_RECORD START_OF_RECORD=8||||4|||| nursing progress note 7a-3p neuro: pt lethargic, yet arousable. oriented x3. cooperative with care. Knows she is in [**Hospital 80**] Medical Center in [**Location (un) 81**]. resp: ls clear. rr 20-30's. wearing 3l nc with sats >94%. cardiac: bp 90-100/50's. hr 60's sr with occasional pvc's. k+3.6-> rec'd 40meq po kcl replacement. elevated transaminases as well which, per renal note, may reflect right vent failure-> therefore, renal would favor swan vs. c-line. gi: tolerating low sodium diet. taking large amt po fluids. abd soft nt. +bs no stool. gu: creat down to 2.5. pt rec'd one 250cc ns bolus this am with minimal effect on bp. pt is presently +695cc. voids ~300cc q3-4 hrs. id: afebrile. access: one #20 angio right upper arm. pt's mother and daughter ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) called ([**Telephone/Fax (2) 82**]) and have been updated on pt's stable condition at this time. ||||END_OF_RECORD START_OF_RECORD=8||||5|||| nsg note: cardiac: remains in nsr with rare multifocal pvc's noted. pt had 1 episode where map's dropped to <60. pt received 250cc bolus ns x1 with good responce. map's now > 60. hr 72-74. con't on amiodarone 200mg qd. resp: o2 @ 2l np. sob with exertion,but does not drop stas. bs cl to course bilat at bases. cough occassionaly,without raising. gi: tol liq. taking po's well. + bs. no stool this shift. gu: voids using urinal. u/o adequate. neuro: lethargic,but is arousable. complient. oriented x3. follows commands. will answer appropriately,but does not initiate conversation. propho: zantac and heparin sq. labs: k+ 3.9 received 20meq kcl bun 39(was 57) creat 1.8(was 2.5) phos 1.7 replaced neutraphos 1 pkt. t bili 2.3 inr 2.1 received vit k as ordered. a: stable overnoc p: am labs con't to monitor i&o goal is for 500cc + follow ms con't same ||||END_OF_RECORD START_OF_RECORD=9||||1|||| Pt transferred to CCU from WARD 3 for management of hypertension, s/p cath today, had restenosis of L circ that had been previously stented, breaky tx and PTCA to L circ. BP in cath lab was 260/140 on Nipride, Nipride dc'd and pt placed on Nitro IV at 200ug. Was On floor BP remained 180-200/, transfered to CCU. ALL: PCN PMH: S/P MI x2([**11-17**], [**01-16**]), S/P stent to L circ with instant thromb and restent in 4/21, CHF, EF 35-45%, DM, HTN, ^chol, anxiety, GERD, hiatal hernia, s/p thyroidectomy, s/p polypectomy-colon. Seen in EW 3days PTA for cough, SOB, diagnosed with bronchitis and sent home on Azithromycin. Frequent anginal equivalents(backpain) over the week prior to adm. Ruled out for MI this adm. Reveiw of systems: CV: arrived on 200mcg of Nitro IV, BP 170's/80, Added IV Lobetalol at 1mg/min. BP down to 150-160/, then down to 120-130's/, weaned Nitro to off, Given 25 Lopressor, Lobetalol now off as of 10PM. HR 70'sNSR. Denies CP/SOB. LS clear, diminished at bases. Vomitted clear fluid shortly after arrival, no further N/V. Droperidol ordered but not needed. Sheaths pulled @ 6PM, no hematoma, pulses all palpable. K+ of 3.2 repleated with 60 mEq po, Mg of 1.5 repleated with 2 amps IV. Given 40mg Lasix at 9PM. Endo: BS 212, covered with 2u Reg ins per sliding scale. Not ordered for NPH, was npo, now may eat, box lunch ordered. Neuro: initially very lethargic, had been given MSO4 and Ativan on floor. Now clearer, still foogy short term memory. Visiting with family. A: hypertension under better control P: wean off IV gtts, control with po meds. Lines: new # 20 placed in R hand by IV team, difficult stick. ||||END_OF_RECORD START_OF_RECORD=9||||2|||| NEURO: A&O X3. PLEASANT & COOPERATIVE. RESP: O2 SATS 95-96% ON RM. AIR. RR 19-32. BS CLEAR. NON-PRODUCTIVE COUGH. CARDIAC: HR 79-84 SR. BP 114-145/36-73. CONT. OFF IV NTG & LABETOLOL. DENIES CP/SOB. R. GROIN SITE C&D. NO EVIDENCE OF BLEEDING OR HEMATOMA. +BPPP. POST-CATH FLUID 1/2NS @ 125CC/HR TO CONT. UNTIL 0600 & THEN WILL BE D/C'D. GI: TOL. DIET WELL. ABD. OBESE. +BS. DENIES N/V. GU: FOLEY->CD PATENT & DRAINING CLEAR YELLOW URINE. U/O 55-150CC/HR. GIVEN ADDITIONAL DOSE LASIX 40MG IV X1 & RESPONDED NICELY. ID: T 99.1. ENDOCRINE: BS 281->TREATED PER SLIDING SCALE. AM BS PENDING. TO RE- START NPH INSULIN BID TODAY. PLAN: IF BP REMAINS STABLE, TRANSFER BACK TO Ward3. ||||END_OF_RECORD START_OF_RECORD=9||||3|||| see admit note for details of hpi, past hx. pt is 55 y/o obese woman allergy to pcn. has htn, cad, dm. since ccu id- adebrile to 99. cv- hr 70-80s sr, no vea, intermittent rbbb from ekg. bp 120-140s/. lopressor increased to 50mg tid, to start isordil 10mg tid. no iv meds for bp at present. c/o 3/10 l back pain in am, pain intermittent. ekg without sig. change. k-3.7, 40po given. creat up to 1.3. ck 193, mb pnd. resp- l/s clear, dim. r/a sat 98. intermittent dry cough, none this am. diuresed form 40mg lasix 4am, repeat 40mg 3pm today. dm- on ss and nph bid, bs 196-281. gi- app. good, no bm. access- difficult. 1 iv 20 in r hand, working well. ms- a+o x3, asking appropriate questions, likes to know all info about meds etc. social- has children. ||||END_OF_RECORD START_OF_RECORD=10||||1|||| Respiratory Care 7a-7p Patient intubated secondary to seizure activity and airway protection. Pt intubated with 7.5 ETT taped 23 @ lip. Pt placed on PB 7200, current settings are AC/700/12/60%/+5. ABG's stable, CXR obtained. Plan to continue with mechanical support. ||||END_OF_RECORD START_OF_RECORD=10||||2|||| SEE ADMISSION FORM FOR DETAILS OF ADMISSION & PMH. NEURO: ON ADMISSION TO CCU, PT WITH SLURRED SPEECH. FOLLOWS SIMPLE COMMANDS INCONSISTENTLY, MOVES LE ON BED, ABLE TO LIFT & HOLD BOTH ARMS OFF BED, PERL. UNABLE TO ANSWER SIMPLE QUESTIONS. WENT FOR HEAD CT ->RESULTS PENDING. APPEARED TO HAVE SOME R. SIDE NEGLECT. SEEN BY STROKE TEAM. ~0300-> TOTAL BODY SEIZURE. O2 SATS 70'S, HR 150, RR30. 100% NON-REBREATHER PLACED & O2 SATS 99%. ABG 7.40/36/228/23. INTUBATED BY ANESTHESIA FOR AIR- WAY MANAGEMENT. GIVEN ATIVAN 2MG IV X1. PLACED ON PROPOFOL GTT FOR AGITATION MANAGEMENT. NO FURTHER SEIZURE ACTIVITY NOTED. RESP: ON VENT: 100% X700 AC 12 5 PEEP. O2 SATS 100%. DECREASED FIO2 80%. ABG->7.44/41/233/29. FIO2 DECREASED TO 60%. BS CLEAR BUT DIMINISHED AT BASES. SX FOR THICK BLOOD-TINGED SPUTUM. CXR DONE POST-INTUBATION. CARDIAC: HR 90-120 SR. BP 172/86 ON ADM.->140-150/70. SINCE INTUBATED & SEDATED BP 95-130/60-70. RECEIVED 2U FFP PLAT 34K. ALSO, SOLUMEDROL 150MG IV. GI: ABD. OBESE. BS HYPOACTIVE. NPO. NO STOOL. GU: FOLEY CATHETER DRAINING CLEAR YELLOW-> AMBER COLOR WITH SEDIMENT. DIURESED NICELY WITH LASIX. PRESENTLY, U/O 30-95CC/HR. ID:T 102.3(PO). URINE C&S SENT. TYLENOL X1. T 101.6. CONT. ON CEFTRIAXONE FOR UTI. ACCESS: R. WRIST SL. IV NURSE UNABLE TO PLACE ANOTHER IV. R & L FOOT IV'S PLACED BY DR. [**First Name (STitle) 83**]. ATTEMPTED ALINE SEVERAL TIMES WITHOUT SUCCESS. R. FEMORAL QUINTIN CATHETER PLACED THIS AM FOR PLASMOPHORESIS. LABS: WBC 19.1, HCT 32.8, PT/PTT 12.9/21.9, INR 1.1, FIBRINOGEN 522, K 3.9, CK 98 WITH TROPONIN 1.6,LD 1372, LACTIC ACID 1.5->7.2-> 2.9. BS 277-323-> TREATED PER SLIDING SCALE. ||||END_OF_RECORD START_OF_RECORD=10||||3|||| CCU NURSING PROGRESS NOTE 7A-3P NEURO: Pt sedated on propofol gtt which has been titrated up during procedures. Pt will respond to verbal/tactile stimulation and is moving all extremities purposefully at times (reaching for ETT when untied). She is unable to follow commands. Was able to nod head during simple yes/no questions. PERL. Wrists restrained for safety. RESP: Intubated on AC 700x12 with 5 peep and 40%. Alkalotic abg. Plan to change to PSV 10/5 after line placement. Suctioned x1 for small amt blood tinged sputum (sent for cx). Pt is presently sedated and not overbreathing set rate. CARDIAC: BP 99-130's. Has rec'd several IVF boluses for BP <140. Plan ot place central access and will most likely require NEO gtt to maintain SBP 140-160 per neuro recommendations. HR 70s NSR. GI: NPO. Team to place NGT. Hypoactive BS. No stool this shift. GU: foley draining amber colored urine with sediment. ID: T max 101.6. Blood cxs sent from pheresis line. Sputum cx pending as well. IV ceftriaxone has been changed to IV levo for UTI. ACCESS: 3 peripheral IVs intact 92 of which are in pts feet). Team to place left femoral line this afternoon. Right radial aline placed this am. SKIN: Left hand with petechiae and gross ecchymosis. Also noted 2 bruises over left shoulder. FAMILY: Pt's husband, brother, sister and friend have all visited and have spoken to team. They are aware of diagnosis and plans for lines/continued pheresis, etc. Case management has also touched base with family for added support. STATUS: full code ||||END_OF_RECORD START_OF_RECORD=10||||4|||| CCU NURSING NOTE ADDENDUM Pt pheresed for 2 hours this am via right femoral quinton cath. BO dipped to low 100's; otherwise tolerated well. Plan for pheresis again in the am. checking PLT count q4 hrs. ||||END_OF_RECORD START_OF_RECORD=10||||5|||| resp. care note: Fio2 decreased to 40%. Pt continued on vent settings AC 700/12/40% +5. Plan is to wean her to pressure support 15/5 40%; but pt has recieved propofol boluses will try to wean later this evening. Pt suctioned for a moderate amount of thick tan/brown secretions. pt remains intubated for airway management at this time. For further information please refer to carevue charting. ||||END_OF_RECORD START_OF_RECORD=10||||6|||| Heme: HCT 23, transfusing with 2 u PRBC's, 1st up at 8:30PM. Plt up to 28 at 6PM. Labs sent at 10PM. Neuro: propofol decreased to 38ug from 60ug, pt arousable, following commands, a little restless at times, can be calmed verbally. [**Last Name (LF) 84**], [**First Name3 (LF) **], purposeful. Stroke team by this eve. CV: BP initially low 90's/, dropped to 80/ with propofol increased for line placement, decreased propofol and gave 500cc NS bolus. BP increased to 130's-140's/. Neo ordered if needed. Resp: remains vented, changed to PS 15/peep5, RR 20's with VT's 4-600. Maintaining sats 98-100%. Suctioned for sm blood tinged sputum. soc; friend and sister in, updated by MD, Husband called, they are separated(not leagally) but friendly per sister. A/P: stable on vent, plt's slowly increasing, transfusing for low HCT, no signs of active bleeding. Consider extubating tomorrow if remains stable. Cont light sedation overnight. ||||END_OF_RECORD START_OF_RECORD=10||||7|||| NEURO: perla. mae. bilat wrist restraints. opens eyes to stimulus. sedated on PROPOFOL @ 30cc/hr. CARDIAC: SR 60s no ectopy noted. SBP 90-100s around midnite, propofol weaned down but BP did not rise, placed on NEO drip titrating up to 80mcg/min, currently at 40mcg/min. SBP 130-140s. Aline intact L radial. L femoral TLC intact. R femoral pheresis line intact. bilat foot PIVs removed (pt diabetic). R wrist PIV patent. Lopressor held on evenings. Rec'd total of 2u PRBCs over last evening and nite. am Labs pending. RESP: LS coarse, sx small amts whitish/ bld tinged secretions. remains on PS 15/ peep 5 40% sats >98%. TV 700s, RR 20s. GI/GU: foley patent, good amts clear yellow urine. abd soft, obese, +BS. no stool. OGT intact, clamped. NPO. PLAN: con't to monitor labs (hct, plt, wbc), monitor hemodynamics, wean off NEO if pt tolerates. ?wean off vent today? ||||END_OF_RECORD START_OF_RECORD=10||||8|||| Patient remains intubated and mechanically vented. Vent checked and alarms functioning. Settings: Cpap/PS 15/5 40% Vt:700's with rates in the teens. Please see respiratory section of carevue for further data. Plan: Continue mechanical ventilation. ||||END_OF_RECORD START_OF_RECORD=10||||9|||| TOL EXTUBATION SAT 97 4L NP .PT ALERT ,ORIENTED ,NO SIEZURE ACTIVITY .VERY ANXIOUS , CO NAUSEA XI. ATIVAN C RELIEF. TAKING CL LIQ WELL . PASSED LG NEG STOOL . TACHYCARDIC TO 120, HTN TO 190/SYS. RESPONDED TO PO LOPRESSER . 80S NSR, BP 160 /75. HUO 50/ 100 CC .PLASMAPHORESIS TOL WELL . LATEST PLATELETS 58,000. BS COVERED C SSRI . ACCEPTED FOR TRANSFER ||||END_OF_RECORD START_OF_RECORD=11||||1|||| 83 yr old transfered from [**Wardname 85**] today s/p intubation for pul edema. Pt was transferred earlier today from [**Hospital 86**] Hosp for cath. She was admitted to OSH with symp of CP/pul edema, ruled in for NQWMI. Had 90 sec of witnessed VT with syncope, resolved spontaneously. Transferred to [**Hospital1 2**] asymptomatic and taken to cath lab at 12n, had stent placed to L cx, EF~50%, posteriorbasal HK. On arrival back to floor was in resp distress with drop in sats to 70's, BP 200/100, HR 100, given 60mg Lasix, 2 mg MSO4, IV NTG, intubated and transfered to the CCU. PMH: asthma ALL: NKDA Reveiw of systems: CV: Arrived on 3 gtts of Nitro, BP 150-160/70, HR 70 NSR. Became very agitated, given 50ug fent and dropped BP to 70/ given 500cc NS bolus and was on Neo breifly. BP returned to 130-150/, again had episode severe agitation, tongueing out ETT, started propofol, gave another 25ug of fent, BP again dropped given another 250cc NS. Remained off Neo. ~8:30PM dropped BP spontaneously, at this point is ~1600cc neg. Restarted Neo at 40ug, titrated up to 60ug and decreased propofol in half, then further to 5ug. BP holding at 110/50. Had also been given lopressor 12.5 at 7pm. Repleating K+ of 2.7 with 120mEq of KCL po, and given 2 amps of MgSO4. Resp: Vented on AC, 50% 500x12 with 5 of PEEP. Initially suctioned for lg amts blood tinged frothy sputum, secretions have tapered off. Had crackles all the way up. ABG:99/44/7.39/28/0 on 50%. ID: T 101.8R on arrival, BCx2, urine and sputum sent. Tylenol given. GI: OGT placed. abd soft, stool on thermometer OG (-). GU: foley, uo brisk after lasix, 1700cc neg. Neuro: responding appropriately since episode agitation, nodding yes/no, following commands. Sedated mildly on 5 ug propofol. Soc: Has 2 children, all visiting , daughter [**Name (NI) 87**] will be spokesperson, Phone #'s on blue chart. Access: 3 peripherals. Status: full code. ||||END_OF_RECORD START_OF_RECORD=11||||2|||| Respiratory CAre Note Pt recieved with 7.5 ETT patent and secure. Pt currently on AC 600x12 5 peep 50%. Pt tol current settings well. Pt sxnd for copiuos amounts of pink frothy secretions. MD [**First Name (Titles) 88**] [**Last Name (Titles) 89**] MDI per home regimen of pt. Will follow and makes changes accordingly ||||END_OF_RECORD START_OF_RECORD=11||||3|||| Pt is a 83 y.o. female Admitted from [**Hospital1 **] [**Hospital1 **] for cath s/p MI. Cath showed 80% of L Cerc occluded, and steant placed, and 60% of RCA occluded. Pt while in cath lab had an episode of flash pulmonary edema. Neuro: Pt is intact moves all extremeties well, pt unable to speak dut to intubation, but able to write. Cardiac: Pt has sinus arrythmia, and infrequent multifocal PVC's. Pts BP can be very labile. Sys BP maintains in 100's -110's at rest adn 120's-130's awake. At one point pts BP spont dropped to 76 sys. Waited about 5 min and BP responded spontainously. Resp: Pt intubated on AC 12, .5%, 600 5/ peep. Pt is due to be extubated in am. By am pt should be on IMV or CPAP with jsut peep and Pressure support. Pt has a non productive cough. Minimal suctioned out. Thick pinkish sputum. Pt given huricaine spray secondary to c.o j.k GI: Pt has OGT in to is NPO except for meds. +BS, moderate liquid to stool. GU: Pt has f/c good urine output. Goal is to be -2L pt for 24 is -1635cc Skin: Intact Misc: Pt is on diprivan at 12.65 mcg, may be decreased by am, report, to aid in extubation. Pt has neo at the bedside of episodes of low BP. Not needed overnight. pt received multiple lytes replaced. Pt denies pain, discomfort, or SOB. R groin site in clean dry and intact. Pt has AL and multiple PIV. ||||END_OF_RECORD START_OF_RECORD=11||||4|||| 0600 Pts diprivan d/c'd and vent changed to CPAP .5% 5/5. Anticipate extubation early in am. ||||END_OF_RECORD START_OF_RECORD=11||||5|||| PLEASE SEE ADMIT NOTE FROM LAST EVE. PT WAS EXTUBATED AT 7AM TODAY W/ DIFFICULTY. SATS 96-98% ON 4LNP. CONTINUES TO HAVE CRACKLES AT BASES. GIVEN 40MG IV LASIX AT 8AM AND HAS DIURESED WELL, CURRENTLY ~ 900CC NEG. PT IN SR 60-70'S NO VEA, BP 108-130/ 50-60. CAPTOPRIL RESTARTED AT 25MG TID, TOLERATING WELL. LOPRESSOR ^ TO 25MG TID. TAKING PO'S W/O DIFFICULTY. HAD LG OB- STOOL THIS AM. FOLEY DRAINING CL YELLOW URINE. T^ 101.8 LAST EVE, FULLY CX. AFEBRILE SINCE. PT HAS 5 CHILDREN, LIVES W/ DAUGHTER [**Female First Name (un) **] WHO IS PROXY. ||||END_OF_RECORD START_OF_RECORD=12||||1|||| NEURO: A&O X3. PLEASANT & COOPERATIVE. MAE. RESP: BS CLEAR. O2 SATS-> 94-96% ON 2L->NP. RR 12-20. CARDIAC: HR 56-71 SR. NO ECTOPY. SBP 189-190 ON ARRIVAL TO CCU. STARTED ON IV NTG 30MCG/MIN. BP 117-161/63-78. IABP 1:1. SEE FLOW SHEET FOR #'S. +BPPP. R. GROIN WITH SM. AMT OOZE. NO SIGNS OF HEMATOMA. VENOUS SHEATH D/C'D BY FELLOW. HEPARIN GTT RESTARTED @ 1000U/HR AFTER 5000U HEPARIN BOLUS GIVEN. PTT 135.6. HEPARIN GTT OFF X 2HRS(0800) & THEN TO BE RESTART- ED AT 650U/HR. K 3.3 & MG 1.6-> BOTH REPLACED & LEVELS PENDING. POST-CATH FLUID INFUSING AT 100CC/HR X24HRS. CK 305 WITH 46%MB. GI: TOL. DIET WELL. NO N/V. NPO AFTER MIDNOC FOR OR THIS AM. ABD. SOFT BS+. NO STOOL. GU: VOIDING QS VIA URINAL->CLEAR YELLOW URINE. ATTEMPT TO PLACE FOLEY CATHETER UNSUCCESSFUL. HO AWARE & WILL PLACE IN OR. ID: T 98.3(PO) LABS: WBC 6.5, HCT 36.8, PLAT CT 92K, PT 15.1, INR 1.5, CHEMISTRIES PENDING. PLAN: OR 0930->CABG. ||||END_OF_RECORD START_OF_RECORD=13||||1|||| O: TM 99.7PO. HR 85-90 VPACED. arrived to CCU approx. 2200: BP 140-160/50. nipride titrated to 4.0mcq/kg/min with BP coming down to 95-120/50. by 0400, nipride weaned to 1.6mcq/kg/min. troponin 1.2, ck 26. completed one UPRBC at 2200. repeat HCT 30 at 2400. resp: vent at AC 500x12/.50/5peep. rr 12-16. sats 95-97%. suctioned for small amts of yellow to white secretions. one sent for Cx. ABG improved to 7.46/37/101. LS diminished bases. clear upper . GU: repeat lasix 40mg at 2230 and again at 0500. ~ 700cc responce to each. GI: TF started at 10cc/hr. impact with fiber. ABD soft, (+) BS. no stool. skin: left breast wound clean, right thigh wound clean/dry. both covered with zeroform and left open. neuro: opens eyes to name , strong cough and gag. propofol increased to 40mcq and then down again to 30mcq. A: good diuresis good BP effect with nipride P: follow sats, ABG, u/o , lytes. follow hct, nutrition consult. ||||END_OF_RECORD START_OF_RECORD=13||||2|||| resp care note: pt received intubated, oet is secure and patent. pt also on mech ventilation, current settings are: ac 500 x 12, peep5, and 50% fio2. pt was transported to ccu from ctic, via ambu to ett with 100% fio2 all took place with out incidence. pt received general veentilator maintence, and suctioning t/o the shift. all is well at this time. ||||END_OF_RECORD START_OF_RECORD=13||||3|||| Pt. remained on CMV all day. There was an order to decrease to PSV but other procedures were [**Last Name (un) 90**] done and she did not make it to this change, The nasal e.tube was advanced to 27cms per CXR. settings CMV 500 x 10 .40 5peep with [**Last Name (un) 91**]-by. abg's post changes = pending at this time. ||||END_OF_RECORD START_OF_RECORD=13||||4|||| Remains intubated and ventilated, sedated, swan ganz in place, tx pulmonary edema w/ cardiac compromise. ROS: CARDIAC: Remains on varying rates of nipride. Very sensitive to change (ranges b/p 80-174/50-60). It's on and off...rates .5 -1.6 mcg/kg/min. Periods of b/p instability where suddenly drops from 140/ to 80/, responding to turning off nipride. Hr 80-90 v-paced. Swan placed and verified by cxr. pa 40/20, pcw 17, cvp 16. Had frequent vpb during swan placement. resolved when in Pa. RESP: suctioning nothing...despite lavage and bagging. Settings: A/C 450cc/10br/40%/ 5cm peep. Spont breaths 3/min. Abg pnd. Clear upper BS, diminished lower. CXR reportedly improved since yesterday. Felt to be pulmonary edema w/ questionable infectious process. FLUID/ELECTROLYTE: RECEIVING kcl and calcium replacements, excellent response to diuresis w/ neg > 2L. lasix changed to BID. NEURO: remains sedated on propofol. 30-40mcg/kg/min. + cough. drew arm up to face x1.pearl. GI: -[**Last Name (un) 92**] sounds, TF d/c. Small coffee gnd. lavage by intern negative. Port saved for TPN. No stool. Increased protonix, following hct. HEME: hct drop to 26. for transfusion prbc tonight. consent signed by hsb. No aparent source of bleeding. SKIN: xeroform gauze and dsd to grafts. ID: new cx sent from swan. afebrile but wbc up to 14 today. More abx added today. ASSESS: intermittent unexplained drops in b/p...? volume related. improving oxygenation, unexplained anemia. Well sedated. PLAN: check abg on these settings. transfuse one unit prbc. follow filling pressures. ||||END_OF_RECORD START_OF_RECORD=13||||5|||| resp care note: pt received intubated nasally, oet is secure and patent. pt also mech ventilated, current settings are: psv 15/5 peep, and 40%. pt changed from a/c due to overventilation. pt still somewhat overventilated, but decreasing psv subsequently drastically increases her rr, and drops her volunes, i believe that problems will arise due to the small nature of the tube. pt received general vent management, and suctioning t/o the shift. all is well at this time. ||||END_OF_RECORD START_OF_RECORD=13||||6|||| s/o: pls see carevue flowsheet for complete vs/data/events id: afeb. cont on levo and vanco. cv: hr 80-90s asensed, vpaced. bp 110-130/60 via r rad aline. nipride at .75mcg/kg/min. pap 30s/18-22. cvp 10-14. co 7.5/ci 3.8. svr 576. resp: changed to ps 15 last noc. tv 400-600, rr 12-18. cont on 40% and 5peep. sats 92-94%. last abg: 7.51/43/69/36/9. bs scatt coarse, dim at bases. sxn'd for scant light tan secretions. gi: npo. med via ngt, min aspirates. no stool. heme: rec'd 1 u orbcs last noc. repeat hct pend. skin: l breast and r thigh dsg changed, xeroforn and dsd applied. no drg from owund. gu: diuresing well to bid iv lasix. ms: sedated on propofol. will wean off this am in attempt to wean ventilator. a: hemodynamics stable. alkalosis. p: wean sedation and vent as tol. pulm hygiene. ||||END_OF_RECORD START_OF_RECORD=13||||7|||| Remains stable on nipride, ntg...extubated today. Doing well. ROS: CARDIAC: Continued to diurese well w/ filling pressures down (PA 34/15, pcw 12-18, cvp 5-10). hr 92 ddd pacer. No c/p. Tapering nipride gtt as captopril increased. On iv ntg 200 mcg/min. RESP: extubated 1pm w/ good abg. Seems comfortable w/ sats mid 90's on 40% cool neb. Good cough, productive thin blood tinged secretions. Nasal intubation, trauma extubation w/ subsequent nasal bleeding. Seems to have ceased. Diminished bs w/ coarse upper airways. GI; ngt remains in place, will d/c when able to swallow meds. Vomited bloody liquid, lavaged clear. Felt to be nasal bleeding as source. Remains clear, nausea relieved w/ .5mg iv ativan. Tolerating captopril. No stool. Renal: bun 25/ cr 1.2. Excellent responses to diuresis w/ negative approx 2L today, (total 4L negative including yesterday) HEME: hct 30.7 after transfusion yesterday. REceiving kcl and mg repletion. Family here and updated on progress and plan. ID: temp spike to 102.2 R. blood cx sent from swan and a-line, urine sent. ASSESS: stable post extubation, normalizing filling pressures. PLAn: cont volume management, d/c nipride as captopril reaches effects, abg this evening. d/c ngt when able to take po meds. ||||END_OF_RECORD START_OF_RECORD=13||||8|||| NEURO: ALERT AND RESPONSIVE. SLEEPY AT TIMES. MOVING ALL EXTREMITES. VOICE RASPY AT TIMES CLEAR. PROBABLY DUE TO ETT. CV: HR 87-90 AV PACED. OCC PVC NOTED. BP DIFFICULT TO CONTROL. CONT ON NTG GTT AT 200 MCG. ATTEMPTING TO WEAN NIPRIDE. GIVEN 100MG CAPTOPRIL WITH LITTLE EFFECT ON BP. DENIES CP. SEE FLOWSHEET FOR HEMODYNAMICS. RESP: O2 SAT ON 50% FM 93-94%. LUNGS HAVE I/E WHEEZES. UNABLE TO KEEP MASK ON. PLACED ON 6L NC O2 SATS 95%. COUGHING AND RAISING THICK BLOODY SPUTUM. CONGESTED COUGH. GI: NGT D/C'D. NO NAUSEA. NGT LAVAGED PRIOR TO PULLING AND LAVAGED FOR DARK BROWN CONTENTS WITH DRIED BLOOD FLECKS. TAKING SIPS OF WATER FAIR. COUGH WITH EACH SIP. GU; FOLEY PATENT. DRAINING CLEAR YELLOW URINE IN GOOD AMTS. SKIN: LEFT MASTECTOMY SITE CLEAN, PINK, XEROFORM GAUZE AND DSD APPLIED, NO DRAINAGE. RIGHT THIGH GRAFT SITE. CLEAN, PINK. XEROFORM GAUZE AND DSD APPLIED. JP DRAIN REMOVED BY SURGEON. SITED CLEAN, OLD BLOODY DRAINAGE NOTED. ||||END_OF_RECORD START_OF_RECORD=13||||9|||| CV: pt denies CP or SOB, Atenolol increased to 50mg bid, given additional 25mg at 8AM. Started Zestril qd and IV nipride and NTG weaned off. BP has been 120-150/60, HR 86 AV paced. Swan and A-line DC'd. Resp: cont on 5L NC with sats 96%. LS course, coughing intermittently, nonproductive. Using insentive spirometry. Skin: Dressings to L chest and R thigh D&I, Sm dressing on L upper back was bloody, covering dehisence of suture line, Area open 1x2cm, area cultured and DSD reapplied, team to call plastics. Neuro: Alert, a bit slow to respond to orientation questions, but was able to later repeat information. Asked for antianxiety medication this AM, given 1mg Ativan po. Pt sleepy remainder of the day. Stated that she did not sleep all night. Family in this afternoon, trying to keep pt awake, giving her po's. ID: afebrile on AB. IV team evaluated for PICC, they state pt will need line placed in radiology. F&E: Pt is ~700 neg on her own, no diuretics given. A: hemodynamically stable, off gtts. PO antihypertensives on board. P: Pt is stable to transfer to floor, awaiting bed. ||||END_OF_RECORD START_OF_RECORD=13||||10|||| AWAKE AND ALERT THIS EVE. RESPONDING APPRPRIATELY TO QUESTIONS. OOB TO CHAIR LAST NIGHT FOR 1 1/2 HRS. TOL WELL. TRANSFERS TO CHAIR AND COMMODE WITH 2 ASSISTS. SL. UNSTEADY ON FEET. CV: BP 130-140'S PROCARDIA XL 30 MG ADDED TO MED REGIME. TOL. WELL. HR 88 AV PACED NO VEA NOTED. DENIES CP. RESP: LUNGS CLEAR IN UPPER AIRWAYS, CRACKLES AT BASES. O2 AT 6L NP WITH O2 SATS 95%. USING INCENTIVE [**Location (un) 93**] Q2-3 HRS WHEN AWAKE. COUGHING AND RAISING PINK-TINGED SPUTUM. RR 22-24. GU: FOLEY PATENT. HUO ADEQUATE. SEE FLOWSHEET FOR I/O DATA. GI: ABD. SOFT AND DISTENDED. OOB TO COMMODE FOR BM LARGE HARD STOOL. GUIAC NEG. TAKING SIPS OF WATER DURING NOC. ENJOYED A POPSICLE LAST NOC. MOUTH FEELS DRY. SKIN: L MASTECTOMY SITE C&D. DRESSING INTACT. RIGHT THIGH GRAFT SITE C&D. DRESSING INTACT. BACK WOUND OPEN AND DRAINING SERO-SANG FLUID. COVERED WITH NS W-D DRESSING. AWAITING PLASTICS TO ASSESS WOUND. ||||END_OF_RECORD START_OF_RECORD=13||||11|||| CV: BP running 116-140/60 HR 80's AV paced, no ectopy. Changed Atenolol to 100mg qd, cont on Zestril 40mg qd. No CP or SOB. LS with fine crackles at bases otherwise clear. Running 500cc neg so far today. Resp: sats 94-96% on 6L nc. RR 16-20, no distress. Doing IS. Neuro: more alert today, oriented x3. OOB to commode and chair x 5 hrs. Ambulating few steps. Did well. Skin: dressings to L breast and R thigh changed, wounds look clean, seen by plastics this AM. Wound dehisence on L upper back seen by surg this PM, suggested w-d dressings bid, do not pack too tightly. drsg [**Name5 (PTitle) 94**] at 2PM. Otherwise skin intact. GI: incontinent of sm amt loose brown stool, very embarased. Up to commode passed some formed stool mixed with liq brown, lg amt, OB (+). Taking in more po today. Soc: husband and other family members in today. A/P: Doing very well today, hemodynamically stable , BP desirably lower today with addition of procardia. Awaiting bed on floor. ||||END_OF_RECORD START_OF_RECORD=13||||12|||| RESP. CARE: PEAK FLOW MEASURED WITH PT. IN S/F POSITION. PF=150L/M. ADMIN. 2 PUFFS ALBUTEROL INHALER WITH SPACER. PF POST ALBUTEROL=150L/M.(43%PRED.) ||||END_OF_RECORD START_OF_RECORD=14||||1|||| HPI: Pt is a 75 y.o female who ws admitted for r/o MI, pt r/o. Pt had stress test which was positive for changes, and pt returned to [**Location 95**] without stress. Pt went to cath lab on [**07-10**] found to have 2 vessel disease, the LAD 80% occ at D1 and RCA 90% occ at PDA and PLB. A PTCA preformed on the LAD and RCA, LAD unsuccessful, causing pt CP. Pt txr to floor, with CP. Pt decompensated, BP in 70's, tachycardic. Pt then PEA and brady arrested. A pericardial sentesis preformed on floor, where pressures were 18 from pericardial tamponade, 600cc blood drained. Pt then went to OR for exploratory surgery, findings of a perpherated D1 , and a septal and/or RV puncture. Pt txr to CSRU. Neuro: Pt grimises to pain, Spanish speaking only, does not follow commands, pt restrained upper extremeties, purpousful movement. Cardiac: Pt is in SR rate of 90's, BP via rad AL in low 100's to 110's sys. Pt has pacer wires, not being used. Pt has a SWAN CVP's in the high mid to high teens, PA pressures in 40's sys, Wedge is 21. Pt has a R rad AL, and a R fem AV line. Both transduced. Fick done with positive results. Pt febrile at 100.2 Resp: Pt intubated on CPAP .5% 5/8. Pts TV low in the 300's, pt tachyapenic. BS are exp wheezy at times and ronchi at times. Suction out pink brown thin secretions from ET tube. Pt has 2 mediasteinal CT draining min sang fluid. GI: Pt has OGT to LCS, nothing draining. -BS, Abd soft GU: Pt has f/c good urine output Misc: Pt on insulin drip at 2u/hr, Pts lines include L IJ SWAN, L IJ cordis, L groin TL, R rad AL, and R groin AV line. Pt restrained due to purpousful movement. ||||END_OF_RECORD START_OF_RECORD=14||||2|||| npn 7p-7a: s: pt intubated please see careview for objective data. o: neuro--pt found to be awake, mae, aggitated/restless w/rr up to 40's, given 2mg mso4 x2 w/out change in aggitation or rr, ct surg aware, pt started on propofol gtt w/gd sedation, at 4mcg, this am is more awake, moving to stimulation resp--initially rr up to 40's, pt appeared uncomfortable, ls coarse throughout, sxn'd for thick tan secretions, abg sent 77-38-7.45-, pt placed on imv w/rate 10-600-50%, am abg pnd, rr through the noc 10-25, sats 97-98%, pt also given 20mg iv lasix d/t ?wet, did have gd response, cxr also done at that time, medialstinal tubes to suction w/min seroussang output, dsg intact cardiac--hr initially 80's sr then into rate of 150's raf w/bp 124/70, team aware, given 5mg iv lopressor w/rate slowing for short time to 100 afib, then back to 140's, given add 5mg iv lopressor, again hr slowed to 100-120 afib, occ converting to sr w/freq apc's then back to afib, at 3:30am pt sustaining rate of 140's, 5mg lopressor given w/out effect, started on procanamide gtt at 2mg/hr after rec'ing 1gm loading over 1hr, hr 80's sr w/freq apc's, bp 90's/60, mg 1.0, given 2gm, k wnl, am labs pnd, pa line intact, pa' 35-46/30's, cvp 10-18, pcwp 16, co/ci pnd this am, pacer attached to wires, turned off at this time gi--abd soft/distended, hypoactive bs, ogt to lcs w/min to no output, gu--foley in place, given 20mg iv lasix w/gd response, u/o now begining to drop off to 30-40cc/hr access---r groin sheaths removed by surg, no drainage, dsg intact, l tlcl inplace, lij swan in place social--pt has many family members, most of family does not speak eng, 1 dtr [**Name (NI) 96**] does speak some eng, dtr spent night in waiting room ||||END_OF_RECORD START_OF_RECORD=14||||3|||| Patient received on SIMV 600 X 10 50%, 8 PSV and 5 peep. Initially paient doing very well, problems with AFIB, hypotension. Decreasing sats in the morning resulted in FiO2 being increased, management of BP and A FIb. Patient stable, changed to PSV of 10/5, 60%, VT 360, rate 28. MDI given as ordered, breath sounds,, Left clear right ? rales, Continue to monitor. ||||END_OF_RECORD START_OF_RECORD=14||||4|||| n-arouses appropriately, communicates with facial and hand gestures with help of family translation, propofol off since early am, med with prn mso4 and toradol with fair effect, discomfort priamrily with movement r-weaned to psv 10/ peep 5 fio2 60% tv's-300-400 rr 25 thick blood tinged sputum, old bloody oral/pharangeal secretions, adequate oxygenation/ventilation, mediastinal chest tube intact with scant outout, breath sds-crackles-cxr per house staff wet marginal response to bid lasix and extra x 1 40mg dose cv-nsr>afib with low bp>re-loaded with 250 proc-compromised bp and oxygenation-therefore dc'd proc- pt stabilized in nsr again, epicardial wires attached to pacer which is off co/ci/svr-3.5/2.0/1600- wedge 21- initiated iv ntg per ct surg with goal of unloading-thus far no effect on svr or filling pressures-titrated up ntg to 100mcgs gi-ogt-bilious gu-qsuo via foley but no significant diuretic response afebrile on iv vanco large supportive family in and updated a/p-optimise hemodynamics, wean vent to extubate, assess fluid volume status ||||END_OF_RECORD START_OF_RECORD=14||||5|||| Resp Care: Pt continues intubated and on ventilatory support with psv 10/peep 5/fio2 .6 maintaining Vt 4-500 ml with Ve 7-9L, spo2 95%; BS coarse, sxn thick yell secretions, rx with combivent mdi as ordered, see carevue for details. ||||END_OF_RECORD START_OF_RECORD=14||||6|||| O:CV=0300 EPISODE OF AF-RXED W AMIODARONE (LOAD & BOLUS)-COMPLICATED BY HYPOTENSION-RXED W DC NTG, IVF, & SHORT TERM LOW-DOSE NEO. 0500 CONVERTED TO SR-NEO DCED & NTG RESUMED @ 100MCG. ***SEE FLOW SHEET FOR #'S***. PULM=INTUBATED & VENTED. SETTINGS-CPAP/PS, FIO2 60%, TV 380-530. RR 18-26, MV 8.7-9.9, & PEEP/PS 5/10. BREATH SOUNDS=COURSE. GU=LASIX 40MG IVB @ 2000. 2300 -.8L & 0500 -.3L. SOCIAL=FAMILY PRESENT THROUGHOUT NIGHT. NEURO=RESPONSIVE. MED W MSO4 2MG IVB X3 W GD EFFECT. A:EPISODE OF AF RXED W AMIODARONE. P:DECREASE AMIODARONE TO 0.5MG/MIN @ 0930. WEAN VENT AS TOLERATED. ?GOAL OF I&O-AUGMENT DIURESIS MOTE AGGRESSIVELY. SUPPORT PT/FAMILY AS NEEDED. ||||END_OF_RECORD START_OF_RECORD=14||||7|||| Resp. Care: Pt. remains intubated and on vent. support-PS 5, P 5, 50%. RR=20-26, TV=320-500ml. Sx-thick tan sputum in lg. amounts. Pt. will cont. intubated due to secretions, fever and increasing WBC. ||||END_OF_RECORD START_OF_RECORD=14||||8|||| n-responds appropriatley to voice, med with prn mso4 with good effect r-weaned to psv 5/ peep 5 fio2 50% tv's 300-400 rr teens to 20 with good oxygenation and ventilation, ^ to psv of 8 just to rest in setting of rml/rll pnuemonia- thick foul purulent sputum- gram neg rods- starting ceftaz/timentin- wbc ^ 16 tmax 37.5 cv-remains in nsr on iv amio decreased to .5mgs/min, co/ci/svr 3.5-4/1.7-2/1200-1600 with pa sats 53-60 map's>70 on iv ntg at 100mcg's, wedge remains 21 cvp 14, fair diureses today tbb negative 1.4 l and neg 2.9 l length of stay l ij pa line intact, new l rad aline placed, l fem cvl dc'd gi-ogt, hypobsds, softly distended gu->qsuo via foley low grade core temp starting abx for gram neg coverage skin intact family in and updated a/p-hemodynamics with marginal cardiac function, filling pressures remain ^ but starting to become negative in body balance, s/sx pnuemonia evident-follow s/sx resp compromise, infection surveillance/rx ongoing, follow fluid volume balance and renal function ||||END_OF_RECORD START_OF_RECORD=14||||9|||| 75 YO SPANIH SPEAKING FEMALE. [**07-07**] 2WK HX OF SUBSTERNAL PRESSURE W INCREASING FREQ & SEVERITY OVER PAST COUPLE OF DAYS. EW-CXR=BORDERLINE FAILURE & EXG=ST DEPRESSION <1MM V5&6 & WO Q'S. ADMITTED TO [**Wardname **]. RO W NEG CK'S. 10/[**Street Address 97**]-BORDERLINE ISCHEMIC ST CHGS WO S/S. [**07-10**] CARDIAC CATH:LVEF 60%. NO WALL MOTION ABNORMALITIES. LAD MID 80% OCCLUSION-STENTED. RCA DISTAL 90% OCCLUSION-STENTED. TRANSFERED BACK TO [**Wardname **] POST PROCEDURE W CO CP. [**Wardname 98**] DEVELOPED CHRUSHING CP & HYPOTENSION-EMERGENT ECHO=LARGE EFFUSION & RV DIASTOLIC COLLAPSE-EMERGENT TAP @ BEDSIDE & ALSO INTUBATED-TAKEN TO CATH LAB FOR FURTHER MANAGEMENT. [**07-11**] OR-REPAIR CARDIAC PERFORATIONS X2. [**07-12**] RAPID AF-130'S RXED W PROCAN LOAD & GTT W CONVERSION TO SR-GTT DCED DUE TO BORDERLINE HYPOTENSION. RECURRANCE OF AF-130'S RXED W AMIODARONE LOAD & GTT (150MG & 60MG/HR X6HR)-TRANSIENT HYPOTENSION RXED W NEO GTT [**07-13**] CXR-R&LLL INFILTRATES. SPUTUM-THICK TAN FOUL SMELLING-CULTURED. ABX STARTED-CEFTAZ 2GM Q12HRS & LEVOFLOX 250MG Q24HRS. O:NEURO=RESPONSE. APPROPRIATE PER FAMILY MEMBERS. MEDICATED W MS04 2-4MG PRN. SOFT RESTRAINTS ON WRISTS DUE TO # OF LINES. PULM=INTUBATED & VENTED. SETTINGS-CPAP/PS, FIO2 50%, TV 390-550, RR 20-22, MV 8-10.2, & PEEP/PS 5/8. BREATH SOUNDS=COURSE THROUGHOUT. SX-THICK TAN SECRETIONS. CV=SR WO ECTOPY-ON AMIODARONE @ 30MG/HR (MAINT DOSE STARTED APPROX [**07-13**] 0930). HEMODY STABLE, BUT W LOW CO/CI. MAPS 80'S, PADS LOW 20'S, W 22-24, CVP 13-16, & LAST CO/CI/SVR ([**07-14**] 0500) 3.43/1.98/1609-TD. NTG GTT @ 100MCG. GI=OGT. NPO SINCE [**07-10**]. WO BM. GU=FOLEY. POS FLUID BALANCE-LASIX BID (40MG IVB). I&0 @ 2300= -2L & @ 0500 -1L. ID=LOW GRADE T. CULTURED. ABX-CEFTAZ & LEVOFLOX. CSURG=STERNAL INCISION-DSD, EPICARDIAL WIRES INPLACE TO PACER (PACER OFF). MEDIASTINAL CHEST TUBES TO UNDER WATER SEAL W SX, DSG D&I, MINIMAL SEROSANG DRAINAGE, WO LEAK/CREPITUS. LABS=AM SENT. A:STABLE S/P CARDIAC PERFORATION REPAIR-COURSE CB ESPISODES RAPID AF & PNEUMONIA. P:PRN SEDATION AS NEEDED. SUPPORT PT/FAMILY (VERY SUPPORTIVE & CARING FAMILY-WILLING TO BE PRESENT @ ALL X'S TO ASSIST W CARE & COMMUNICATION). PULM TOILET. MAINT ADEQ OXYGENATION. FOLLOW CO/CI-? ASSIST CARDIAC FUNCTION W DOBUTAMINE/MILRINONE. ?TF. CONTIN TO DIURESE AS NEEDED. FOLLOW T & CK CULTURES-ADJUST ABX AS INDICATED. ?EPICARDIAL WIRES & CT-DC. CK AM LABS-REPLACE AS INDICATED. ||||END_OF_RECORD START_OF_RECORD=14||||10|||| Resp. Care Note Pt remains intubated and vented on current settings CPAP 5 PSV 8 and 50%. Tv 500 range RR 15-18 for VE 8.0-8.5L. No changes made this shift. Cont to receive combivent MDI Q vent check. BS coarse bilat. ||||END_OF_RECORD START_OF_RECORD=14||||11|||| NPN 7P-7A: ICU PROGRESS NOTE: NEURO--PT SPANISH SPEAKING, FAMILY CONVERSING W/HER AND SHE IS APPROPRIATELY NODDING HEAD, NO SEDATION OR PAIN MED TONIGHT RESP--LS W/RONCHI THROUGHOUT, BEING SXN'D Q2HRS FOR THICK YELLOW/TAN SECRETIONS, CONTS VENTED, PS8, PEEP 5, 5O% FIO2, NO CHANGES MADE, ABG THIS AM WNL, PT HAS LG AMT OF ORAL SECRETIONS AS WELL, CONTS ON IVAB FOR GNR PNEUMONIA CARDIAC--HR 70'S SR, NO ECTOPY, BP 110-124/60'S, CONTS ON NTG AT 100MCG/HR, AMIO AT 30MG/HR INFUSING, PA'S 30'S, PAD 10-14, PCWP--14-16, CVP 8-10, CO/CI--5.6/3.24, SVR 1057, GI--ABD SOFT, SL DISTENDED, (+)BS, TF'S CONT INCREASED TO 40CC/HR OF PROMOTE W/FIBER, MIN RESIDUALS OF 5-10CC, NO STOOL GU--FOLEY TO GRAVITY, DRAINING CLEAR YELLOW URINE, CONTS TO REC LASIX W/LG DIURSIS AFTER DOSE, AM K PND ||||END_OF_RECORD START_OF_RECORD=14||||12|||| CCU NURSING PROGRESS NOTE 7A-7P NEURO: SPANISH SPEAKING FEMALE, OPENS EYES WITH STIMULATION. FOLLOWS COMMANDS APPROPRIATELY. BILAT RESTRAINTS TO WRISTS, PREVENT PULLING TUBES. CV: HR 70-80'S SR. IV AMIO AT .5MG/MIN, TO BE DC'D AND CHANGED TO PO AMIO. NO VEA NOTED. BP 110-120/60'S. CONT IV NTG AT 100MCG/MIN. PAP'S 30'S/15-19. CVP 8-10. PM CO/CI UNCHANGED FROM THIS AM. PA LINE DC'D BY HO THIS EVENING. PACER WIRES ATTACHED, PACER REMAINS OFF. K AND MG REPLETED THIS AM. KPHOS 15 MMOL INFUSING AT PRESENT. PULM: LS COARSE THROUGHOUT. SX Q2HRS THIN WHITE FROTHY SECRETIONS. CON'T INTUBATED PS 8 PEEP 5 FIO2 50% VT'S 400'S. PM ABG 87/41/7.51/34/8. LASIX DC'D AND CHANGED TO DIAMOX. GI/GU: ABD SOFT, +BS. TUBE FEEDS INCREASED TO GOAL PROMOTE WITH FIBER AT 50CC/HR. NO RESIDUALS NOTED. NO STOOL THIS SHIFT. FOLEY DRAINING LG AMTS CLEAR YELLOW URINE. +++ DIURESIS TO LASIX. -3L THUS FAR TODAY. ID: TMAX 99.5 BLOOD. CONT IV ABX ENDO: FS'S 257 AND 236. COVERED PER SS INSULIN. HO AWARE ON ^FS. SKIN: STERNAL STAPLES C/D/I. MEDIASTINAL OLD CT DSG DRY/INTACT. BACKSIDE INTACT. PLAN: WEAN TO PS 5/5 IN AM, PLAN TO EXTUBATE ON ROUNDS IN AM. CHANGE AMIO IV TO PO, CHANGE LASIX TO DIAMOX. FAMILY PRESENT MOST OF DAY. ||||END_OF_RECORD START_OF_RECORD=14||||13|||| O: TM 99.2po, ceftaz. and levo IV HR 71-80 SR. BP 93-120's/50-70's. BP up to 150's/ when restless or uncomf. when coughing. amio po started and gtt d/c'd 1 1/2 hr later. TNG at 100mcq. - vent at 10/5/.50 w/sats 98-99%. RR 16-19, Tv 400-500. suctioning med. to large amt. of white thin/thick secretions. clear oral secretions. course BS. ABG pnd at 0400. plan to change to 5/5 at 0500 and extubate ~ 0600. - pt. very awake and appearing uncomf. with facial grimacing, shaking head. family here in eve and requesting sedation med. for pt. given morphine 2mg x2 with only min. effect. awake much of night, light sleeper. strong gag and cough. through family interpretation, pt. reporting that breathing was feeling good in eve with no SOB. - lasix changed to diamox po(NG). u/o 75-150cc/hr. (-) 3l at MN and currently ~ 400cc neg. NPO at 0200 for extubation. no stool. 2 daughters visited and expressing concern about mother. A: plan to extubate ||||END_OF_RECORD START_OF_RECORD=14||||14|||| RESP CARE Pt remains intubated and ventilated with a puritan [**Male First Name (un) 99**] vent which has been checked for leaks and alarms tested according to dept policy.Currently pt is on psv5/peep5 and 50% with spont vt of 380cc and rr of 20-24. Suct for loose white sput. Will cont to follow as needed.Pt also given combivent mdi as ordered. ||||END_OF_RECORD START_OF_RECORD=14||||15|||| ccu nursing progress note s/p extubation this am neuro: pt alert, following simple commands this am. appropriate per family pulm: extubated this am. sats 96-100% on 70% cool neb mask. ls coarse, diminished at bases. coughing up thin white sputum. pt with episode tachypnea this am. chest pt done, neb tx given, mso4 given for comfort. cv: hr 70-90's sr. no vea or afib noted. pt c/o chest pain this am via daughter. states felt like difficulty breathing, not heart. ho called to see pt, ekg done. pt on ntg 100mcg/min. per ho, no acute changes, cpk/mb/trop done. given mso4 x2 with effect. troponin result 12. pt transferred to ccu service. left and right sided ekg done per request, pt stating pain free at that time. ekg changes noted, pt given iv lopressor by ho. started on iv heparin as ordered. pt taken to cath lab to evaluate chest pain/ + troponin. pt became hypotensive and bradycardic in lab, cardiac arrest called and pt intubated. pt expired in cath lab. family called and given information. chaplain and interpreter called to speak to family, cont to await all of family to arrive. supportive measures provided for family. ||||END_OF_RECORD START_OF_RECORD=15||||1|||| 46 year old male came into [**Hospital1 2**] on [**04-14**] with comlaints of bilateral leg swelling, erythema and pain, and a cough x1 month. Pt. was being treated on floor, developed and increasing Creatine to 6 (baseline is 2.5) on [**04-18**] pt. developed increasign lethargy with poor abg's with pco2 in the 90's and low po2. Pt. was tried on bipap on the floor without success, and was transferred to the MICU for further management. PMHX: Obstructive sleep apnea Pulmonary hypertension COPD Cor Pulmonale Pt. arrived in MICU in resp. distress on bipap, pt. continued with poor abg's with low po2 in the 30-60 range and elevated co2 (see careview). Initially after discussing worsening resp. status with pt and his wife, pt. refused intubation. PT. was tried on bipap and masked ventilation without any improvement in resp. status. Pt. was given lasix without any response. THis am pt's resp. status worsened, minimally responsive, not cooperating with masked ventilation, using all accessory muscles to breath. Dr. [**Last Name (STitle) 100**] aware. Pt. then asked to have tube inserted. Wife made aware of decision to intubate pt. and pt. was intubated. Neuro: initially pt. alert and cooperative at times. Mostly combative and not cooperating with care. Pt. had received haldol 5mg iv x2 with minimal effect. This am pt. lethargic, after intubation became agitated, and was started on propofol gtt. ResP: Initially treated with bipap, however abg's remained poor, and pt. deteriorating, masked ventilation attempted however pt. continued to deteriorate. Pt. intubated this am after DNI was rescinded. LUngs are diminished. Post intubation gas to be drawn. CV: Bp stable, NSR, with rare PVC's. Pt. able to have hydralazine changed to iv. GI: pt. kept npo and after intubation ogt placed with coffee ground drainage. Awaiting CXR for confirmation. GU:Pt. initally refuse foley, however after speaking with wife, 14 french foley placed with good drainage intially. Pt. tugging on foley and kicking it. Urine output now with mild hematuria. SKIN: Lower leg ulcer. See careview for further details. Family at bedside and aware that code status has been changed. ||||END_OF_RECORD START_OF_RECORD=15||||2|||| Resp: vent settings AC 800x12 PEEP 5, FiO2 30%, rr 22-28. O2 sats 86-88% with pPIP's >50. PEEP was increased to 10 and FiO2 increased to 50%. Sedation was increased to help ventilate pt. The propofol was increased to 40mcg/kg/min (~500mcg/hr) with boluses of ativan during procedures 4-6mg given at a time so that over 5h (7a-12n) he received a total of 40 mg. At 12:30 he was started on Morphine at 10mg/hr to help with sedation. ABG drawn at 1400 was 119/51/7.39 with PIP's 38-40. He was suctioned x2 for small to mod amount of white secretions. HEME: during intubation pt started bleeding in the oral pharynx. 200cc of BRB was suctioned in 2h. ENT was called and tried to visualize the location of the bleed, he suctioned lot of very large clots from the pharynx but still did not know where the bleeding was from. They finally packed his throat with kling for 1 1/2-2h then came back pulled the packing and stated that he had stopped bleeding. Since then he has continued to ooze blood but the bleeding has slowed significantly. HCT drawn at 1400 was 28.3 (down from 33.4. Pt is to have a swan placed and he will receive 2u FFP and DDAVP prior to line placement. Platelet ct down to 185 from 232. Cardiac: vital signs have been very stable. B/P 120-130/70, HR initally was 100's but decreased to 60's with sedation. GI: Pt has OGT. At 11am he was given the dilt and catapres but w/i 15min he vomited it up with ~50cc BRB (swallowed from the pharyngeal bleed. GU: Foley draining brown to amber urine with sediment. Social: Family has called several times to update on his condition and are kept informed. Dr. [**Last Name (STitle) **] [**Last Name (STitle) 101**] (his PCP) was in to check on Mr. [**Known patient lastname 102**] and will follow up with family. ||||END_OF_RECORD START_OF_RECORD=15||||3|||| RESP--CONTS ON AC 12, 800, PEEP 10 FIO2 DROPPED TO 40%. SX'D X1 BY RT FOR THICK BLOODY SPUTUM. CARD--PA LINE PLACED INITAL # PA 70/35, CVP 22, PCWP 21. AWAITING CXR TO CONFIRM PLACEMENT PRIOR TO SHOOTING CO #'S. WITH HISTORY OR TR, WILL MOST LIKELY NEED CO BY FICK METHOD. IONIZED CA 0.86, CURRENTLY RECEIVING 8 AMPS CA GLUCONATE. RECEIVED 2U FFP, AND DDAVP FOR SWAN INSERTION. NEURO--PT VERY RESTLESS AND AGITATED DURING SWAN INSERTION, PROPFOL INC TO 75MC/KG/HR, MED WITH ATIVAN 4MG IVP, BOTH WITH GOOD EFFECT. GU--U/O GOOD. GI--ABD SOFT AND OBESE, CONTS WITH BLOOD IN MOUTHM ALTHOUGH ONLY SM AMOUNTS. ||||END_OF_RECORD START_OF_RECORD=15||||4|||| Resp. Care Note Pt remains intubated with 8.0ETT secured at 27cm and current vent settings A/C 800x 12x 40% peep 10. In AM Pt very out of phase with vent, freq. pressure limiting and desating. Required ^ sedation and ^ FiO2 and peep to improve, see flowsheet for specific changes made. In afternoon, Pt better sedated, ABG on 50% 119/51/7.39.No autopeep measured. BS with decreased aeration, receiving Albuterol and Atrovent MDI's Q vent check. SXn for clear tenacious secretions per ETT, bloody oral secretions( although decreased amount). Cont current settings, wean FiO2 as tolerated. ||||END_OF_RECORD START_OF_RECORD=15||||5|||| PT. received s/p swan placement. Remains intubated and sedated in MICU with ARF, and resp. failure. NEURO: PT. received sedated on 85mcg/kg/min of propofol and 10mg/hr of morphine. Pt. minimally responsive, with only mild flexion noted in extremeties. This am have begun to titrate propofol to 65mcg/kg/min and pt. remains minimally responsive. Bilateral soft restraints on to prevent pt. from pulling at ett. RESP: Remains orally intubated. ETT pulled back 2cm per Dr. [**Last Name (STitle) 103**]. Lungs are very coarse, suctioned for blood tinged secretions via ett. Pt. noted to have very minimal bloody oral secretions. Sat's in the 90's. ABG this am on tv800 +10, 40%, AC 12, with pt. not breathing over the vent are PaO2 132, PCo2 35 PH 7.35. CV: Bp stable, pt. tolerating hydralazine, and isordil. Cardizem held secondary to heart rate being in the 50's all night. NSR, no exctopy. Swan confirmed by CXR. Cardiac outputs done by thermodilution and fick per Dr. [**Last Name (STitle) 103**]. Thermodilution CO 11.18 with ci 3.58, FICK CO 18.9 and CI 6.10. Dr. [**Last Name (STitle) 103**] aware, due to pt's TR will use fick method to evaluate cardiac output. Pt's output and index have remained elevated throughout night. PCWP initially 31 and after 80mg iv lasix x2 [**26**]. Goal is to have wedge around 22, and then get a set of outputs. CVP in the 20's with PAP's elevated with systolics in the 70's. GI: Abdomen obese, hypoactive bowel sounds, pt. not getting tube feeds as of yet. GU: pt. diuresing in response to lasix. See careview. ELECTROLYTES; iniozed calcium this am .89. Will notify ho. See careview for further details. Multiple family members have called and wife has been instructed to pick a spokesperson. ||||END_OF_RECORD START_OF_RECORD=15||||6|||| Pt. on a/c 800x12/10/40% no changes made. Sedated on propofol/mso4 t/o shift which has been titrated down slightly, however pt. unresponsive.Abgs w/in acceptable range with sats 96-100%. BS coarse exp. wheezes with gd. response to bronchodilators. Pcwp 27 and thermodilution done with CO 11. ET pulled back from 26 to 24 because it was close to R. mainstem. Hr normal, secreations minimal with occasional bloody oral secreations. ||||END_OF_RECORD START_OF_RECORD=15||||7|||| RESP--CURRENTLY ON AC 10 800 PEEP 10 40%. SX'D Q4 FOR THICK BLOODY SPUTUM. SATS 90-98%. CARD--HR 44-60, INC MORE BRADYCARDIC OVER COURSE OF SHIFT, BP 125-170/70-90. SWAN GANZ ONLY WEGES WITH 1CC OF AIR IN BALLOON. PAP 60-70/30-35, CVP 22-25, PCWP 15-19, CO FICK 14. PT WITH INC MV O2 SAT, BEDSIDE BUBBLE STUDY SHOWING SHUNT, RIGHT TO LEFT. IONIZED CA 0.86, RECEIVED 8 AMPS CA GLUCONATE, WITH REPEAT ION CA AT 0.96. ORDERED FOR CA CHLORIDE INFUSION, 8GM IN 400CC TO RUN AT 33CC/HR OVER 12 HOURS, WILL HANG WHEN AVAIL. PT WILL NEED ION CA CHECKED Q2-3 HOURS AFTER INITIATION OF GTT. GU--RECEIVED ANOTHER LASIX 80MG IV AT 12P, WITH SLOW RESPONSE. U/O VARIES. 35-150CC/HR. PHOS REMAINS ELEVATED, BY SLOWLY COMING DOWN. BUN CREAT 140/6.4. RENAL ATTNEDING IN AND SPOKE WITH FAMILY REGARDING NEED FOR HD OVER NEXT 48 HOURS. GI--ABD OBESE WITH HYPOACTIVE BS. TF REC'S WRITTEN AND WILL BE STARTED ON NEPRO GOAL 50CC/HR, WILL START WHEN TF PUMP AVAIL. NEURO--SEDATED ON PROPOFOL AND MSO4 GTT, PROPOFOL AT 45MC/KG/HR, MSO4 AT 10MG/HR. PT RESPONSIVE TO NOXIOUS STIMULI ONLY. SOCIAL--PT'S WIFE [**Name (NI) **] AND STEP DAUGHTER [**Name (NI) 104**] IN TO VISIT WITH PT, SPOKE WITH RENAL ATTENDING AND RESIDENT, UPDATED AND QUESTIONS ANSWERED. AWARE OF PT'S POOR PROGNOSIS. ARE WILLING TO ALLOW PT TO BE DIALYSED TO IMPROVE HIS CHANCES OF COMING OFF VENT. ||||END_OF_RECORD START_OF_RECORD=15||||8|||| Resp Care Note: Pt cont on mech vent as per vent flowsheet. Lung sounds coarse. Mdi given as per order. No vent changes made this shift. ABG's adequate at present. Cont mech vent support. ||||END_OF_RECORD START_OF_RECORD=15||||9|||| Pt. remains intubated with resp. and renal failure. Neuro: Pt. remains sedated on morphine at 10mg/hr and propofol at 45mcg/kg/min. Pt. does on occasion grimace to noxious stimuli, and noted to flex lower extremeties to pain. Resp: remains intubated on ac8,tv800 +10 40%. abg done with pco2 of 50 and ph 7.35. sat's in the 90's. Lungs are coarse with occ. wheezes. Suctioned for thick tan secretions via ett. CV: Bp stable 120-130/70's. Throughout the night HR has been noted to decrease from 50's to 40's. HR has gone as how as 39. Dr. [**Last Name (STitle) 105**] aware. EKG obtained x2 this evening showing only sinus brady. Atropine at bedside and cardizem has been held. CVP in the 20's. PAP 60's/20's. Unable to wedge swan. HO aware. GI: hypoactive bowel sounds, abdomen obese. Passing flatus. Started on nephro at 10cc/hr, however after 2 hours noted to have 600cc of bile colored residual. 600cc discarded and attempted to start tube feeds again at 10cc/hr, however pt. after one hour had increased residuals. Tube feeds currently off. Dr. [**Last Name (STitle) 105**] aware. GU: pt. initially with adequate amounts of urine output. At 4am noted to have decreased to 10cc over a 2 hour period. Dr.[**First Name (STitle) 106**] aware and 40 mg iv lasix given, foley also irrigated without difficulty, however urine output has dropped off to 0. Dr. [**Last Name (STitle) 105**] aware, pt. has received a liter NS fluid challenge and urine output has not picked up. Pt. also continues on 24 hour urine. ELECTRolytes: Remains on CACL gtt. Inionized calcium being checked q3 hours. last ionized ca 1.01. K this am 5.0 with elevated po4. Dr. [**Last Name (STitle) 105**] aware. Repeat lytes sent again at 6am secondary to pt's decreasing heart rate and worsening renal failure. See careview for further details. Plan to possibly initiate dialysis today. ||||END_OF_RECORD START_OF_RECORD=15||||10|||| RESPIRATORY CARE: PT. REMAINS WITH 8.0 ORAL ETT AT 24 LIP. A/C 8/800/.40/10 PEEP WITH STABLE ABG. MEASURED VO2 FOR CALCULATION OF CO VIA FICK EQUATION AND WAS 284 ML/MIN. VD/VT WAS .44 ON FULL SUPPORT. VENTOLIN MDI Q4. [**First Name11 (Name Pattern1) 107**] [**Name7 (MD) 108**], RRT ||||END_OF_RECORD START_OF_RECORD=15||||11|||| Neuro; Sedated on Propofol gtt, decreased to 28mcg/min, MSO4 gtt remains at 10mg/hr. HR, SBP increase with stimulation, otherwise not responsive to command Resp: FiO2 decreased to 30%, remains on A/C mode, sats >96%, except again, with stimulation of bathing, turning, he desats to mid 80's, mouth, tongue looking dusky CV: Remains in SB mainly 40's, although has dropped as low as 38 overnight, Diltiazem on hold, receiving Isordil, Hydralazine. BP stable. Afebrile GI: No audible bowel sounds, OG tube has drained almost 1 liter bilious fluid overnight. No stool Unable to perform CT scan d/t pt's weight. GU: Received Lasix 40mg IV, with fair response Ionized Ca++ remains low, receiving CaCl 8Gm in 400ml NS over 12hours Skin: Lt leg ulcer without change from previous documentation. Remains on Big Boy BariAir bed in rotate mode, skin otherwise intact Social: Pt's wife in to visit earlier in evening, no other conatct with family overnight ||||END_OF_RECORD START_OF_RECORD=15||||12|||| Pt's PA line D/C'd by HO, TLC passed via cordis with good blood return. PA tip sent for cx. ||||END_OF_RECORD START_OF_RECORD=15||||13|||| Resp Care Note: Pt cont on mech vent as per vent flowsheet. Lung sounds dim. MDI given as per order. No changes made this shift. Oral airway placed to prevent patient biting his tongue. ABG's stable. ||||END_OF_RECORD START_OF_RECORD=15||||14|||| Cardiac: B/P 120's/ most of the day but around 1600 pt started drifting down to the 100/ the around 1630 he dropped his B/P to 80's/. The propofol was dropped to 23 mcg/kg/min then 18 mcg/kg/min with some improvement in B/P. ABG showed resp acidosis so he was lavaged and suctioned and the ionized calcium was 0.9 so he was given 6 amps of calcium gluconate. By 1830 his B/P was 110/58. His HR slowly improved during the day to 60-62, and with stilmulation HR was as much as 70-80. Resp: vent settings unchanged, A/C 800x8 Peep 10, FiO2 30%. When he started to drop his B/P he also started to drop his O2 sats to 80's. FiO2 was increased to 40%. The lavage and suctioning obtained yellow secretions with old blood clots with improvement of sats to 93% but not back to the 96-98% from earlier this am. GI: Still with not bowel sounds, no flatus or stool. Some PO meds stopped due to non absortion. GU: U/O has been adequate today without lasix. BUN up to 154, creat to 6.6. No talk of dialysis yet. Neuro: Propofol decreased as stated above. The morphine was D/C'ed, in an attempt to improve GI absorption, and was started on ativan 2mg/hr (This was done at 1400 prior to drop in sats and B/P). Pt has yet to wake up, he does not respond to stimuli. ||||END_OF_RECORD START_OF_RECORD=15||||15|||| RESP NOTE:PT REMAINS INTUBATED AND VENTILATED WITH NO REMARKABLE CHANGES IN RESP STATUS.B/S DIMINISHED BILAT >ON RIGHT,SECRETIONS THICK BROWN/YELLOW BLOOD TINGED AT TIMES.PRESENT VENT SETTINGS AC/800/8/40% PEEP10 AND TOLERATING WELL,ABG"S AVAILABLE IN CAREVUE.WILL CONTINUE WITH VENTILATORY SUPPORT AND WEAN AS TOLERATED. ||||END_OF_RECORD START_OF_RECORD=15||||16|||| Resp Care Note: Pt cont on mech vent as per vent flowsheet. Lung sounds coarse sx for sm th tan. MDI's given as per order. Pt ABG @ beginning of shift w/ inc PaCO2. Inc RR to 10 to correct. Cont vent support. ||||END_OF_RECORD START_OF_RECORD=15||||17|||| Neuro: Sedated on Propofol and Ativan gtts, with activity, heart rate increases to 80's, desats to 70's settles back to baseline within minutes of being left undisturbed Resp: As above note, acidotic on rate of 8, improved with increase in rate to 10. Suctioned for thick tan-old bloody secretions q2-3hrs. BS coarse bilat. Sats slightly improved by this morning to 95-96% CV: Remains bradycardic except for when he's stimulated. SBP stable, although will also increase with stim to 180's. GI: Absent bowel sounds, now off MSO4 gtt, OG tube to LWS drained 1L bilious fluid, no stool. GU: Adequate urine output, no diuretics given overnight F/E/N: Continues hypocalcemic, replaced with additional 8Gm CaGluconate IV overnight, AM labwork pending. Needs nutritional status addressed Social: Telephone update to Mrs [**Known patient lastname 102**] x2 overnight ||||END_OF_RECORD START_OF_RECORD=15||||18|||| RESP NOTE:PT REMAINS VENTED AND UNRESPONSIVE WITH NO REMARKABLE CHANGES IN RESP STATUS TODAY.B/S DIMINISHED BILAT WITH SX FOR SMALL AMOUNTS TAN/PALE-YELLOW SECRETIONS DURING SHIFT.PRESENT VENT SETTINGS AC/800/10/40% PEEP10 AND TOLERATING WELL.ABG"S AVAILABLE IN CAREVUE,WILL CONTINUE WITH VENTILATORY SUPPORT AND WEAN AS TOLERATED. ||||END_OF_RECORD START_OF_RECORD=15||||19|||| Resp Care Note: Pt cont on mech vent as per vent flowsheet. Lung sounds coarse. MDI's given as per order. No changes made this shift. Cont mech vent support. ||||END_OF_RECORD START_OF_RECORD=15||||20|||| Neuro: Remains on Propofol, Ativan gtts, eyes flutter with stimulation, HR, SBP rise as well. Resp: No vent changes made overnight. Episode during turning side to side when pt became difficult to ventilate, ambued on 100% briefly with resolution. BS coarse, suctioned for thick tan, old bloody sputum CV: SB 40's except when aroused, HR up to 80's GI: Unsuccessful attempts at oral, bilat nare insertion of NG tube. Pt began to bleed profusely from both nares, required loose packing with Gelfoam with effect. Hct stable, Dr [**Last Name (STitle) 105**] paged to bedside to assess, no further intervention at this time. GU: adequate urine output overnight F/E/N: NPO, unable to insert NG tube as noted. Remains hypocalcemic despite what have been continuous Calcium Gluconate infusions. Nephrologist following, anticipate initiation of hemodialysis today Skin: Open area on upper back covered with Tegaderm dsg. Lt leg ulcer dsg changed, scant yellow drainage Social: Pt's wife in to visit briefly during evening ||||END_OF_RECORD START_OF_RECORD=15||||21|||| RESP NOTE:PT REMAINS SEDATED AND VENTED WITH NO REMARKABLE CHANGES IN RESP STATUS TODAY.NO VENT CHANGES MADE,ABG"S AVAILABLE IN CAREVUE.B/S DIMINISHED BILAT WITH SX FOR SMALL/MOD AMOUNTS THICK YELLOW SECRETIONS, BLOOD TINGED AT TIMES.WILL CONTINUE TO MONITOR AND RE-ASSESS IN AM. ||||END_OF_RECORD START_OF_RECORD=15||||22|||| Resp Care Note: Pt cont on mech vent as per Carevue. Lung sounds dim & coarse. Sx mod th tan. MDIs given as per order. No changes made this shift. Pt has had episodes of dropping O2 sat transiently for no apparent reason but rebound without intervention. Pt scheduled for trach today. Cont mech vent support. ||||END_OF_RECORD START_OF_RECORD=15||||23|||| review of systems respiratory-> pt continues to to be intubated and vented on ac 10x800 w/peep5 on 40% fio2. he remains on propofol and is not breathing over the vent. he was suctioned x2 overnoc for small amts of thin, clear sputum. plan is to trach sometime later today. cardiac-> pt was less bradycardic tonoc w/hr 50-60, sb-sr; however, he was [**Last Name (un) 109**] hypotensive with sbp's less than 100 for much of the noc. he did not receive am doses of isordil or hydralazine. neuro-> sedated w/o any spontaneous movement. gi-> ogt was replaced and placement was confirmed by cxr. he had 20-50cc bilious residuals checked q4hrs overnoc. tube feedings were not resumed d/t potential trach placement. gu-> plan to dialyze again today. of note, ionized calcium level is down this morning. id-> less hypothermic last with tmin 06.2 orally. continues to receive abxs as ordered. ||||END_OF_RECORD START_OF_RECORD=15||||24|||| Resp. Care Note Pt remains intubated with 8.0ETT secured at 24cm lip. Ventilation supported on current settings A/C 700x 10x 40% peep 10. ABG on these settings 73/53/7.36/31/+2. TV decreased today from 800-700cc to allow PaCO2 to return to Pt's baseline of around 60. Cont to receive Albuterol and Atrovent MDI's Q vent check. Sxn for sm-mod. amounts of pale yellow secretions. Decision made to defer trache a few days due to dialysis and coagulation parameters.. ||||END_OF_RECORD START_OF_RECORD=15||||25|||| NEURO--PROPFOL D/C'D DURING HYPOTENSIVE EPISODE IN HD. PT MIN RESPONSIVE, FURROWS BROW TO PAINFUL STIMULI, REMAINS ON ATIVAN 2MG/HR IV. CARD-- BP DOWN TO 86/ DURING HD THIS AM, HR INC 80-90'S. RECEIVED 2L TOTAL IN NS IVF BOLUS WITH LITTLE EFFECT. HD STOPPED AND BP IMPROVED SLIGHTLY. 3P BP AGAIN DOWN, AND RECEIVED 500CC NS WITH GOOD RESPONSE. ANTIHYPERTENSIVES ON HOLD. EKG DOWN WITH NONSPEFIC ST CHANGES, PULSUS CHECKED, NO PULSUS NOTED. BEDSIDE ECHO DOWN TO EVAL FOR UREMIA INDUCED PERICARDIAL EFFUSION, NONE NOTED. RESP--CONTS ON AC 10 PEEP 10 40% TV DECREASED TO 700CC TO HELP RETURN PC02 TO BASELINE. SX'D Q4 FOR THICK WHITE SPUTM. PLAN TO TRACH ON THURS, WIFE IN AND CONSENT OBTAINED. GI--OGT ASP BILIOUS AND OB(+). ABD WITH ABSENT BS. TF NEPRO RESTARTED AT 10CC/HR, TO HOLD FOR RESIDUALS >100CC. NO BM. GU--HD THIS AM AS ABOVE, PT DID NOT TOL. WILL ATTEMPT AGAIN TOMORROW. CA REMAINS LOW AND CURRENTLY ON CACL 8GM/400CC @33CC/HR INFUSION. WILL NEED ION CA RECHECKED AT END OF INFUSION. U/O DECREASED WITH HYPOTENSION TODAY, TEAM AWARE. SKIN--DERM IN TO SEE PT'S FEET TODAY. PT HAS ELEPHANTIASIS. NEEDS COMPRESSION STOCKINGS TO TREAT, ALSO METROGEL BID. PT MOST LIKELY NOT STOCKING CANDIDATE DUE TO STAGE 2-3 ULCER ON LEFT ANKLE. WILL CONSULT OT AND SKIN CARE RN. HEME--INR REMAINS ELEVATED, WILL RECEIVED IV VIT K. SOCIAL--PT'S WIFE IN TO VISIT, UPDATED ON EVENTS OF TODAY. ||||END_OF_RECORD START_OF_RECORD=15||||26|||| Resp Care Note: Pt cont on mech vent as per Carevue. Lung sounds coarse & dim. Sx sm to mod th tan. MDI's given as per order. Pt not breathing over vent despite adjusting vent to yield a "normal" PaCO2 for this patient. Cont vent support. ||||END_OF_RECORD START_OF_RECORD=15||||27|||| systems review: neuro: patient remains sedated on ativan 2mg/hr. responding to painful stimuli. bp and hr up/o2sat falling with activity. cv: bp at 11pm in the 90's systolic. 90-140/ overnight. bp up to 140's with suctioning/turning, etc. hr mid 70's-100, no ectopy noted. calcium continues to be low, free ca 1.00 during the night. continues to get 500cc/8amp bag currently. will recheck with am labs. resp: conts on a/c peep10, 700x10, 40% fio2, not breathing above vent. pc02 rising as per plan to get him to start breathing on his own. abg overnight 81/59/7.31/31. ambued/lavaged and suctioned x1 for sm amts of white thick secretions. plan remains for trache thursday. gi: hypoactive bs heard. tube feeds off at begin of shift >120cc in belly, refed w/po meds. no residuals at 3am, nepro restarted at 10cc/hr, to advance s tolerated. ob+ aspirates/pH of 2 noted. gu: u/o 30cc/hr cl yellow urine. id: conts on clindamycin. a febrile this am. tmax 100.0 po at midnight. social: no calls overnight. ||||END_OF_RECORD START_OF_RECORD=15||||28|||| Resp. Care Note Pt remains intubated and vented on settings A/C 700x 10x 40% peep 10. Attempted to decrease rate to 8 today but Pt became to acidotic so rate back up to 10. cont to receive Albuterol and Atrovent MDI's Q vent check. Sxn for sm. amount white secretions. Plan is for trache possibly on Friday. ||||END_OF_RECORD START_OF_RECORD=15||||29|||| RESP CARE, PT. REMAINS INTUBATED ON A/C 10/700/.4/10PEEP. NO ABG. SAT 95%. RESTED COMFORTABLY, NO VENT CHANGES. ||||END_OF_RECORD START_OF_RECORD=15||||30|||| Reveiw of Systems: Neuro: Pt more awake than yesterday. Opens eyes to voice/stimulus. Occasionally moves fingers, but does not follow commands at this point. Pt becomes hypertensive/tachycardic with suctioning/turning. CV: Pt heart rate Sinus rhythm. Blood pressure stable at 130-140/70-80's. Pt is afebrile. Resp: No vent changes were made today. Pt is not taking spontaneous breaths. Suctioning scant amounts of yellow thick secretions from OETT. Trach is postponed until Monday due to elevated BUN, and bleeding from dialysis access. GI: Tube feedings restarted at 5pm. Nepro at 10 cc/hr. Advance at tolerated. No BM today. GU: Dialysis done today. Pt. tolerated well. 1kg removed. Urine output unremarkable. Will continue dialysis 3x a week. Undecided if pt will be dialyzed in am. IV: IV therapy evaluated for PICC today. They will come attempt a PIIC in am. IV therapy recommends PICC placement under Floro; however, ICU team wants therapists to attempt PICC placement in room first. Family: Wife called, daughter called. They are going to try to come in this evening. SKIN: Derm consult in today to biopsy feet. Orders for foot care in chart. ||||END_OF_RECORD START_OF_RECORD=15||||31|||| Respiratory Care Note Pt remains on Assist Control 700x10 PEEP 10 40%. Pt rxd x3 with 4 puffs Combivent MDI. Sxnd x 3 for scant amounts of yellow/white secretions. BS coarse t/o day with scattered expiratory wheezes. No changes in BS post rxs. Pt more awake today, opens eyes to commands. Will change vent settings when pt is ready. Will continue to support as ordered. ||||END_OF_RECORD START_OF_RECORD=15||||32|||| Resp Care, Pt. remains intubated A/C 700/10/.4/10peep. ABG 7.29/59/67/30. Suctioned small amount yellow sputum. No vent changes, see vent flowsheet. ||||END_OF_RECORD START_OF_RECORD=15||||33|||| NPN 7p-7a: S/O: pt cont on A/C 700 x 10/.40 peep 5... rarely overbreathing.. sats 91-90%, but with acceptable PO2's per team.. slightly more acidotic, however abg sent after bath, when pt had been aggitated, popping off.. will resend. pt with episodes of pap 50.. poping off vent.. sx, bagged and lavaged for thick yellow secretions..Also hypertensive, bp 170's-100... team aware.. did not resolve with ativan 2mg iv x 2.. med with usual hydralazine and haldol with good effect. Pt also with cont oozing of brb from dialysis line... pooling on chux under site... team aware, hct stable.. no blood products at this time.. also with coffee grounds out of ogt.. team aware. ? most likely r/t bleeding in oropharynx. awake and answering questions appropriately by nodding... A/P: pt wide awake, appearing uncomfortable, popping off vent. also hypertensive, cont with bleeding.. ? next dialysis run... will need to follow hct, abg's... to have trache on Monday.. will need sedation better managed until that time. ||||END_OF_RECORD START_OF_RECORD=15||||34|||| Respiratory Care Note Pt continues on AC 700x10 PEEP 10 40%. Pt sxnd x4 for small amounts of white/clear sputum. Pt also rxd x 2 with combivent MDI. PIPs remain high 35-61. Plat pressure also high 32-38. Pressures do not change post sxn and rxs. MICU team aware. Trach still scheduled for Monday. ||||END_OF_RECORD START_OF_RECORD=15||||35|||| Resp. care note: Pt continues to be ventilated on AC 700/10/40% +10. No changes made this shift. Pt suctioned for a moderate amount of yellow secretions. Breath sounds slightly course and decreased in the bases. plan is for a trach possibly on monday. for further information refer to carevue charting. ||||END_OF_RECORD START_OF_RECORD=15||||36|||| NPN 7p-7a: S/O: Cx w/u completed... new R SC central line placement confirmed, and blood cx with fungal isolator sent from this line. Also new aline placed and old aline removed and tip sent for cx. Vent settings unchanged.. A/C 10 x 700/peep 5/.40.... overbreathing 1-4x/min.. sx for minimal secretions x 2. wide awake at times, able to nod appropriately to questions. nodding "no" when discussed giving him medecine to help him sleep.. states he is comfortable. abg slightly acidotic.. no changes at this time. Cont with skin care as outlined in med sheets. remains hemodynamically stable. minimal bleeding at dialysis line site. A/P: stable o/n. follow cx data, cont abx. cont skincare. to have trach placed on Monday. ||||END_OF_RECORD START_OF_RECORD=15||||37|||| PMICU NURSING PROGRESS review of systems CV- have been stable, even throughout dialysis.hydralazine and isordil as ordered.bp has been 130-160/ and hr has been 78-48 SB with no ectopy noted. RESP-no changes made on vent-remains on a/c rate of 10 x 700ccs x 40% with 5 peep.overbreathes vent rate 5-10.sx a few times for thick light tan secretions.lungs sound coarse anteriorally.CXR done 3 pm. NEURO-is responsive to voice, opened eyes and responds appropriately to questions, follows commands (lifts legs,etc.)states he is comfortable.no sedatives given GI-tube feeds on hold,? will start TPN tommorrow.small amts aspirates from ogt, bilious.on zantac ID-afebrile.WBC=16.2.iv clinda d/cd after nasal packing removed.tx with 1 dose iv vanco after dialysis today. BC with 1 bottle (a-line) positive for gm+ cocci in pairs. F/E-was dialyzed for ~3 hrs today-received epogen during tx.still with tremendous peripheral edema.please see labs as listed in carevue-on phoslo as ordered. HEME-hct this am=31.9.plts 190.nasal packing removed without any bleeding-no apparent bleeding anywhere. SKIN-soaks and dressings done-no change a- stable,no change p-next dialysis planned for monday.no vent changes at this time.?trach planned for monday-will need ddavp. ||||END_OF_RECORD START_OF_RECORD=15||||38|||| resp. care note: pt received intubated with a #8 ett secured at the 24 cm mark at the lip. pt also ventilated with the current settings: ac 700 x 10 peep 10, and 40% fio2. pt received routine ventilator management t/o the shift, as well as suctioning was performed when needed. all is well at this time. [**Name7 (MD) 110**] rrt ||||END_OF_RECORD START_OF_RECORD=15||||39|||| No vent changes this shift, pt. on AC 700x10/10/40%. BS exp wheezes intermitantly t/o shift, tx'd with 10 puffs combivent q4. No ABG's, CXR still pending, will follow. ||||END_OF_RECORD START_OF_RECORD=15||||40|||| systems review neuro: more awake. follows commands. mae. cv: bp 150-160's ovrenight. received hydralizine/isordil as ordered. hr 45-90's sinus brady no ectopy noted. ionized ca overnight 1.10. k 4.2 this am. resp: remains vented on a/c 700x10 fio2 40%. no vent changes made. suctioned x2 for thick lt yellow secretions. gi/gu: tube feeds remain on hold. port saved for tpn. urine collection begun for 48 hour creatnine clearance. bun/creat down this am 88/3.4. id: afebrile. wbc 11.2 from 16. received one time vanco dose last eve. skin: soaks/ointments applied to bilat feet. bacitracin dressing to ll leg. feet look improved. cont care as ordered. social: no calls ||||END_OF_RECORD START_OF_RECORD=15||||41|||| RESP. CARE: PT RECEIVED WITH A #8 TRACH FUNCTIONING PROPERLY. PT BEING MECH VENTILATED , CURRENT SDETTINGS ARE: SIMV 14 VT 600, PEEP 5 PSV 10, AND 40%. PT TAKEN FROM VENT AT 9 AM,ON 4LPM W/O DISTRESS. GENERAL TRACH CARE GIVEN MEDNEBS GIVEN, AND ALL IS WELL AT THIS TIME. [**Name7 (MD) **] RRT ||||END_OF_RECORD START_OF_RECORD=15||||42|||| pmicu nursing progress 7a-7p review of systems CV-vs have been stable,bp a little on the high side. hydralazine was increased to 50 mgs qid. GI-abd is soft and large.has positive bowel sounds. no stool today-to start on colace. ID-afebrile.wbc=11.2 with L shift.random vanco level=9.3. no vanco given today.has had several blood cultures come back positive for gm+ cocci, and quinton cath positve for enterococcus.the quinton was removed and the tip sent for culture.also, 2 sets blood cultures were sent, 1 set from a-line and the other set was drawn peripherally. NEURO-his alertness continues to increase, he is much more interactive.tried to write but was too weak.no sedatives given. F/E-still with some peripheral edema. no dialysis today.has a good urine output.please see labs as listed in carevue.receiving phoslo as ordered.to start TPN tonight. HEME-pt was tx with 40 mcgs DDAVP,then the quinton cath was removed without incident.there was no excessive bleeding and the site was tx with gelfoam and then covered with tegaderm.his hct today=32.9. inr=1.2 SKIN-all soaks and dressings done. the L leg ulcer looks healed and I think maybe should be left open to air.noo change in other skin issues. RESP-pt was quite alert this am and his abg looked good and so we tried him on PSV. on PS of 15, 10 of peep and 40% his TVs were about 500ccs and his resp rate was 10.abg=70/57/7.33/31/1. we let him acclimate to the psv and in a few hours his abg=78/53/7.33/29/0.has been sx a few times for clear thick secretions.ETT retaped.tolerated this well.lungs sound clear on top and diminished at bases.has minimal oral secretions. a-stable day. p-will follow vs on increased hydralazine.next dialysyis planned for tommorrow-will need to have new line placed.check further culture results,vanco level.continue with good skin care.will rest overnight on his usual vent settings and ? trach in the am.have not heard any definitive word on this.? if he should be NPO after 12m. ||||END_OF_RECORD START_OF_RECORD=15||||43|||| RESP. CARE NOTE: PT RECEIVED INTUBATED WITH A #8 ETT SECURED AT THE 24 CM MARK. PT ALSO MECH VENTILATED, CURRENT SETTINGS ARE CPAP 10, PSV15, AND 40% SPONT. VT'S ARE 300-500, AND RESP. RATE RANGES FROM 14-24 BPM. PT RECEIVING COMBIVENT Q4HRS, AND PT BEING SUCTIONED WHENEVER NEEDED. ALL IS WELL AT THIS TIME. ||||END_OF_RECORD START_OF_RECORD=15||||44|||| Pt. remains intubated c/ no sedation. Currently on CPAP/PSV 12/10/40% drawing tidal volumes of 350-560 spontaneously, RR 16-24. Combivent MDI's q4Hrs. Sxn'd for sm. amts thin white x1 during shift. Last ABG 76/56/7.34 after decreasing PS from 15 to 12. Tolerating well at this point, plan is to wean on days. ||||END_OF_RECORD START_OF_RECORD=15||||45|||| patient remains vented, tolerating psv overnight. decreased ps to 15/peep remains at 10, 40% fio2. rr 15-22, stv's 490-550. abg this am, 86/54/7.34/30. ?may try further weaning today. vs. trach placement anyway with severe sleep apnea. vss overnight. tolerating hydralizine/isordil doses. a febrile. tpn infusing via tlc. hibiclens soaks to feet w/ointments applied. feet continue to look improved. continue bacitracin to L leg wound. patient continues to be alert/interactive. asking for something to eat overnight, explained tpn infusing and him not being able to eat while ett is in. cont to follow culture results, resp status. ?trache placement today. ||||END_OF_RECORD START_OF_RECORD=15||||46|||| PT status unchanged from this am. New MICU team following patient today. Pt's case discussed on rounds today. Main topics were tracheotomy and tube feedings. Team decided to try weaning PEEP today. Pt did not tolerate weaning. ICU team discussed trach in am. Will also attempt TF after trach. Pt is alert. Mouths words. Right side appears stronger than left. Pt's wife in to visit with patient. Team discussed trach with pt and pt's wife. ||||END_OF_RECORD START_OF_RECORD=15||||47|||| Patient remains intubated on PSV 12/10, Vt 450-500, rate 15-18. Sux for mod amts of yellow sputum. Rx with Combivent Q4 hours. Weaned Peep to 5 cm, Vt decreased to 250-300, Resp Rate increased to 35-38. Increased peep to 10. Will attempt to decrease Peep and PS later this evening. [**Name7 (MD) 111**], RRT ||||END_OF_RECORD START_OF_RECORD=15||||48|||| resp. care note: Pt was changed to simv+ps 700/10/40% 12/+10; secondary to pts resp. rate in the 30's, desaturation, and tidal volumes 230-320. Pt tolerated simv well. Pt suctioned for a large amount of thick tan secretions. Pt given combivent mdi x3. plan is for trach possibly today. for further information please refer to carevue charting. ||||END_OF_RECORD START_OF_RECORD=15||||49|||| Pt. remains in intubated with slowly improving resp. and renal failure. Neuro: Pt. alert this whole night, taking small naps. Pt's right hand restrained because pt. keeps reaching for ett when left unrestrained and making a gesture to pull out the ett. Pt. asked if he wants the tube out and he nods his head "yes", pt. informed that he will have the tube taken out sometime later today and have tracheostomy placed. Pt. appears to understand what is being said and nods appropriately to yes/no questions. Attempts to mouth words asking to eat, and drink. Pt. very restless numerous times trying to bend himself so that he can reach ett. Dr. [**First Name8 (NamePattern2) 112**] [**Name (STitle) 113**] aware and in to talk with pt. Pt. medicated with 2mg iv ativan x2 with minimal effect. Resp: Received pt. on ps ventilation, however had increased resp. rate in the 30's with tidal volumes in the 270-300 range. Pt. also appeared tachypnic. Dr. [**Last Name (STitle) 114**] aware. Decision made to rest pt. on simv over night. ABG done on SIMV 10 +10 TV 700 40% WNL, see careview. Dr. [**Last Name (STitle) 115**] aware of abg. SPontaneous tidal volumes remain in the low 290-300 range. PT. is suctioned q2 for thick white/tan secretions via ett. Lungs are very coarse. CV: BP stable, NSR, pt's hr is elevated to 120 when he needs to be suctioned. GI: active bowel sounds, abdomen obese, no stool. Currently on tpn and pt. npo except meds for possible trach sometime today. GU: 48 hour urine sent for creatine clearance. Voiding adequate amounts of amber colored urine. Skin: Skin care done as ordered. Wife called and asked what times the tubes will be out today. See careview for further details. ||||END_OF_RECORD START_OF_RECORD=15||||50|||| Resp: Maintained on SIMV 700 x10 Peep 10 today for the trach today. Suctioned x2 for scant amt of tan secretions. Bedside trach started at 1430 and proceded without difficulty, he recieved 140 mcg propofol, MSO4 10 mg and vecuronium 4mg IV for the trach. Pt did have more bleeding than normal so he was given 40mg of DDAVP following the procedure. Cardiac: B/L 150-160/70's, HR 90-100 SR. GI: Pt remains NPO for trach. Following the trach he can be trialed on tube feedings again, his bowel sounds are the most active I have heard and he is C/O being hungry. Start Nepro at 10cc/hr and get a nutrition consult for a goal. No stool, He can get a dulcolax supp this evening and lactulose to help him to stool. GU: renal fellow unable to get quinton catheter in pt this am for dialysis. Transplant Resident to come later and place catheter, plan for dialysis tomorrow. U/O ~75-100cc/hr. Neuro: pt awake and alert, Helping with AM care. Moving his right side more than left. Social: wife called for an update following the trach. ||||END_OF_RECORD START_OF_RECORD=15||||51|||| Picked up pt shortly after trach was performed at the bedside and found site to be bleeding a lot. I changed the trach sponges for saturated with blood three times in the first 90 minutes and called the team to evaluate pt. Stat clot to BB was sent as well as stat crit. Pt had bronchoscopy to evaluate the bleeding and medical team ended up calling surgery. The bleeding was not able to be put under control despite pt getting two doses of DDAVP and suturing at the site. The decision was maed to take out the trach and try to control the bleeding. He was reintubated orally and the trach was taken out after which he proceeded to bleed more quickly. Pt was sent to the OR for emergent trach exploration and closure. He is due back any moment. ||||END_OF_RECORD START_OF_RECORD=15||||52|||| (Continued) her details. ||||END_OF_RECORD START_OF_RECORD=15||||53|||| Resp Care: Pt received from OR after trach, placed on ventilatory support with A/C 700x10 fio2 weaned down to .5 and +10 peep with acceptable abg; BS rhonchorous, sxn bloody secretions, rx with mdi combivent q vent check, see carevue for details. ||||END_OF_RECORD START_OF_RECORD=15||||54|||| Pt's BP and MAP after receiving 4U PRBC's did not improve. Dr. [**Last Name (STitle) 116**] made aware, and pt. started on dopamine to titrate for a BP ranging 110-130. ||||END_OF_RECORD START_OF_RECORD=15||||55|||| REVIEW OF SYSTEMS- NEURO- REMAINS SEDATED ON PROPOFOL AND MSO4 DRIPS AS PER FLOWSHEET. CARDIAC- CONTINUES ON DOPA AT 1-3MCGS/KG/MIN TO KEEP SBP 110-130. SURGERY DOES NOT WANT SBP TO GO ABOVE 130 DUE TO BLEEDING. HR 59-80'S SB TO NSR WITH RARE PVC. K3.2 THIS AM WAS TO GET 40MEQ PER NGT REPEAT K 4.0 KCL NOT GIVEN DR [**Last Name (STitle) 117**] AWARE. MG LEVEL 1.6. ORDER WRITEN FOR 2GMS MAG IV. NO PORT TO RECEIVE THIS IN. DR [**Last Name (STitle) 117**] AWARE. TO GIVE IF CAN WEAN DOPA TO OFF. IONIZED CA TO BE CHECKED WITH NEXT ABG. # 8 TRACH IN PLACE AS WELL AS PACKING. NO NEW BLEEDING. RESP- REMAINS ON AC 10 BREATHING 10. TO HAVE FIO2 WEANED TO 40% RESP AWARE. ABG TO BE CHECKED. SUCTIONED FOR THICK OLD BLOODY BROWN SECRETIONS. SATS 96-100% ON 50% FIO2. BS COARSE. GI- ABD OBESE BS PRESENT. NGT CLAMPLED. RETURNS FROM NG BILIOUS. GU- FOLEY PATENT. URINE FROM 5-35 CC/HR. NEW LEFT SUBCLAVIAN QUITON PLACED BY SURGERY. CXR DONE. HD NOTIFIED. INTERN TO CALL RENAL FELLOW TO SEE IF THE PATIENT WILL BE DIALYZED TODAY. QUINTON SITE W/O BLEEDING OR HEAMTOMA. HEME- HCT 24.1 THIS AM. REPEAT AT 0900 S/P 4U PRBC PATIENT RECEIVED LAST NIGHT 30.9. REPEAT HCT TO BE CHECKED AT 1PM OR BEFORE THE PATIENT GOES ON HD. SOCIAL- NO CALLS FROM FAMILY THIS AM. ||||END_OF_RECORD START_OF_RECORD=15||||56|||| Patient ventilated throughout the shift on AC 700 X 10, 10 Peep, 40 %, Peep increased to 12 resulting in ABG of 75/61/7.32. Suctioned for small to mod amounts of thick bloody sputum. No weaning attempted this shift, to reevaluate patient in am for weaning. No bleeding at trach site. combivent 6 puffs Q 4 hours, breath sounds coarse, decreased bilat. no change post rx. ||||END_OF_RECORD START_OF_RECORD=15||||57|||| PMICU NURSING PROGRESS NOTE 11P-7AM NEURO: propofol gtt 5.62mcg/k/m. Mso4 gtt 2mg/h. Arousable, able to communicate. Follows commands inconsistently. Keeps asking to go home, will cont to explain plan for rehab. CV/Pulm: cont on sm amt of dopamine gtt. SBP 92-110. HR 70-80's. Vent A/C, rate inc to 12. ABG 99/49/7.38. LS coarse w/ min secretions. Trach site cont to ooze blood, but clot visible at opening. GI/GU: tpn continues. no stool noted. U/O sufficient. +3300 at midnight. Social: wife called x 2. ||||END_OF_RECORD START_OF_RECORD=15||||58|||| resp. care note: pt received with a # 8 trach functioning properly, pt also mech ventilated: current settings are ac 700 x 12, peep 10, and fio2 40%. pt received general ventilator management as well as suctioning t/o the shift. with each ventilator check, pt received 6 puffs of combivent. all is well at this time. ||||END_OF_RECORD START_OF_RECORD=15||||59|||| patient remains trached, alert this am. bp labile this am in the 90's sys range. dopamine/propofol and morphine all off together ~1030. bp has been 120-140's/sys since. trache site oozing sm amt blood changed x1 today w/am care. hct 29.4 this am. patient switched over to psv 15/peep10, abg 97/62/7.29. ps increased to 20 yielding 131/54/7.34. mv essentially unchanged on ps of 15 vs. 20. rr 9-12, stv 550-900. sats 98-100%. receiving hd this afternoon, has tolerated well thus far. patient alert today, able to assist somewhat with am care. pt does have difficulty w/strength in l arm. cannot lift off bed. team is aware. restraints off this am, pt has been cooperative in not pulling at lines, etc. ||||END_OF_RECORD START_OF_RECORD=15||||60|||| Paitent weaned to PSV 20/10 , 40%, Vt 650-700, rate 13-16, tol well. Breath sounds coarse rhonchi, suctioned for copious amounts of bloody thick sputum. Continue to wean, evaluate for rehab in am. ||||END_OF_RECORD START_OF_RECORD=15||||61|||| Resp Care Note: Pt cont trached on mech vent as per Carevue. Lung sounds coarse w/ rhonchi improving w/ suct for large amts th bloody sput. MDI given as per order. Pt cont to do well on PSV and currently in NARD. Cont wean w/ PSV. Pt awaiting placement. ||||END_OF_RECORD START_OF_RECORD=15||||62|||| Neuro: Pt. remains awake most of night, despite encouraging him to rest. Denied a sleeping pill, and denies any discomfort or pain. Able to move R side well, however he is very weak on the left side. Resp: Remain on PSV with good o2 sat's and tidal volumes and acceptable resp. rate in the teens. Lungs are coarse, and being suctioned frequently for thick, copious amounts of blood tinged secretions. CV: BP stable, NSR-ST, afebrile. GI: Received will on tube feeds at 10cc/hr, however when residuals were checked at MN, had increased amounts of residuals. Tube feeds stopped. Pt. had a large liquid brown stool, fecal bag applied. Active bowel sounds. Remains on tpn. GU: voiding small amounts via foley. HEME: pt. given one unit of PRBc for hct of 28. Post transfusion hct will be done with am labs. Pt. continues to ooze from r am heparin injection site, and also from the nare that has the ngt, and from around his trach. Dr. [**Last Name (STitle) 118**] aware. See careview for further details. ||||END_OF_RECORD START_OF_RECORD=15||||63|||| Pt condition unchanged. Vital signs stable. Pt alert and oriented. No c/o pain. Pt having continuous liquid brown stool. Tube feeding restarted at 1500. Plan is to monitor coagulopathy, continue to wean patient vent settings as tolerated, and transfer to rehab facility when tolerating tube feedings. ||||END_OF_RECORD START_OF_RECORD=15||||64|||| Resp Care remains trached/vented ..mode today remains psv,.level weaned slightly now back up to 20 for noc. present settings 20/10/40%. bldy sputum. bronched by dr. [**Last Name (STitle) 119**] .combivent q4h. c/w slow weaning. ||||END_OF_RECORD START_OF_RECORD=15||||65|||| Resp Care Note: Pt cont trached on mech vent as per Carevue. Lung sounds dim. MDIs given as per order. Pt with apnea on PSV switched to SIMV. Pt had good Vt on PSV but RR dropped to 3 at one point. Since pt trached pt may have central component to his apnea. Cont mech vent. Could possibly tol BiLevel w/ BU RR. ||||END_OF_RECORD START_OF_RECORD=15||||66|||| Neuro: Pt. alert and cooperative. Nods head appropriately, and cooperates in his care. Pt. sleeping most of the night. RESP: Received on ps20 +10, 40%. Rate in the teens-twenties with good tidal volumes, ABG @ MN WNL (see careview). After pt. fell asleep, ventilator began to frequently alarm low exhaled tidal volume, and apnea with a resp. rate around [**02-02**]. Dr. [**Last Name (STitle) **] and [**Doctor Last Name **] aware. Decision made to place pt. on a back up SIMV rate. Will check abg with am labs. Lungs are coarse, with occ. wheezes, suctioned for thick blood tinged secretions via trach. Trach site with very minimal oozing of blood. CV: BP stable, NSR-SB, no ectopy noted. GI: Tolerating tube feeds at 10cc/hr. Will advance slowly due to past history of increased residuals. GU: voiding via foley. SKIN care done. Pt. resting comfortable throughout night. K am MN on abg 5.9, Dr [**Last Name (STitle) **] aware, and repeated 4.9. See careview for further details. ||||END_OF_RECORD START_OF_RECORD=15||||67|||| RESP NOTE:PT REMAINS TRACHED AND VENTED WITH NO REMARKABLE CHANGES IN RESP STATUS TODAY.SEVERAL ATTEMPTS AT WEANING TODAY,HOWEVER, PT NOT TOLERATING AS APNEA MODE WAS TRIGGERED AFTER A FEW MINUTES WITH EACH TRIAL.MOD AMOUNTS BLOOD TINGED SECRETIONS SX DURING THE SHIFT,B/S DIMINISHED BILAT,SATS MAINTAINED 99-100%.ONE LAST ATTEMPT AT WEANING TODAY IS SUCCESSFUL THUS FAR WITH PT TOLERATING PS20 PEEP10 40%,WILL CONTINUE TO MONITOR AND WEAN AS TOLERATED. ||||END_OF_RECORD START_OF_RECORD=15||||68|||| NEURO: PATIENT AWAKE AND ALERT. SLEEPING IN NAPS. ORIENTED X3. ABLE TO COMMUNICATE NEEDS WITH MOUTHING OR WRITING WORDS. ANSWERING APPROPIATELY TO YES/NO QUESTIONS. MOVING LEGS, AND RIGHT ARM ABOVE HEAD. MINIMAL MOVEMENT IN LEFT ARM, ABLE TO MOVE FINGERS. FOLLOWS COMMANDS. CARDIAC: PATIENT INITIALLY WITH HR IN THE 50'S-60'S BUT ONCE DIALYSIS STARTED HR DROPPED TO 40'S AND AS LOW AS 39. NO ECTOPY NOTED. PATIENT IN A SB/SR. P WAVES VISIBLE. ONCE DIALYSIS STOPPED HR BACK TO 60 WITH OCCASIONAL DIP TO 40'S BUT HAS NOW SETTLED IN THE 60'S. BP STABLE VIA ART LINE 107-148/52-84. TOLERATING CARDIAC MEDS. GOAL IS TO KEEP SBP ~120'S. NO PITTING EDEMA NOTED. D/C'D PHOSLO AS PO4 WAS 2.5. RESP: RECEIVED PATIENT ON IMV RR 12 PS 20 PEEP 10 40%. PATIENT NOT OVERBREATHING VENT AT THIS TIME. CHANGED BACK TO CPAP 20/10 40% WITH ABG 112/58/7.31/31 RR WAS [**03-05**] WITH TV 800'S. CHANGED BACK TO IMV RR 14 AND ABG 116/44/7.40. RR WAS DECREAED TO 12. PATIENT NEVER OVERBREATHING VENT. WEANING AGAIN TRIED THIS EVENING AND SO FAR PATIENT IS TOLERATING . NO APNEIC EPISODES. RR 8-12. TV'S 800-900 SATTING 100%. LS CLEAR TO COARSE AND DIMINISHED BASES. SXT FOR MOD AMOUNT OF THICK BLOODTINGED SPUTUM. GI: ABD OBESE. BS+. BROWN LIQUID STOOL. RECEIVING TPN @83CC/HR. ZANTAC AND REGLAN IN FORMULA. ALSO RECEIVING PROMOTE WITH FIBER AT 10CC/HR. NGT IN PLACE. UNBALE TO ASPIRATE RESIDUALS AS THIS NGT IS SOFT AND COLLAPSES WHEN ASPIRATED. GI: DIALYZED X3.5 HRS FOR 1.5L OFF. TOLERATED WELL EXCEPT FOR BRADYING DOWN. U/O 30-80CC/HR OF YELLOW CLEAR URINE. ID: TMAX 96.8 PO. EMYCIN D/C'D CONTINUES ON AMPICILLIN. SKIN: BILAT FEET ROUGH HIBICLENS SOAK AND LOTRIMIN APPLIED. LEF ANKLE SHIN WITH 2 ULCERS, BOTH PINK WOUND BASE AND SMALL AMOUNT OF YELLOW DRNG. BACITRACIN APPLIED AND COVERED WITH DSD. MID UPPER BACK WITH ABRASION OPSITE COVERING. ACCESS: LSC QUENTIN, RSC CL, R ART LINE. SOCIAL: WIFE IN AND UPDATED. PATIENT IS A FULL CODE. BELIEVE PATIENT WAS SCREENED BY [**Hospital **] REHAB TODAY. ||||END_OF_RECORD START_OF_RECORD=15||||69|||| Pt assessment unchanged from previous shift. Pt rested well throughout night. Large hematoma noted around left subclavian dialysis access. Dr. [**Last Name (STitle) 120**] notified. 3+ edema noted in left arm. Chest x-ray needs to be ordered. RN spoke with patients wife about transfer to rehab facility. Questions answered. ||||END_OF_RECORD START_OF_RECORD=15||||70|||| Dr. [**Last Name (STitle) 114**] in to examine left shoulder/arm edema. Ultrasound ordered. ||||END_OF_RECORD START_OF_RECORD=15||||71|||| RSP NOTE:PT REMAINS TRACHED AND VENTED WITH NO REMARKABLE CHANGES IN RESP STATUS TODAY.B/S DIMINISHED BILAT WITH SX FOR SMALL/MOD AMOUNTS THICK TAN SECRETIONS DURING SHIFT.ATTEMPTED WEANING PS A BIT TODAY,HOWEVER,PT DID NOT TOLERATE(SEE ABG IN CAREVUE)RETURNED TO PREVIOUS SETTING.PRESENT VENT SETTINGS CPAP7.5 PS20 FIO240% AND TOLERATING WELL.WILL CONTINUE WITH PRESENT COARSE AND WEAN AS TOLERATED. ||||END_OF_RECORD START_OF_RECORD=15||||72|||| Resp Care Note: Pt cont trached on mech vent as per Carevue. Lung sounds coarse. MDI given as per order. No changes made overnoc. Pt tol PSV w/ flow-by well. Cont wean w/ PSV. ||||END_OF_RECORD START_OF_RECORD=15||||73|||| Mr. [**Known patient lastname 102**] is unchanged from previous shift. He is alert and oriented. He slept about 2 hours continuously and then off and on for about 4 hours. Tube feedings infusing through ng tube. Breathing comfortably on current vent settings. No episodes of apnea through night. He has a strong cough and able to get secretions up. Mr. [**Known patient lastname 102**] has been excepted at [**Hospital 30**], awaiting consent to discharge from medical team. ||||END_OF_RECORD START_OF_RECORD=15||||74|||| resp. care note: pt received with#8 trach in place and fully functioning. pt also mech. ventilated, current settings are: psv 20, and peep 5, fio2 30%. pt resp. rate varies 12-20bpm,while his vt's are 450-650cc's. pt received general ventilator management, as well as suctiong and inhalers t/o the shift. all is well at this time ||||END_OF_RECORD START_OF_RECORD=15||||75|||| Neuro: Awake and cooperative most of the shift. Had a few short naps. Pt c/o discomfort in the left shoulder and weakness in his arm. At first he refused to turn to get clean sheets under him at 9PM but then let me do it. Pt given tylenol with slight effect. Arm is swollen, elevated on a pillow. Cardiac: Stable vital sugns. Resp: No weaning this evening. Suctioned a few times for thick tan sputum. Remains on PSV 20 with 5cm peep. Lungs are coarse and intermittently wheezes noted. GI: Tube feeds advanced to 45cc/hr. Goa; is 80 cc/hr I think. Low residuals noted. Continues on the TPN but rate decreased to 52cc/hr since he is getting some increased nutrition from the tube feeds. GU/Renal: Foley draining large amts clear yellow urine. Pt is tentatively scheduled for insertion of permacath on [**05-10**] so he needs to be NPO after MN on Tuesday night. ||||END_OF_RECORD START_OF_RECORD=15||||76|||| Resp Care Note: Pt cont trached on mech vent as per Carevue. Lung sounds dim. Suct mod th tan. MDIs given as per order. Cont wean with PSV. Pt awaiting placement. ||||END_OF_RECORD START_OF_RECORD=15||||77|||| PT CONT TO BE TRACHED/ON VENT, NO CHG'S MADE OVERNIGHT. PT SX FOR LRG AMT'S OF THICK TAN/YELLOW SECRETIONS OCC. LUNG SOUNDS COARSE AND DIMINISHED. PT REFUSED TURNING AND LEG DSG DEFERRED TILL AM. PT HYPERTENSIVE AT TIMES AND WILL SETTLE DOWN ON HIS OWN. PT ALSO ON ANTIHYPERTENSIVES TOLERATES WELL. CONT ON TUBE FEEDS TOL WELL. SM AMT OF LIQ STOOL. FOLEY CATH DRAINING GOOD AMT'S URINE. ||||END_OF_RECORD START_OF_RECORD=15||||78|||| patient remains stable trached on psv 20/peep5, 30% fio2. stv~600cc, rr 15-18. suctioned x2 over the day for thick pale yellow sputum. vss. patient remains afebrile. prelim blood culture from a line showing gm- rods. will await further data ?contaminant. per renal/surgery, surveillance blood cultures were drawn yesterday. if negative plan was for insertion of perm-a-cath. L arm continues to be swolen, pt unable to lift off of bed. hematoma/swelling around quinton persists. neuro in this afternoon to evaluate for ?nerve injury. pt/ot to come by later this afternoon to see pt as well. patient continues to be screened by rehab facilities, is amenable to go almost anywhere at this point. plan to cont w/u of l arm swelling, permanent dialysis catheter placement needed before he can go to rehab, no other active issues holding patient here. ||||END_OF_RECORD START_OF_RECORD=15||||79|||| Neuro: awake. Aggravated when I told him that the OR was put on hold. I later found out that the permacath will be done tomorrow but later than planned due to an unexpected renal transplant that needs to be done during that time slot. I have told him this. Pt had numerous visits from neurologists to assess the left arm weakness as well as PT and OT evaluations. He later had a visit from his wife and was very tired and slept on/off in naps after this. He is anxious to get going to rehab and keeps saying that he is going tomorrow. Cardiac: Stable except one dose of IV hydralazine was held at 6PM due to BP under the parameter of 100. HR in the 70's. BP 95-120. Renal: Pt had 3.3 liters fluid taken off today with dialysis and his UO is still OK 50-80/hr. Resp: No weaning tonight. Frequent suctioning for thick tan/pale yellow secretions. Lungs are coarse. GI: Pt on his tube feeds. No stool this shift. Fecal bag fell off and left off. He is NPO after MN for OR tomorrow. Heme: Surgery called late in the shift and asked for stat coags to be sent as well as a new clot to BB for type and screen. Both were done. If INR comes back >1.7 they want our intern to be called so he can order FFP prior to the OR. ||||END_OF_RECORD START_OF_RECORD=15||||80|||| Resp Care Note: Pt cont trached on mech vent as per Carevue. Lung sounds coarse. Suct mod th tan. MDI's given as ordered. No changes made overnoc. No periods of apnea noted this shift. Cont wean w/ PSV. ||||END_OF_RECORD START_OF_RECORD=15||||81|||| PMICU NSG PROGRESS NOTE: pt alert and oriented, cooperative with care and communicates well with writing and mouthing words.No movement of LUE or LLE noted, skin care done wit improvement noted over past few days. NPO for dialysis line placement in AM, labs sent. suctioned thick secretions, to be discharged to rehab after quinton placed for dialysis. Gm - rods noted in Aline culture futher identification pending. Still c/o L shoulder pain. ? from turning. Plan-quinton cath today. eval for rehab. follow cultures, lytes and neuro status. ||||END_OF_RECORD START_OF_RECORD=15||||82|||| S/O: Respir: Remains vented on PS-18(down from 20), FIO2 30%, spon RR 12-20, spon VT's 300-400, O2 sats 97-99%. L/S course bilat. suctioning q2hr for lrge amts thick light yellow sputum. C/V: BP 130-140/80, HR 80's NSR, no ectopy. Renal: Quinton cath in Left SC, left arm still extremely painful, ?'ing hematoma around cath. To have HD in AM, BUN/CRE 88/3.1. U/O50-100cc/hr. ID: Temp 99.4 PO max WBC-7.3. Positive BC's from one bottle drawn from A-line on the 11th. One set of cultures drawn perpher. A-line d/c'd. Additional set to be drawn by resident from Quinton cath. If cultures are negative will have a Permacath placed on Fri. GI: TF's were on hold for ? of Permacath placement, were restarted when Permacath palcement was placed on hold. Restarted back on 75cc/hr goal rate increased to 90cc as per Nutrition, will increase as tolerated. Social: Anxious and upset today due to delay in placing Permacath and being transfer out of the hospital. Was accepted by [**Hospital 121**] but cannot leave until after the Permacath is placed on Friday if the blood cultures are negative. Is also asking/wanting to go home. ||||END_OF_RECORD START_OF_RECORD=15||||83|||| RESP. CARE NOTE: PLAN IS TO TRY TO WEAN PRESSURE SUPPORT AS TOLERATED. PT IS AWAKE AND ALERT. PT SUCTIONERD FOR A MODERATE AMOUNT OF THICK YELLOW SECRETIONS. BREATH SOUNDS DECREASED WITH SCATTERED RHONCHI. PT AWAITING REHAB PLACEMENT. FOR FURTHER INFORMATION PLEASE REFER TO CAREVUE CHARTING. ||||END_OF_RECORD START_OF_RECORD=15||||84|||| Pt remains on unchanged vent settings. MDi's as noted. Sx mod thick white secretions. No weaning done this shift, plan on weaning as tol. ||||END_OF_RECORD START_OF_RECORD=15||||85|||| pmicu nursing progress 11p-7a mr [**Known patient lastname **] had a very uneventual night.no vent changes made,was sx a few times for small amts sputum.receiving mdis as per RT.O2 sats >95%.had a good urine output.next dialysis planned for today.afebrile on ampi. Skin care done,pt bathed.tube feeds at 75/hr, no stool.pt alert and interactive, enjoying his music.c/o L shoulder pain for which he was medicated with 2 mgs iv morphine with good results. a-stable, p-awaiting permacath and then placement ||||END_OF_RECORD START_OF_RECORD=15||||86|||| addendum micro just phoned to tell us mr [**Known patient lastname **] had a positive blood culture taken on [**05-08**], drawn from his r hand. was positive for gm + cocci in pairs and chains.team notified. ||||END_OF_RECORD START_OF_RECORD=15||||87|||| S/O: RESPIR: Remains vented on PS-13 down from 18, tolerating well FIO2 30%, RR 13-20. Suctioning q1-2hr for lrge amts thick/frothy white to light yellow sputum. L/S course bilat. ID: Additional BC's bottles positive for Enterococcus from [**05-08**], to obtain a TEE to check for vegitation. Temp 98.2 PO max, WBC 7.0. Awaiting results from new cultures drawn yesterday. No new antibx's added. Renal: Rec'd HD this morning tolerated well, BUN/CRE 94/3.4. Quinton cath remains in Left SC. ?ing when a Permacath will be able to be place secondary to positive blood cultures, will check the results from the PND cultures and Surg will have to make a decesion tomorrow. GI: TF's up to new goal of 90cc/hr tolerating well, no stool noted. Neuro: Very anxious to get out of Hospital and to rehab and to home. Awaiting what the decesion will be tomorrow about the Permacath. C/O'ing of pain from L shoulder. Social: Had a bed @ St A. but will need to be rescreened when a Permacath is place and is ready for transfer. ||||END_OF_RECORD START_OF_RECORD=15||||88|||| RESP CARE, PT. REMAINED ON CPAP IPS 13/.3/5PEEP OVERNOC. VT 600'S RR 15. SUCTIONED FOR LARGE AMOUNT FROTHY WHITE SPUTUM. COMBIVENT Q4, FLOVENT BID. CONT. TO WEAN AS TOL. ||||END_OF_RECORD START_OF_RECORD=15||||89|||| PMICU NSG PROGRESS NOTE: alert and cooperative, suctioned thin yellow secretions q 2-4 hours, lungs with diminished breath sounds, PS at 13 with TV 550-600. VSS, afebrile, started on bactrim IV for GNR from bld culture. Dialyzed yesterday. still awaiting permacath which is on hold due to + bld cultures. tolerated tf's at goal. Still c/o severe pain L shoulder. ? if plain films obtained yesterday. Plan-portacath and then to rehab. follow L shoulder exam and check x ray. ||||END_OF_RECORD START_OF_RECORD=15||||90|||| PT/RSD Attempted to see patient this afternoon. Pt very agitated, refusing to perform exercise in the bed and only agreeable to trying to sit at edge of bed. Unfortunately pt cannot sit at edge of bed because of manufacturer restrictions. Unable to treat patient today given above, will f/u [**05-15**]. Should consider other bed options in order to maximize pt's ability to move, at this time pt is very limited. Pager: #[**Pager number 122**] Time Frame: 3:15-3:45pm ||||END_OF_RECORD START_OF_RECORD=15||||91|||| NEURO: PATIENT A&OX3. FOLLOW COMMANDS. ABLE TO MOVE EXTREMITIES EXCEPT LEFT ARM 2NDARY TO PAIN IN SHOULDER R/T HEMATOMA. OFFERED MSO4 THAT PATIENT REFUSED, GIVEN T#3 WITH LITTLE EFFECT. PATIENT COOPERATIVE UNTIL THIS AFTERNOON. PATIENT BECOMING QUITE ANGRY AND STATING THAT HE WANTED TO LEAVE HOSPITAL AND SIGN AMA. DESPITE EXPLANATION FROM THIS NURSE [**First Name (Titles) **] [**Last Name (Titles) 123**] PATIENT STILL INSISTENT ON LEAVING. SW CALLED IN BUT UNABLE TO DETERMINE FROM PATIENT WHAT WAS CAUSING THIS. ETHICS WAS CALLED AND MAY BE UP THIS EVENING TO TALK TO PATIENT. PATIENT CALMER THIS EVENING AND SLEEPING. STILL ASKING ABOUT GOING HOME. CARDIAC: HR 67-88 NSR WITH NO ECTOPY. BP 128-142/76-90. PATIENT HAD TTE DONE WHICH WAS NEGATIVE. WILL HAVE TEE IN AM. TOLERATING CARDIAC MEDS. RESP: NO VENT CHANGES. PS 13/5 30%, RR 14-24, TV'S 400'S. SATS 92-96%. LS COARSE. SXT FREQUENTLY FOR COPIUS FROTHY WHITE SPUTUM. GI: TUBE FEEDS AT 90CC/HR. TOLERATED WELL. BS+ NO STOOL ON COLACE. NPO @12AM FOR TEE. GU: U/O 25-110CC/HR OF CLEAR YELLOW URINE. CREAT 3.0. WILL LEAVE QUENTIN IN FOR NOW. ID: FOLLOWED BY ID ABX CHANGED TO BACTRIN DS 1 TAB Q6HRS AND AMPICILLIN 1GM Q6HRS. BWC 7.1. TMAX 98.0. ONE SET BLD CX'S SENT PER ID. PATIENT WITH STENOTROPHOMONAS ONLY SENSITIVE TO BACTRIM. ON CONTACT PRAUUATIONS. SKIN: LEFT SHIN ULCERS WITH PINK BASE. BACITRACIN DRSG. UPPER BACK ABRASION WITH OPSITE. ACCESS: LSC QUENTIN, RSC CL. PROPHYLAXIS: SQ HEPARIN (REFUSES BOOTS), PROTONIX. SOCIAL: FULL CODE. WIFE AND STEP DAUGHTER VISITING TALKING TO PATIENT ABOUT STAYING. ||||END_OF_RECORD START_OF_RECORD=15||||92|||| Pt remains on PSV, no weaning done. RR in 20's, adequate Vt's. BS coarse and dimin. Sx mod-lg thick yellow secretions. MDI's as noted, no change in BS. Will follow, wean PSV as tol. ||||END_OF_RECORD START_OF_RECORD=15||||93|||| PMICU NSG PROGRESS NOTE: alert and cooperative, discouraged at times. asking to have window closed, ? sleep deprived vs, ICU psychosis. given tylenol and codiene for shoulder discomfort with some effect. Slept in 2-3 hour increments. Suctioned thin yellow secretions every 2-3 hours. ABG done and no changes made. TEE to be done on Monday. TTE negative for endocarditis. Continues on iv antibx for bacteremia. Permacath when cultures negative. HD today. Poor flow from HD line 2 days ago. Plan-continue to treat with antibx, looking for source, follow cultures. dialyze, TEE and portacath when able. continue to wean from vent and follow exam of L shoulder for further decompensation. Cont. PT and OT. ||||END_OF_RECORD START_OF_RECORD=15||||94|||| patient remains alert, cooperative with care today. continuesd to be discouraged at times, wife in this afternoon, pt quite animated, wanting to go home. soon after, patient more calm, understanding why he is still here, and that he will hopefully go to rehab soon. patient continues to be a febrile. to cont to draw q48 hour blood cultures, next due tomorrow, until negative and permacath can be placed. received tylenol#3 x2 for l shoulder/arm discomfort. ps decreased to 10 this am, tolerating well -- and at patient's request, down to 5 this afternoon. abg 71/68/7.24. patient back to 10, tolerating well. tan thick secretions via ett. tolerated dialysis this am. vss. labs sent this afternoon post dialysis. hct down to 27.1 this am. skin care as per orders, patient able to help much more with turning, etc. feet cont to improve. cont weaning vent, pulm toileting, once permacath placed will be ready for re-screening. ||||END_OF_RECORD START_OF_RECORD=15||||95|||| resp. care note: pt received with a #8 trach patent and secure. pt current ventilator settings are psv 10/5 of peep, and 30% fio2. general ventilator management as well as suctioning and mdi's were done, and given t/o the shift. pt tried on [**01-30**] today, did well but gas sub par, with a increase in the co2. all is well at this time. ||||END_OF_RECORD START_OF_RECORD=15||||96|||| Pt remains on minimal vent settings, no weaning. Appears comfortable, adequate Vt's on PSV. Sx mod-lg thick white secretions. MDI's given as noted, no change in BS. Will follow. ||||END_OF_RECORD START_OF_RECORD=15||||97|||| Pt status unchanged. Pt slept from 12am to 5am. Foot care and bath done at 2200. Pt tolerated well. L leg ulcer almost healed. Central lumen catheter noted to have yellow discharge at insertion sight. Dressing change done. Resident in to observe sight. No orders at this time. ||||END_OF_RECORD START_OF_RECORD=15||||98|||| resp care note: pt received with #8 trach patent and secure, pt current ventilator settings are: psv 10/5 peep and 30% fio2. pt received general ventilator maintenance as well as suctioning t/o the shift. mdi's given as ordered. all is well at this time. ||||END_OF_RECORD START_OF_RECORD=15||||99|||| NPN Days: S/O: cont on ampi q 6 hrs for enterococcus in blood cx... blood cx neg now x past 48 hrs... surv cx sent via TLC and peripheral stick today... plan is to replace dialysis line and ? hickman for long term abx once blood cx neg x 48hrs.. team unsure if lines can be done tomorrow or not.. pt to be npo after mn for TEE tomorrow. R sc tlc with yellow exit site.. evaluated by intern.. no puss, but yellow tissue growing at exit site.. will leave in place for now. cont on PSV 10/5 today.. tolerating well..good tv's, good mv, rr 20-24. good uo. skin care as usual. hemodynamically stable.. sx for thick yellow secretions. a/P: tee tomrrow npo after mn... cont abx, follow cx. needs new lines and then transfer to rehab. ||||END_OF_RECORD START_OF_RECORD=15||||100|||| Pt remains on minimal vent support. RR in 20's most of night, adequate Vt's. BBS coarse t/o, Sx mod-lg thick white/pale yellow secretions. MDI's as noted with no changes. Will follow. ||||END_OF_RECORD START_OF_RECORD=15||||101|||| RESP-- CONTS ON PS 10 PEEP 5, TOL WELL. RR 15-20. SX Q2-4 FOR THICK WHITE SECRETIONS. CARD--BP STABLE, RECEIVING ANTIHYPERTENSIVES WITH GOOD EFFECT. NEURO--PT ALERT AND PLEASANT. COMMUNICATING VIA MOUTHING WORDS AND WRITING. ANXIOUS TO LEAVE MICU AND GO TO REHAB. GI--NPO AT MN FOR TEE. GU--U/O WAXING AND WANING, 5-100CC/HR. SKIN--FOOT SOAKS AND CREAMS APPLIED TO FEET. RIGHT TLCL WITH YELLOW PURULENT AREA AT INSERTION SITE. LEFT SHOULDER WITH LG HEMATOMA UNDER QUINTON INSERTION SITE, PT C/O PAIN IN SHOULDER, MED WITH TYLENOL #3 X2 WITH FAIR EFFECT. ID--AFEBRILE. ||||END_OF_RECORD START_OF_RECORD=15||||102|||| pt alert, orientedx3. [**First Name8 (NamePattern2) 12**] [**Last Name (NamePattern1) 124**] [**Last Name (NamePattern1) 125**] from speech and swallow in today. pt on passe muir valve this am for over 1/2 hour, also attempted bedside swallow eval. it is not indicated at this point for him to be eating solids po and he will need to be evaluated again at some point. decreased ps to 5 this am, on for ~3 1/2 hours. abg 65/58/7.28. ps increased back to 10. patient in good spirits after trial on pm valve, attempted this pm for abou the same time, but pt appeared to be tired rr in the 50's, denied feeling sob though, sats remained >92%. no tee today per id/cards attending. plan is for mr. [**Known patient lastname **] to be dialysed tomorrow as usual with old line and will go for perm-a-cath on wednesday. (alsoinvestigating possibility for iv line to be included in dialysis access so we are able to remove tlc line -- surgery will let us know if this is possible). if not, pt will go to IR for picc placement, as he is not possible to do at the bedside. will call case mgmt to start to have pt re-screened for rehab, as he will be ready after line is in...presently patient remains stable, vss on hydralizine/isordil regimine. tube feeds to be turned back on shortly. skin care as per usual, no changes. ||||END_OF_RECORD START_OF_RECORD=15||||103|||| resp. care note: pt. had two inline passy-muir trials x30 mins. Pt tolerated trials ok. but needs close supervision. pt suctioned for copious clear to white secretions. Pressure support was decreased to 5 x2hours. plan is for possible perma-cath placement on wednesday; and to continue pmv inline trials as tolerated. for further information please refer to carevue charting. ||||END_OF_RECORD START_OF_RECORD=15||||104|||| resp care note: pt received with #8 trach fully functioning, patent, and secure. pt also on mech ventilation; current settings: psv 10/5 peep and 30% fio2. pt received inhalers, general ventilator management, as well as suctioning t/o the shift. at one point last evening pt was placed on passe muir valve, inline with ventilator; cuff deflated at that point for half an hour. pt did well. pt then placed back on current settings, with cuff re inflated. all is well at this time. ||||END_OF_RECORD START_OF_RECORD=15||||105|||| RESP--CONTS ON PS 10 PEEP 5 30%, TOL WELL. STV 350-400, RR 15-24. TOL 30 MIN PASSE MUIR VALVE TRIAL THIS PM WELL, RR 20'S. SX Q2-4 FOR THICK WHITE SECRTIONS. NEURO--ALERT AND ORIENTED X3, ANXIOUS TO GO TO REHAB. C/O LEFT SHOULDER PAIN, MED WITH TYLENOL #3 WITH FAIR EFFECT. SLEEPING IN NAPS. CARD--REMAINS IN SR, BP STABLE. GU--CONTS TO MAKE GOOD URINE, 50-100CC/HR. PLAN IS FOR HD TODAY. GI--CONTS TO TOL TF, PROMOTE WITH FIBER AT 90CC/HR. BM X2. SKIN--FOOT SOAKS DONE, LEFT ANKLE CONTS TO IMPROVE. BLISTER LIKE RASH ON LEFT UPPER BACK, HO AWARE. ||||END_OF_RECORD START_OF_RECORD=15||||106|||| patient remains trached, awaiting placement of dialysis catheter scheduled for tomorrow. case management to have pt rescreened after that. vss. tolerating dialysis this am w/o incident. k 5.5 this am, tube feeds switched to nepro, awaiting new formula from the kitchen. pt on passe muir valve this afternoon in line w/the vent for over an hour now. no c/o sob. no changes made to vent. remains on psv10/peep5. skin care as per reqs. new blisters noted to upper back and l inner arm area. ho in to see with turning this afternoon. ||||END_OF_RECORD START_OF_RECORD=15||||107|||| RESP: PT INITIALLY ON 20PS AND RESTING COMFORTABLE. BY 4AM TV NOTED TO BE CONSISTENTLY 700-800CC. PS DECREASED TO 15 WITH TV DOWN TO 500-600(WHICH IS CLOSER TO PT BASELINE) RR REMAINS 16-20 WITH STABLE 02 SATS. SUCTIONED FOR SM AMTS FROTHY SECRETIONS. COPIOUS AMTS YELLOW DRAINAGE NOTED AROUND TRACH SITE. CARDIAC: BP AND HR STABLE. CONT WITH GOOD UO. GI: TUBE FEEDS ON HOLD FOR PERMA-CATH PLACEMENT IN AM. PT INCONT LG AMT(AT LEAST 2L) OF LOOSE BLACK/BROWN STOOL. ID: T-MAX 100. CONT ON BACTRIM/AMPI AND CONTACT PERCAUTIONS. ||||END_OF_RECORD START_OF_RECORD=15||||108|||| Respiratory Care: Patient trached wit 8.0 shiley trach. Vent settings Psv 15, Cpap 5, Fio2 30%, with flowby [**02-27**]. Spont vols 500-600's with RR 14-20. Psv increased from 10 to 20 due to increased WOB. RR 40's with spont vols 190-200's. Vols increased to 500-600's with increased Psv to 20. Psv later weaned to 15 due increasing vols 700-800's. Bs rhonchi bilaterally. Sx'd for moderate amounts of thin white sputum and thick yellow sputum x1. Combivent given Q4hr and flovent Bid. No further changes made. Continue to wean Psv as tolerated with passimuir valve trials. ||||END_OF_RECORD START_OF_RECORD=15||||109|||| CHART REVIEWED AND EVENTS NOTED, PT HAVING EGD THIS PM THEREFORE WILL DEFER PT F/U TODAY, WILL F/U IN NEXT 1-2 DAYS AS APPROP. PG [**Pager number 126**] ||||END_OF_RECORD START_OF_RECORD=15||||110|||| Vent settings, Treatments, and outcomes in care view charting. Passy Muir valve not attempted today due to status change with poss. GI bleed and patients breathing status. ||||END_OF_RECORD START_OF_RECORD=15||||111|||| Pt has been passing black liquid stool, three times this AM. OB+. Hct had dropped from 28 on [**05-16**] down to 20 today. Pt seen by GI service. Increased dose of protonix to BID and performed EGD at bedside which showed small gastric ulcer and duodenitis. No active bleeding at this time. Pt has been NPO and the plan for the perm-a-cath is on hold for today. Pt is to receive two units PRBC's each over four hours. First unit almost done at this point. His vital signs have been stable. I did hold the 12 noon hydralizine as he was being prepared for the EGD and was having lrg amts black liquid stool at that time. His family is not aware of the days happenings. ||||END_OF_RECORD START_OF_RECORD=15||||112|||| Neuro: Alert and oriented, writing on paper, pt. wants to know how much longer he will be here, and is frustrated with the complications that keep occuring. Emotional support provided. Pt. has slept the rest of the night. RESP: vent settings unchanged, lungs are coarse, suctioned for moderate amounts of white foamy secretions via trach. Sat's in the 90's. CV: BP stable, NSR, without any ectopy. GI: Has had one tary small stool. guiac positive. Npo except meds per ngt. GU: voiding adequate amounts of urine via foley. HEME: HCT post transfusion 22. Pt. has received two additional units of blood and will check post transfusion HCT with am labs. Wife has called, and step duaghter called. See careview for further details. ||||END_OF_RECORD START_OF_RECORD=15||||113|||| Post transfusion HCT this am 24.6. Dr. [**Last Name (STitle) **] aware, 2 additional units of prbc's ordered. ||||END_OF_RECORD START_OF_RECORD=15||||114|||| pt remains vented/trached on psv. ps decreased to prev tolerated setting of 10, tolerating well. on passe muir valve on/off through the afternoon w/o problem. dialysed this am, tolerated. vs remain stable. plan remains to go for permacath tomorrow w/poss d/c to rehab on monday. ||||END_OF_RECORD START_OF_RECORD=15||||115|||| RESPIRATORY CARE: PT. WITH 8.0 TRACH. IPS DECREASED TO 10/.30/5 AND DOING WELL. COMBIVENT/FLOVENT MDI'S/SX. THICK WHITE. PASSY MUIR VALVE TOLERATED FOR ABOUT 30 MINUTES. [**First Name11 (Name Pattern1) 107**] [**Name7 (MD) 108**], RRT ||||END_OF_RECORD START_OF_RECORD=15||||116|||| Resp Care Note: Pt cont trached on mech vent as per Carevue. Lung sounds coarse suct for mod th white. No changes made overnoc. Pt placed on PMV when family visited X 30' tol well. Cont PSV wean and PMV as tol. ||||END_OF_RECORD START_OF_RECORD=15||||117|||| PATIENT A&OX3 C/O L SHOULDER PAIN MEDICATED WITH 2 TABS T#3 WITH EFFECT...HR 50-60'S SB BP STABLE TOLERATING CARDIAC MEDS GIVEN TWO UNITS PRBC'S AM HCT 30.7...ON PS 10/5 30% SATS 94-98% RR 14-25 TV'S 400-500'S SXT FOR THICK WHITE SPUTUM LS COARSE TO RHONCHEROUS TOLERATED PASSEY MUIR VALVE...NPO FOR PERMACATH PLACEMENT IN OR TODAY BS+ NO STOOL...FOLEY WITH U/O 40-[**Age over 90 127**] YELLOW AND CLEAR BUN 85 CREAT 3.4...TMAX 99.6 CONTINUES ON AMPICILLIN AND BACTRIM NOW WITH SHINGLES RECEIVING ACYCLOVIR AM WBC 4.9...SKIN UNCHANGED...WIFE AND FRIEND CAME IN AT MIDNOC TO VISIT. ||||END_OF_RECORD START_OF_RECORD=15||||118|||| Pt. currently on 10/5/50%. Tolerating settings well had tachypnic edpisode earlier, with desats to 76% Ambued/lavaged/sxn'd lrg. tan plug from trach. Sats improved back to baseline. Pt. transported to nuclear med. for scan, r/o kidney obstruction. Scan showed nrml. perfusion. Will follow. ||||END_OF_RECORD START_OF_RECORD=15||||119|||| Resp Care Note: Pt cont trached on mech vent as per Carevue. Lung sounds coarse. Sx mod th white sput. No changes made overnoc. Tol PSV well. Cont PSV wean. ||||END_OF_RECORD START_OF_RECORD=15||||120|||| NEURO: ALERT AND ORIENTED X3. COMPLAINS OF LEFT SHOULDER AND SHINGLE PAIN. TREATED WITH TYLENOL #3 2 TABS @12AM AND 6AM WITH GOOD EFFECT. CARDIAC: HR 52-63 SB/SR NO ECTOPY. BP 105-153/45-74. TOLERATING CARDIAC MEDS. NO EDEMA. NO IVF. HCT 27.1 @3AM. RESP: CONTINUES ON PS 10/5 @30%. TV'S 300-400'S. RR 14-17. SATS 94-97%. LS COARSE TO CLEAR. NO SXT. GI: BS+ NO STOOL. TF'S ADVANCED TO 40CC/HR VIA NGT. TOLERATED WELL, MINIMAL RESIDUALS. RECEIVING COLACE AND SENNA. GU: BUN 86, CREAT 3.8. U/O 40-80CC/HR OF CLEAR YELLOW URINE. TO BE DIALYZED TODAY. ID: CONTINUES ON ZOSTER AND CONTACT PRECAUTIONS. STILL WITH BLD CX'S PENDING BUT OTHERS SHOWING NO GROWTH. WBC 5.1. TMAX 99.0. CONTINUES ON AMPICILLIN, BACTRIM DS, AND ACYCLOVIR. SKIN: NO CHANGE TO LEFT ANKLE WOUND. ONE WITH PINK BASE AND OTHER WITH RED BASE. SCANT YELLOW DRNG. BACITRACIN AND DSD APPLIED. SHINGLE VESICLES INTACT ON LEFT CHEST AND FLANK. ACCESS: RSC CL, RSC PERMACTH, LSC DIALYSIS (TO BE REMOVED). SOCIAL: FULL CODE. WIFE CALLED THIS AM. PATIENT SCREENED BY REHAB AND SHOULD LEAVE EARLY NEXT WEEK. ||||END_OF_RECORD START_OF_RECORD=15||||121|||| PT. PLACED ON PS 5/5 WITH PASSE MUIR VALVE AT 10:30AM. AT 1:30 PLACED ON 40% AEROSOL MASK WITH PASSE-MUIR VALVE. PT TOLERATING VERY WELL RR 10-23 WITH SPO2 93-100%. PLAN IS TO REST PT. TONIGHT, AND CONT. TO WEAN DURING DAYS TOMMOROW. ||||END_OF_RECORD START_OF_RECORD=15||||122|||| cardiac: vital signs very stable with B/P 120-140/50-60, hr 80's. Resp: Pt placed on PSV 5/Peep5 at 11am tolerated it very well, no C/O SOB, O2 sats 95-96%, RR 14-20. He was placed on the Passey muir valve around noon with no difficulty, then he was placed on a trach mask -FiO2 30% and he has done very well being able to talk and cough. He has been suctioned a few times but he has been able to cough most of the secretions into his mouth where he suctions then himself. He will be placed back on the vent with PSV for the night and then taken off again in the am. GI: Tube feedings being tolerated well. Rate increased to goal of 55cc/hr of nepro with promod powder. (+) BS, no stool. Pt able to swallow a glass of water this afternoon without any aspiration. May try clear liquids tomorrow. GU: pt had dialysis today. U/O was ~60cc/hr this am prior to dialysis, following diaylsis U/O ~40cc/hr. Neuro: Pt awake, alert and oriented, cooperative with care. Social: wife in today for several hours, seemed pleased to hear him talk. Still plans for possible rehab on tuesday. ||||END_OF_RECORD START_OF_RECORD=15||||123|||| Pt. alert and watching tv, talking with speaking valve on trach. Asked for pain medicne after having bath, and medicated with two tylenol #3. Lungs are coarse, suctioned for white secretions. Inner cannual cleaned out for thick brown secretions. BP stable, nsr. Able to swallow pills and juice. see careview for details. Skin care done. ||||END_OF_RECORD START_OF_RECORD=15||||124|||| Resp Care Note: Pt cont trached on .5 FIO2 cool mist via trach collar on PMV til midnight without difficulty. Lung sounds rhonchi improv with suct copious tracheal as well as orally th white and tan. Pt currently in NARD on .5 FIO2 cool mist to trach. MDIs given as ordered. ||||END_OF_RECORD START_OF_RECORD=15||||125|||| Pt alert oriented x3. Pt remained on 50% trach mask overnight with O2sats 89-93 RR 19-24. Pt w/ strong productive cough, suctioned via trach x2 for thick tan-white secretions. Lung sounds coarse throughout. BP 114-173/ (up to 173/ just before meds due). Afebrile. Cont on Ampicillin. Cont on TF nepro at 45cc/hr. u/o down overnight from 70cc/hr to 25cc/hr. Given tylenol #3 once for c/o pain left arm ||||END_OF_RECORD START_OF_RECORD=15||||126|||| Pt. a/ox3 on 50% aerosol trach mask with passe-muir valve. RR 12-22 Spo2 89-100% with NSR, BS's coarse anteriorly.Following for combivent mdi's vent still in room in case it is required during noc, however pt. has been off support since [**12**]:30am [**05-20**]. ||||END_OF_RECORD START_OF_RECORD=15||||127|||| Pt. tolerating 50% cool aerosol mask until early afternoon. Became slightly tachypnic 20-25 with desats into mid 80's, and corresponding poor abg's, pt. very lethargic. Placed back on vent 10/5/50% pt. tolerating well, secreations some thick white x2. ||||END_OF_RECORD START_OF_RECORD=15||||128|||| Resp Care Note: Pt cont trached on mech vent as per Carevue. Lung sounds coarse suct mod th yellow throughout shift. MDIs given as per order. No changes made overnoc on PSV. ||||END_OF_RECORD START_OF_RECORD=15||||129|||| Pt more alert last evening. Pt alert, awake and oriented from [**2002**] to 2400. Pt slept well trhough night. Pt continues to be on CPAP+PS peep5 PS10 and fio2 .50%. Pt comfortable on those settings. Pt will due for dialysis today. Nursing home placement needs to be verified today. ||||END_OF_RECORD START_OF_RECORD=15||||130|||| patient remains stable. dialysis this am 2kilo's removed. tol procedure well. plans for pt to go this afternoon 4pm, to [**Hospital 128**]. awaiting ambulance for transfer. pg 2,3 done. ||||END_OF_RECORD START_OF_RECORD=15||||131|||| PT/RSD Rx deferred this afternoon, pt being d/c'd to [**Hospital 129**] at 4:00pm. Will f/u for therapy if discharge delayed. Pager #[**Pager number 122**] Time 3:00pm ||||END_OF_RECORD START_OF_RECORD=15||||132|||| Resp Care Note: Pt cont trached on mech vent as per Carevue. Pt returned to MICU from ER after an apparent resp arrest secondary to trach occlusion at nursing home. Temporary inner cannula replaced with regular. MDIs given as per order. Cont mech vent support. ||||END_OF_RECORD START_OF_RECORD=15||||133|||| Pt day uneventful. Vital signs stable. Heart rate continues to be bradycardic rate between 40-55. BP stable. Physicians rounded this morning and discussed plan. Chest x-ray done. Sputum culture sent. Will monitor tonight and evaluate in am on rounds. Speech therapy in to see patient. Swallow study will be done when patient is able to tolerate pass muir valve. Pt is awake and alert. Pt communicates per mouthing words. Neuro consult to evaluate anoxic event. Neuro recommends CT, however pt is obese. Pt's wife was in. She spoke to RN. ||||END_OF_RECORD START_OF_RECORD=15||||134|||| # 8 trache appears patent/secure. B/S diminished all fields, with few scattered rhonchi and dependent crackles. ETS for small to moderate, thick yellow. MDI's given post SXN for resolution of induced bronchospasm. Last ABG was well oxygenated with slight respiratory acidosis. Pt. appears stable and synchronous with current level of support. Will continue pulmonary hygiene. ? attempt wean back to PSV as tolerated. ||||END_OF_RECORD START_OF_RECORD=15||||135|||| PMICU NURSING PROGRESS NOTE: Neuro: Intact, alert- asking when he will go home or to rehab. Anxious to start rehab-ing. Pulm: Trach care done-> trach area w/ lg amt of tan tenacious drainage. Suture sites on right sl. eroded. Pt suctioned for LARGE thick brown/black plug. AM abg good. Sputum from [**06-02**] 3+ g+rods. CV: hemodynamically stable w/ baseline SB as low as 40. Aline w/ dampened tracing. Difficult to w/d blood w/o pulling way back on cath hub. D/C ??? now that abg's wnl. GI/GU: NPO, asking for and recieving ice. Rec'd 100mg lasix-> u/o 1500cc. Labs: K= 5.1 hemolyzed. I Ca++ 1.17. Tmax 99.0 ||||END_OF_RECORD START_OF_RECORD=15||||136|||| Pt. on IPS16/5 tolerating well with VT's in 500's and RR 12-22, spo2 >92%. BS: rhonchi ant., sxn'd for occ. thick brown with few plugs.Pt transported w/o incident to head CT, to r/o possibility of anoxic brain injury. Scan showed no hemmorhage or intracranial pathology.Pt. anxiously awaiting rehab either tommorrow or sat. ||||END_OF_RECORD START_OF_RECORD=15||||137|||| Mr. [**Known patient lastname 102**] is awake, alert and mouthing words that are appropriate. Mr. [**Known patient lastname 102**] had a CT of his head this afternoon that was negative for stroke. Mr. [**Known patient lastname 102**] will be ready to go to [**Hospital 129**] tomorrow first thing in the am. ICU team has approved his discharge. The cooridinator from [**Hospital **] was here today and spoke with the ICU team. Pt's vital signs are stable. Pt tolerated dialysis well today. Pt's wife called and is aware of transfer. Art line dc'd due to poor waveform. ||||END_OF_RECORD START_OF_RECORD=15||||138|||| #8 trache patent/secure. B/S diminsihed all fields with scattered rhonchi and occasional induced wheezes. SXN for moderate secretions ranging from yellow to beige. MDI's given as ordered with increased VT's noted. Pt. appears comfortable on presnet level of support. Plan for discharge to rehab today. ||||END_OF_RECORD START_OF_RECORD=15||||139|||| Pmicu Nursing Progress Note Pt slated to go to rehab([**Hospital **]) today, a bed is available and pg 2 addendum is done and in chart. "Last meds given" will have to be rewritten this am. Pt alert and O x 3, appropriate and cooperative, looking forward to transfer. Hemodynamically stable. Remains on PS 16/Peep 5 at 50% w/ sat >95%. Required sx Q2-3hrs. Able to cough secretions to mouth and self sx via yankeur. Trach w/ copious amts of drainage. Stage 1 pressure sore under trach plastic collar w/ new duoderm. Also sm erosion at suture site on R. Remains NPO, except for meds. No stool, ++Flatus. Moving well with turning. U/O 10-30cc. ||||END_OF_RECORD START_OF_RECORD=15||||140|||| Pt is prepared to go to [**Hospital **] Vital signs stable. Pt alert and oriented. Pt mouthing words. Pt tolerating po meds well. Physicians rounded this am. Labs within normal limits. Ambulance phoned, it will arrive at 1 pm. Mrs. [**Known patient lastname 102**] aware of transfer. ||||END_OF_RECORD START_OF_RECORD=15||||141|||| ALL INFO ON THIS NOTE IS INCORRECT, AND FOR A DIFFERENT PATIENT [**Name7 (MD) **] RRT ||||END_OF_RECORD START_OF_RECORD=16||||1|||| Pt admitted to MICU from [**Wardname 85**] for increasing SOB. Mr. [**Known patient lastname 130**] was admitted to [**Wardname 85**] for increasing confusion, weakness, and SOB on [**04-11**]. This was increasing for several days, he was also having loose stools and decreased mobility. He was recently dc'd from [**Hospital1 2**] TCU with prolonged stay of 99 days. He was home for one month. He lives at Carpenter Assisted living with 24 hour health aide. PMHX: RLL pneumonia with Staph bacteremia, HTN, Osteoprosis, prostate CA'[**90**], GERD, s/p pelvic fx4/97, right arm fx [**2000-01-26**], left hip decub ulcer, s/p back surgery '[**87**]. Daughter is health care proxy. [**Name (NI) 131**] is very involved in care. Pt was admitted at 1300. Upon admission Mr. [**Known patient lastname 130**] was on 100%NRB with NC at 6ltr. Pt's breathing was labored at 24-32 BPM. Pt was alert, nods yes and no to quesions appropriately, follows commands. Family accompianied Mr. [**Known patient lastname 130**] to unit. Pt's daughter spoke to ICU team. ICU team spoke with patient and family regarding intubation. Pt wishes to be intubated if necessary. TLC and Artline were placed at 1730 per ICU team. Consents obtained from patient and family. Review of systems: Neuro: Pt is awake, alert. Follows simple commands. Answers questions appropriately. Resp: Lungs sounds coarse. Pt SPO2 94-97% on 100%NRB and 6ltr NC. Respirations labored, tachypneaic. ABG per lab flow sheet. CV: Heart rate SR with occcaisional PVC's/PAC's. BP 90s/30-40s Pt is febrile with temp of 99.9 rectally. GI: Abdomen distended, soft. Positive bowel sounds. Pt is having frequent loose stools. GU: Foley catheter draining clear/yellow urine. Pt recieved a 120 lasix on floor this am and put out approx a liter of urine since then. Plan: Continue to monitor respiratory status. ||||END_OF_RECORD START_OF_RECORD=16||||2|||| NPN CV: BP stabalized, now in SN in the 70-80s, able to wean him off of the neo during the night. Pulm: Resp status is still tenuous, he remains on 100% and 6 L NC, his SATs are in the upper 90s but when his mask comes off he quickly desats to the 70s-80s though this does return to the 90s as fast as he desaturated. He has a wet cough when he is encouraged to cough but no production. His ABG has slowly improved now with a Pa02 of 82. Oxacillian conts. GI: Drinking liquids, rather thirsty, sm amount of stool GU: fair u/o Neuro: A&Ox3, good memory, asking approapriate questions ||||END_OF_RECORD START_OF_RECORD=16||||3|||| NEURO: A+Ox3. Afeb. Follows all commands. Asks appropriate questions. CV: Monitor shows SR without ectopy. VSS. PPx4. No edema noted. S1S2 with murmur noted. K+ this am was 2.9, replaced with 60meq IV. recheck was 4.1. RESP: Remains on 100% and 6LNC. Lungs very coarse. Has wet cough, but unable to produce any sputum. Sats are 98-100% while pt at rest, drops to 70-80's if mask removed. Also drops with anxiety. Sputum culture ordered but not sent d/t lack of specimen. GI: Taking po's well, although restricting to po fluids d/t possibility of intubation. ABSx4. Stoolsx2 today. OB-. Abd S/ND/NT. GU: Foley draining clear yellow urine in adequate amounts. SOCIAL: Family at bedside. Very inquisitive. Questions answered. Pt has home health aide at bedside ATC. PLAN: Monitor resp status. pulmonary toilet. Encouarge family to allow pt to rest. Reaasure pt that he is not alone. ||||END_OF_RECORD START_OF_RECORD=16||||4|||| PT ON 100%NRBM AND 6LNC. PT HAVING MUCH DIFF BREATHING USING ALL ACCESSORY MUSCLES. HAVING MUCH DIFF RAISING SPUTUM. LUNG SOUNDS VERY COARSE. DOPPED 02 SAT'S OFF AND ON DURING THE NIGHT. PT NASOTRACHEALY SX FOR LRG AMT OF PASTEY YELLOW/TAN SECRETIONS WHICH DROPPED HIS O2 SAT'S TO THE LOW 80'S AND PT WAS UNABLE TO RECOVER FROM THIS AND WAS DECIDED AT THIS TIME TO INTUBATE PT AND PT AGREED. ANESTHESIA CALLED, PT MED WITH ETOMADATE AND SUCCX IV. PT INTUBATED EASILY WITH #7.5 ETT AT 23CM AT THE LIP. TUBE PLACEMENT CHECKED BY XRAY. PLACEMENT GOOD. PT STARTED ON PROPOFOL DRIP TO MAINTAIN SEDATION AND COMFORT. FOLEY CATH DRAINING ADEQUATE AMT'S OF YELLOW URINE. INCON SM AMT'S OF SOFT STOOL DURING THE NIGHT. K 3.4 RECEIVED 60MEQ KCL. PT HAS REMAINED IN SR ALL SHIFT, BP STABLE BUT DROPPED SLIGHTLY WHEN STARTED ON PROPOFOL. RATE DEC AND BP BACK UP TO ACCEPTABLE RANGE. FAMILY MADE AWARE OF INTUBATION. ||||END_OF_RECORD START_OF_RECORD=16||||5|||| Resp Care Note: Pt on NRB mask + 6L NC required NT sx due inability to clear secretions. Sx copious th yellow sput. Pt sats didn't recover after sx + A&A Tx. Pt intubated and placed on vent setting as per vent flowsheet. CXR confirmed ETT placement and ABG's stable. Pt sx after intub for mod th yellow. Cont mech vent support. ||||END_OF_RECORD START_OF_RECORD=16||||6|||| NEURO: Remains sedated on Propofol gtt currently at 40 mcg/kg/min. Withdraws to painful stimuli. PERRLA. Afeb. CV: Monitor shows SR without ectopy. VSS. MAP>60. PPx4. S2S1 murmur noted. Lytes this am WNL. RESP: Orally intubated with 7.5 ETT 23 at the lip. AC / 450x10/ 50%/ 15peep. PAP 35-39. O2 sats 98-100%. Lungs very coarse. Suctioning for large amounts of thick yellow pasty secretions. Last ABG WNL. GI: NGT intact with + placement. Readicat given for CT of Abd scheduled for 5pm. Hypoactive bowel sounds noted. No stool today. GU: Borderline uop today. Foley flushed x1 with very slight increase in uop. UOP remains > 30cc/hr. SKIN: No edema noted. R hip wound debrided by plastics today. Recommend tid dressing changes. Duoderm to coccyx intact. SOCIAL: Daughter very involved in pt care. Very inquisitive. Questions answered. ID: BC + staph aureus 4/4 bottles. Sensitive to Oxacillin and Clindamycin. Covered with both. No fevers. WBC count is down to 16.9. Plastics does not feel R hip is source of infestion. PLAN: Continue vent support. Abd CT this pm. Continue with abx regimine. Pulmonary toilet. ||||END_OF_RECORD START_OF_RECORD=16||||7|||| Pt dropped SBP to 60's. Fluid bolus 500cc given and Neosynephrine started. BP now in the low 100's. CT on hold for now, will retry later. ||||END_OF_RECORD START_OF_RECORD=16||||8|||| RESP NOTE:PT REMAINS INTUBATED AND VENTILATED AT THIS TIME WITH NO RESP DISTRESS NOTED.B/S DIMINISHED BILAT WITH SX FOR SMALL/LARGE AMOUNTS OF THICK TAN/YELLOW SECRETIONS DURING SHIFT.PRESENT VENT SETTINGS AC/450/10/50% PEEP15 AND TOLERATING WELL. ABG"S AVAILABLE IN CAREVUE,WILL CONTINUE WITH PRESENT COARSE AND WEAN AS TOLERATED. ||||END_OF_RECORD START_OF_RECORD=16||||9|||| NPN CV: Pt still requiring neo, gtt increased a little due to low BP. he remains in a SR, HR 60-70s. Pulm: LS bronchial on the R, clear on the L, very little sputum from his ETT. No changes were made in his vent. GI: Stooled x2, gelatonous, brown, OB neg. TF started Replete with fiber at 10cc/hr GU: decreased u/o Neuro: Remains on Propofol, he has been well sedated Skin: Decube on his R hip, dressing done, white base, very little drainage ||||END_OF_RECORD START_OF_RECORD=16||||10|||| Resp Care Note: Pt cont on mech vent as per vent flowsheet. Lung sounds coarse. Sx mod th pale yellow. No changes made this shift. Cont mech vent support. ||||END_OF_RECORD START_OF_RECORD=16||||11|||| NEURO: Remains sedated on Propofol gtt. PERRLA. Responds to painful stimuli. CV: Monitor shows SR without ectopy. VSS. Remains on Neo at 32mcg/min. S1S2. PPx4. Labs WNL. RESP: Remains vented. AC 450x10 40% 15peep. Lungs coarse. Suctioning for thick yellow sputum. Sats 100%. GI: CT done today. Results pending. Tol po well. Replete with fiber at 20cc/hr. Stooling today. GU: UOP decreased. Fluid bolus given with slight increase in uop. Continue to monitor closely. SKIN: R hip wound culture sent. Dressing change tid. Duoderm to coccyx intact. SOCIAL: Daughters into see pt. Spoke with team. PLAN: Wean vent as tolerated. Support BP. ||||END_OF_RECORD START_OF_RECORD=16||||12|||| RESP NOTE:PT REMAINS INTUBATED AND VENTILATED THOUGH SOME IMPROVEMENT IN RESP STATUS TODAY.FIO2 LOWERED TO 40% WITH PT MAINTAINING SATS 98-100% AND NO RESP DISTRESS EVIDENT.SECRETIONS MINIMAL AND PALE/YELLOW,B/S GEN CLEAR AND DECREASED R>L.ABG"S AVAILABLE IN CAREVUE,WILL CONTINUE WITH VENTILATORY SUPPORT AND WEAN AS TOLERATED. ||||END_OF_RECORD START_OF_RECORD=16||||13|||| Resp Care Note: Pt cont on mech vent aas per vent flowsheet. Lung sounds ess clear. No changes made this shift. Cont mech vent support. ||||END_OF_RECORD START_OF_RECORD=16||||14|||| NPN CV: conts on neo, his dose has needed to be increased through the night to maintain a SBP in the 100s. His HR has been in the 50s SB. Pulm: Conts on the respirator no changes were made. LS cleared after suctioning, bronchial on the R. He has had a lg amount of tan, thick putum from the ETT and from the back of his throat. GI: Conts to have loose, golden stool. He had a 270cc residual from his NGT, they were OB pos, TFs were shut off. GU: U/O has increased from yesterday. Neuro: Well sedated on the propofol, appears comfortable. Skin: Dressing on his R hip changed no change in the wound during the last 2 days. ||||END_OF_RECORD START_OF_RECORD=16||||15|||| RESP NOTE:PT REMAINS SEDATED AND VENTED WITH NO REMARKABLE CHANGES IN RESP STATUS.PRESENT VENT SETTINGS AC/450/14/40% WITH PEEP LOWERED TO 10 AND TOLERATING WELL.SECRETIONS MINIMAL AND PALE/YELLOW,B/S DIMINISHED BILAT,ABG"S AVAILABLE IN CAREVUE.SATS BEING MAINTAINED AT 99/100% ON CURRENT SETTINGS,WILL CONTINUE TO MONITOR AND WEAN AS TOLERATED. ||||END_OF_RECORD START_OF_RECORD=16||||16|||| NEURO: PT REMAINS SEDATED ON PROPOPHOL...ATIVAN JUST STARTED THIS EVENING. GOAL IS TO WHEEN PROPOPHOL OFF AND CONT WITH JUST ATIVAN. PT UNRESPONSIVE TO STIMULI...FACIAL GRIMACING WITH TACTILE STIMULI. AFEBRILE. CV: NEO WHEENED TO OFF THIS AFTERNOON. BP RANGING FROM 90-110/40-50'S VIA R RADIAL ALINE. SB WITH NO ECTOPY NOTED. POOR PALPABLE PULSES ALL AROUND. S1S2 ON AUSCULTATION. RESP: PT WHEENED TO AC/40/450/10/14...BREATHING WITH VENT. SUCTIONED FOR LG AMTS THICK YELLOW SECRETIONS ORALLY AND VIA ETT. PT HERE THIS EVENING AND WORKING WITH PT. LUNGS CLEAR WITH SCT RHONCHI THROUGHOUT BASES AND DECREASED BASES. WILL SEND ABG 30 MINS AFTER PT DONE SUCTIONING AND DOING CPT. ETT 23CM AT LIPLINE. GI/GU: FOLEY DRAINING CLOUDY YELLOW URINE. UO RANGES FROM 0-100CC/HR. NSS BOLUSES GIVEN THROUGHOUT DAY TO IMPROVE UO AND BP. TOLERATED WELL. TF REMAIN ON HOLD...HIGH RESIDUALS (GASTRIC HEME +...PH 2). TEAM AWARE. WILL START ON REGLAN. PT INCONT SEVERAL TIMES OF LIQUID BM...DULCOLAX GIVEN YEST D/T PT RECIEVING BARIUM IN CT SCAN. ABD S,D,NT...ACTIVE BSX4. WILL CONT TO CHECK RESIDUALS AND ATTEMPT TO RESTART TF. INTEG: R IJ TLC P/I...CVP READING OFF DISTAL PORT. R RADIAL ALINE P/I. R HIP WOUND REPACKED AND CLEANSED THIS AFTERNOON. TUNNELLING AREA YELLOW WITH PINK TISSUE SURROUNDING EDGES. ESCHAR NOTED IN CENTER APPROX 1MMX1MM. CONT TURNING PT Q2H. PT WITH NEW R HIP FRACTURE...ORTHO BY TO SEE PT. SOCIAL: SPOKE WITH DAUGHTER [**Name (NI) 132**] ON PHONE SEVERAL TIMES TODAY. SHE WAS UPDATED ON PT STATUS AND WILL BE STOPPING BY LATER TODAY. ||||END_OF_RECORD START_OF_RECORD=16||||17|||| PT REMAINS INTUB/VENTED, NO FURTHER CHG'S MADE. FOLLOWING O2SAT'S, MAINTAINING SAT'S 95-97%. LUNG SOUNDS CONT TO BE VERY COARSE. SX FOR MOD AMT'S OF THICK YELLOW SECRETIONS. WEANING OFF PROPOFOL AND CONT ON ATIVAN WITH ADEQUATE LEVEL OF SEDATION. NEO REMAINS OFF, RECEIVED 500CC NS BOLUS TO KEEP SBP ELEV AND INC U/O. CONT ON ANTIBIOTICS. TUBE FEEDS REMAIN ON HOLD. PT INC SM AMT'S OF LIQ BROWN STOOL. HIP DSG CHG'D NO CHG IN APPEARANCE. WET TO DRY DSG APPLIED AFTER BEING CLEANED AND GEL APPLIED. FOLEY CATH DRAINING ADEQ AMT'S OF CLEAR DK YELLOW URINE. FAMILY SPOKE WITH HO ABOUT BRINGING IN A CONSULT FROM THE [**Hospital1 34**]. HO SPOKE WITH DR. [**Last Name (STitle) 133**] ABOUT THIS. ||||END_OF_RECORD START_OF_RECORD=16||||18|||| Resp Care Note: Pt cont on mech vent as per Carevue. Lung sounds ess cl. No changes made this shift. Cont mech vent support. ||||END_OF_RECORD START_OF_RECORD=16||||19|||| Resp: remains intub/vented on ac 450x14 40% 10 peep with sats high 90's abg 79/37/7.36. suctioned for mimimal secretions. Remains afebrile. Cardiac: bp stable 100-110/40-50 without further fluid boluses. Remains off neo. Cont in sinus brady hr in 50's. Neuro: remains sedated on 1mg ativan. Pt off propofol. ? need to further wean ativan as pt essentually unresponsive. GI:Abdomen soft. passing loose brown stool. Tube feeds remain on hold. ?restart today. ||||END_OF_RECORD START_OF_RECORD=16||||20|||| Resp. Care Note Pt remains intubated with 7.5ETT secured at 23c lip. Current settings A/C 450x 14x 40% peep 7.5 with ABG 70/37/7.36/22/-3. Peep decreased today from 10-7.5 with adequate oxygenation. Pt occas assisting above vent, could probably be changed to PSV. Sxn for mod. amount of thick tannish secretions. Cont support. ||||END_OF_RECORD START_OF_RECORD=16||||21|||| NEURO: PT REMAINS EXTREMELY SEDATED ON ATIVAN GTT...GTT DOWN TO 0.5MG/HR. MAY CONVERT TO PRN ATIVAN IV...PLAN TO ASSESS PT AND SEDATION REQUIREMENTS. AFEBRILE. CV: PT REMAINS OFF NEO. ABP 110-120/40-50'S. L ALINE CORRELATING WELL. SB WITH 1ST AV AND BBB ON MONITOR. EKG THIS SHOWED NEW T WAVE ABNORMALITIES AND POSSIBLE NEW ISCHEMIA. TEE DONE...NEGATIVE FOR VEGETATION. CARDIAC ENZYMES SENT X2. RESULTS PENDING. S1S2M ON AUSCULTATION. POOR PALPABLE PULSES ALL AROUND. CVP 9-10. RESP: PT REMAINS ON AC/450/14/40%/PEEP DOWN TO 7.5. ABG DONE AND WNL. SUCTIONING OUT THICK TAN SECRETIONS ORALLY AND VIA ETT. LUNG SOUNDS COARSE, DECREASED LOWER LOBES. O2SATS 96% WHEN TRACKING. GI/GU: OGT PULLED FOR TEE. REPLACED AND XRAY DONE..WAITING TO HEAR IF PLACEMENT IS GOOD. ABLE TO START TF THIS AM AT 0900...RESIDUALS OF 10CC. TF ON HOLD SINCE NOON FOR TEE. ABD S,D, ACTIVE BSX4. CONT WITH FREQ LIQUID STOOLS. SENT FOR CDIFF. FOLEY DRAINING SMALL AMTS YELLOW URINE. TEAM AWARE, MAY BOLUS WITH MORE FLUID. INTEG: R IJ TLC P/I. SKIN NURSE BY TO EVAL R HIP WOUND. TUNNELING WITH YELLOW AND ESCHAR TISSUE IN CENTER, PINK TISSUE SURROUNDING EDGES. ORTHO BY TO EVAL PT...SUSPECT HIP WOUND IS ACTUALLY A TUMOR VS ABSCESS. FAMILY NOT AWARE YET. CAST REMOVED FROM R HAND...SPLINT ON. CONT ON FIRST STEP MATTRESS. ||||END_OF_RECORD START_OF_RECORD=16||||22|||| PMICU NURSING PROGRESS NOTE: Neuro: all sedation off. unresponsive to stimuli. CV: stable, SBP 110-130. HR 60's BBB. Troponin of yest negative. TEE negative. EKG due this am. Ca++ repleted. Resp: Vent settings unchanged. Sx x 3 for thick yellow mod amt. ^^oral secretions. LS crackle, coarse. ID: afebrile. cont on Oxacillin, clinda for + bld cx Skin: buttocks excoriated from constant mucoid green stool. Rectal bag applied. R hip dsg x 2. Need to contact skin care RN for more appropriate chemical debriding gel (collagenase?), wound sloughing-tunneling. GI/GU: TF's restarted, now 35cc. U/O sporatic but averaging ~30cc/h. Social: no calls from family. Remains full code. ||||END_OF_RECORD START_OF_RECORD=16||||23|||| Resp Care Note: Pt cont on vent as per Carevue. Lung sounds rhonchi impr after suct mod th tan sput. No changes made this shift. Cont mech vent support. ||||END_OF_RECORD START_OF_RECORD=16||||24|||| NEURO: Afeb. Has received no sedation since 6 am. Will open eyes slightly verbal command. Not following any commands. BC x1 sent today. per orders. CV: Remains in SR without ectopy. VSS. Continue with d5.45NS at 75cc/hr. PPx4. S1S2 murmur. No edema noted. EKG unchanged from yesterday. RESP: Vent changed to CPAP 5/5 this am. Tolerating well. ABG WNL on this setting. Lungs coarse. Suctioning for thick yellow sputum. GI: Tolerating TF well. Replete with fiber at 40cc/hr. Stooling, rectal bag intact. ABS. ABD S/ND/NT. GU: Foley draining clear amber urine in adequate amounts. Remains + for this hospitalization. ID: Remians on Oxacillin and Clindamycin. WBC this am was32.1. Remains Afeb. INTEG: R hip ulceration with yellow tissue. Continue with dressing changes TID. Coccyx with duoderm. SOCIAL: Family into visit today. Spoke with myself and Dr. [**Last Name (STitle) 134**]. Questions answered. Asked to speak with social worker. Meeting arranged for tommorow afternoon. PLAN: Allow to wake up from sedation. Wean vent as tolerated. ? Tap pleural effusion today. Consent signed and on chart. ||||END_OF_RECORD START_OF_RECORD=16||||25|||| PT/RSD Re-evaluation S: Intubated O: Please refer to initial evaluation [**04-11**] for further information regarding PMH and HPI Labs: 13.6>32.1<313 Vent: PS 5/PEEP 5, Tv 450, 40%FiO2 Pulmonary: Breath sounds coarse throughout Mobility: Pt sedated, no active movement at this time ROM: PROM all joints WFL although stiffness noted throughout Vital Signs: Pre-rx: 148/60 77 28 99% During/post-rx: 140/60 78-84 28 98-100% Rx: Gentle passive ROM bilateral upper and lower extremities. Percussion to right lung field in left sidelying followed by in line suctioning for minimal yellow secretions. Pt positioned back in supine post rx. A: 85y.o male with staph aureus bacteremia and hypoxic respiratory failure. Pt presents with impaired respiration, ventilation and secretion clearance associated with respiratory failure. Pt tolerated chest PT well today and will benefit from continued pulmonary toileting. Should begin mobility when pt able to participate. Pt will require rehab placement once medically stable with guarded potential given prolonged hospitalization/bed rest. Goals(5-7 days): 1.Pt will maintain O2 saturation >95% without mechanical ventilation 2.Pt will be independent in secretion clearance 2.Pt will transfer bed to chair with moderate assist of 2 P: F/U [**04-20**] Pager #[**Pager number 135**] Time Frame:4:30-5:30pm ||||END_OF_RECORD START_OF_RECORD=16||||26|||| Resp. Care Note Pt remains intubatd and vented on current settings CPAP 5 PSV 5 and 40%. Pt changed to these settings today from A/C and has done well with stable ABG's and RR 24 TV 450-500. RSBI today 66. Sxn for pale yellow secretions, decreased amount today. Pt with cough response and slight gag but still uresponsive to commands. Cont present settings, assess for ext. when Pt more alert. ||||END_OF_RECORD START_OF_RECORD=16||||27|||| RESP CARE, PT. REMAINS ON CPAP IPS5/.4/5PEEP. VT 400, RR HIGH 20'S. RESTED COMFORTABLY, NO VENT CHANGES. ||||END_OF_RECORD START_OF_RECORD=16||||28|||| PT REMAINED ON CPAP THROUGHOUT THE NIGHT. SX FOR MOD AMT'S OF THICK YELLOW SECRETIONS. LUNG SOUNDS VERY COARSE THROUGHOUT. MAINTAINING O2SAT'S IN THE HIGH 90'S. PT CONT TO BE VERY LETHARGIC AND BARELY RESPONSIVE WITH STIMULI. VITAL SIGNS STABLE. TEMP 99.8 PO. FOLEY CATH DRAINING ADEQ AMT'S OF CLOUDY URINE. DSG CHG TO R HIP. NO CHG' IN APPEARANCE. NO STOOL AND RECTAL APPLIANCE INTACT. FAMILY CALLED DURING THE NIGHT AND UPDATED. ||||END_OF_RECORD START_OF_RECORD=16||||29|||| Rehabilitation services/physical therapy Patient traveling to CT for needle aspiration and having echo presently. Unable to see for pulmonary care, tho nursing has been able to position and suction patient throughout day. Will follow [**04-21**] ||||END_OF_RECORD START_OF_RECORD=16||||30|||| NEURO: Tmax 99.4. Remains lethargic. PERRLA. Has not recieved Ativan since 6am on [**04-19**]. CV: Monitor shows SR without ectopy. Prolonged QTC noted. Cards feels this is d/t abx therapy. PPx4. S1S2. VSS. K+ and Ca++ replaced this am. RESP: Remians orally intubated. Vent settings per flow. ABG pending. US guided tap done today. 750cc Fluid removed. Lungs remain coarse. Suctioning for large amounts of thick yellow secretions. GI: Tolerating TF well. Rectal bag remains intact. No stools. GU: Foley draining clear amber urine in adequate amounts. INTEG: Stoma RN following for R hip wound. CT of area done today, abcess not drained d/t risk of infection and location of abcess. SOCIAL: Family spoke with team today. updated on POC. Questions answered. PLAN: Wean from vent as tolerated. Pulmonary toilet. ||||END_OF_RECORD START_OF_RECORD=16||||31|||| Respiratory Care Note Pt remains on CPAP PSV 10 PEEP 5 40%. Vt 450-500 RR 24-28. Last ABG was 7.42/32/82. Pt seems comfortable on these settings. Pt transported to CT scan today for pelvic scan. Pt also had R sided pleural effusion tapped for 750cc. Pt sxnd for mod amount of thick tan secretions. BS much improved this evening. Will maintain current settings and wean when patient is more alert. ||||END_OF_RECORD START_OF_RECORD=16||||32|||| PT STILL INTUB AND VENTED ON SAME SETTINGS. SEE FLOWSHEET. PT SX FOR LRG AMT'S OF YELLOW BLD TINGED SECRETIONS. O2SAT'S MAINTAINING HIGH 90'S WITH NO DROPS. LUNG SOUNDS COARSE THROUGHOUT. PT CONT TO BE VERY SEDATED BUT HAS PERIODS WHEN SBP GOES UP TO THE 170'S AND IS ATTEMPTING TO OPEN EYES BUT UNABLE. PT MED WITH ATIVAN 1MG IVP WITH GOOD EFFECT. PT CONT ON GOAL RATE TUBE FEEDS WITH ACCEPTABLE RESIDUALS. RECTAL BAG DRAINING SM AMT'S OF LIQ BROWN STOOL. RIGHT HIP DSG CHG WITH SM AMT OF YELLOW DRAINAGE. WOUND CLEANSED/WOUND GEL APPLIED AND PACKED WITH WET TO DRY DSG. DUODERM ON SPINE INTACT. FAMILY CHECKED IN BY PHONE AND WERE UPDATED. PT CONT ON ANTIBIOTICS AND IV FLUID DISCONTINUED. PT HAS SEVERE GENERALIZED PITTING EDEMA. FOLEY CATH DRAINING MOD AMT'S OF YELLOW URINE. PT HAS LOW GRADE TEMP AND VITAL SIGNS ARE STABLE. ||||END_OF_RECORD START_OF_RECORD=16||||33|||| Resp Care, Pt. remains intubated on CPAP IPS 10/.4/5peep. VT 500, RR 20. Suctioned for yellow sputum. Cont. to wean as tol. ||||END_OF_RECORD START_OF_RECORD=16||||34|||| PT/RSD S: Intubated, opened eyes during chest physical therapy O: Pt seen to address goals set at re-evaluation on [**04-19**] Labs: 15.6>29.1<353, Tm 99.8 Vent: 40%FiO2/PS 10/PEEP 5/TV 500 Vital Signs: Pre-rx: 128/41, 77, 95%, 23 During rx: 170/60, 83, 98% 23 Breath Sounds: Coarse anterior, diminished bilateral lower lobes Rx: Chest PT, percussion and vibration, to bilateral anterior lung fields in supine, bilateral lower lobes in sidelying. Followed by in-line suction for minimal amount of yellow secretions. Mouth yank. suctioned for moderate amount yellow sputum. A: Pt continues to benefit from chest PT and mobility in the bed to assist with secretion clearance. Pt continues to have less secretions and require less frequent suctioning. P: F/U [**04-24**] Pager #[**Pager number 135**] Time Frame: 3:15-4:00pm ||||END_OF_RECORD START_OF_RECORD=16||||35|||| Respiratory Care Note Pt weaned to CPAP with PSV 5 and PEEP 50. 40%. Pt tol wean well Vt 460 and RR 20-26. Sxnd pt x2 for small/mod amount of white sputum. Bs with scattered rhonchi. Pt much more awake today...following some commands. Plan to ? extubate in next couple of days. ||||END_OF_RECORD START_OF_RECORD=16||||36|||| resp. care note: Pressure support increased to 10cmh2o. Pt's resp rate 30s-40s, decreased sats and increased BP. Pt suctioned for a moderate amount of thick tan secretions. Plan is to try to wean pressure support back to 5; then extubate. For further information please refer to carevue charting. ||||END_OF_RECORD START_OF_RECORD=16||||37|||| NEURO: PT SLEEPING MOST OF DAY, OPENS EYES AND SQUEEZES HANDS ON COMMAND...OTHERWISE NOT MOVING AROUND OR AWAKE. NOT ANSWERING ANY QUESTIONS. TMAX 99.8 AX. TEAM AWARE. ATIVAN DC'D AND PRN FOR HALDOL IF NEEDED. CV: SR ON MONITOR, NO ECTOPY NOTED. BP SLIGHTLY HIGH AT TIMES, 140-160/50'S PER ALINE. ANASARCA NOTED UPPER AND LOWER EXT'S. S1S2M ON AUSCULTATION. RESP: VENT WHEENED TO CPAP 40%/[**01-30**]...ABG WNL. PLAN TO HOLD ON EXTUBATING SECONDARY TO LG AMT ORAL SECRETIONS. SUCTIONED SMALL AMT VIA ETT, THICK TAN, BLD TINGED. LUNGS CLEAR TO COARSE THROUGHOUT. VT 400-500, RR 20-30'S. FAMILY MADE AWARE OF DECISION TO WAIT ON EXTUBATION. GI/GU: CONT TO BE INCONT OF LOOSE STOOL, 3RD CDIFF CULTURE SENT. RECTAL BAG REPLACED TODAY. PLAN TO START IMMODIUM IF LAST CULTURE IS NEGATIVE. FOLEY NOT DRAINING THIS AM, CHANGED TO #14G AND DRAINING CLEAR BLD TINGED CLEAR YELLLW URINE. MIVF STARTED TO D5NS @75CC/HR. TF INFUSING WITHOUT DIFF. WILL FOLLOW. ||||END_OF_RECORD START_OF_RECORD=16||||38|||| resp. care note: pt received intubated with a 7.5 ett, secured at the 23cm mark. pt also mech. ventilated, current settings: cpap 5 psv 5 and 40%. pt received general ventilator management as well as suctioning when needed. pt is to remain intubated overnight secondary to excess oral secretions. possible plan to extubate tomorrow. [**Name7 (MD) 136**] rrt ||||END_OF_RECORD START_OF_RECORD=16||||39|||| PT CONT TO BE INTUBATED AND VENTED. REMAINS ON PRESSURE SUPPORT AND PEEP, SEE FLOWSHEET FOR SETTINGS. SX OCC FOR MOD AMT'S OF THICK YELLOW SPUTUM. LUNG SOUNDS COARSE THROUGHOUT. O2 SAT'S IN THE HIGH 90'S. PT CONT TO BE QUITE SEDATED BARELY RESPONDING TO STIMULI. BP OCC GOING UP TO 180 RANGE WHEN STIMULATED WITH TURNING OR SUCTIONING. FOLEY CATH DRAINING ADEQUATE AMT'S OF YELLOW URINE. RECTAL BAG CHG'D, NOT DRAINING MUCH STOOL, IMODIUM HELD. TUBE FEEDS CONT AT 40/HR WITH SM RESIDUALS. BOWEL SOUNDS PRESENT AND ABD SOFT/DISTENDE. FAMILY VISITING TILL MIDNIGHT AND UPDATED. ||||END_OF_RECORD START_OF_RECORD=16||||40|||| resp. care note: pt assessed for extubation by rrt, rn, and md. pt. found fit for extubation. pt extubated, and placed on a cool aerosol mask at 50%, which will be titrated to keep spo2 > than92%. following extubation there were no increases in resp. rate, heartrate, or decrease in spo2. all is well at this time. [**Name7 (MD) 136**] rrt ||||END_OF_RECORD START_OF_RECORD=16||||41|||| NEURO: PT VERY LETHARGIC EARLY THIS AM AND WAS NOT RESPONDING TO VERBAL STIMULI. BY 1400, PT FOLLOWING COMMANDS AND MORE AWAKE. EXTUBATED AND DOING WELL. CONT TO FOLLOW COMMANDS, MOVING AROUND MORE AND INTERACTING WITH FAMILY. PT ABLE TO VERBALIZE ONE WORD ON OCCASSION. APPEARS TO BE ORIENTED TO FAMILY. AFEBRILE. CV: SR ON MONITOR, NO ECTOPY NOTED. VSS...BP HIGH ON OCCASSION PER ALINE, (170-190/60-70'S). RECIEVED COZAAR THIS AM. S1S2M ON AUSCULTATION. R TLC P/I. OVERALL ANASARCA NOTED, POOR PALPABLE PULSES ALL AROUND. RESP: PT EXTUBATED THIS AFTERNOON, ON 50%FM AND TOLERATING WELL. POST ABG WNL. RR 20-26. LUNGS REMAIN COARSE ANTERIORLY AND UPPER POST LOBES...CLEAR,DECREASED B/L BASES. ORALLY SUCTIONING SMALL AMT'S THICK YELLOW. NTSUCTIONED X1. O2SATS 99-100%. GI/GU: FOLEY CHANGED TODAY...LEAKING AROUND INSERTION SITE. #16 FR FOLEY PLACED AND DRAINING BLD TINGED URINE. LASIX GIVEN WITH GOOD RESULTS. IMMODIUM GAVE THIS AM X1..NO BM NOTED TODAY. ABD SLIGHTLY DISTENDED WITH POSITIVE BS..WHEN TF INFUSING, NO RESIDUALS WERE NOTED. CURRENTLY: D5NS @75CC/HR INFUSING VIA TLC. FAMILY AT BEDSIDE AND PT DOING WELL. TLC AND ALINE FROM [**2000-04-12**]...TEAM AWARE AND WILL EVAL PT FOR PICC LINE. ||||END_OF_RECORD START_OF_RECORD=16||||42|||| PT REMAINS EXTUBATED WITH 50%FACE MASK. O2 SAT'S MAINTAINED HIGH 90'S . LUNG SOUNDS COARSE AND IS ABLE TO COUGH UP SOME SECRETIONS WITH MUCH ENCOURAGEMENT. ABLE TO SUCTION THEM FROM BACK OF THE THROAT. PT VERY LETHARGIC AT START OF THE SHIFT BUT BECAME INCREASINGLY MORE ALERT AND OPENING EYES AND ATTEMPTING TO SPEAK. WILL COUGH A WEAK COUGH WHEN TOLD TO. VITAL SIGNS STABLE. LOW GRADE TEMP. FOLEY CATH DRAINING GOOD AMT'S OF PINK TINGED URINE AND OOZING CLOTS AROUND CATH FROM PENIS. CATH IRRIGATED TO CLEAR CLOTS. OCC WILL DRAIN LRG AMT'S OF URINE AROUND CATH IF CLOTS HAVE OBSTRUCTED CATH. HIP DSG CHG, WOUND LOOKS SLIGHTLY IMPROVED. FAMIL WENT HOME EARLY AND CHECKED IN DURING THE NIGHT. PT STARTED ON IV UNASYN SINCE UNABLE TO TAKE PO MEDS. ||||END_OF_RECORD START_OF_RECORD=16||||43|||| S: MOANING O: PT SEEN FOR PROBS/GOALS PER R/E [**04-19**] MS: ALERT, ORIENTED TO NAME AND HOSPITAL, MIN VERBALIZATION T/O RX VS'S: 96 97%(50%FM) 20 BS'S: DECREASED BILAT WITH CRACKLES LL'S COUGH: WEAK, CONGESTED, INEFFECTIVE BR PATTERN: NON-LABORED RX: PROM X4 EXTREMITIES, POSITIONED S-S WITH HOB LEVEL FOR PERC/SHAKING TO BILAT LUNG FIELDS, PRE-OXYGENATED WITH 100% FIO2 AND NTS FOR MOD TO LARGE AMOUNTS THICK YELLOW SECRETIONS. COMMUNICATION WITH RN AND MD [**Last Name (Titles) **]: PTS STATUS A: PT DOING FAIRLY WELL S/P EXTUBATION BUT DOES HAVE A LOT OF SECRETIONS, UNABLE TO CLEAR ON OWN AND NEEDS FREQUENT NTS. PTS EXTREMITIES VERY STIFF WITH KNEE FLEXION CONTRACTURES PRESENT. P: CONTINUE TO FOLLOW FOR BPH, ROM AND MOBILITY AS ABLE PG [**Pager number 137**] ||||END_OF_RECORD START_OF_RECORD=16||||44|||| NPN 7a-7p: Review of Systems: Resp: pt NT sx for copious amts yellow/tan secretions this shift... q 2hrs.. CPT done x 1 by PT as well. Cont on 50% CSM, with sats 99%, although abg 68/44/.7.37/26. desats to 85% quickly with mask off. RR 16-28. Aline dc'd as was red and small amt puss at site... tip sent for cx. team to place new aline, as pt's resp status tenuous. CV: pt in NSR 80's-90's. BP 130's-150's. NGT placed to give meds.. ASA and Cozaar. GU: pt cont with clots via foley today. irrigated x 1 d/t pt reporting unable to "Pee".. large clot removed... 3 way foley placed and await GU irrigant to run o/n. uo 40-60cc/hr. F/E: lytes wnl. cont on maintanence ivf. Cont edematous. ID: afebrile. wbc 9.0... as noted aline dc'd, and resited... cont on unasyn and oxacillin. Integument: Skincare CNS in to evaluate R hip wound today... Per CNS report.. wound with slightly more yellow, "dead" tissue... sharp debrided by CNS, cleansed with wound cleanser, and filled with wound gel and moist 2x2's, dsd ... taped to duoderm border... also, small blister on upper back cleansed and duoderm replaced. Social: pt's daughter and son in all day.. met with team to discuss plan of care.. pt to remain DNR, but would be reintubated. family very attentive. NEuro: pt A+ O x [**10-30**]... more awake this afternoon, voice much more clear. asking to watch tv. Access: remains with TLC to R SC... to have PICC placed tomorrow by iv team.. please save L antecube. a/P: pt with tenuous resp status... large amts secretions.. desats easily, but perking up... to cont abx, follow abg's, cont skin care, pulmonary toilet.. PICC line tomorrow. cont emotional support to pt and family. ||||END_OF_RECORD START_OF_RECORD=16||||45|||| NPN 7a-7p: RESP: Pt requiring NT x 3 this shift... copious to moderate amts thick tan/yellow secretions. LS very course, bronchial at bases... team aware that pt is also + 1L fb... to discuss dose lasix. Cont on 50% csm with sats 99-100%... abg wnl.. po2 66-90's... po2 lower with pt on R side. RR 20's. ID: afebrile. abx changed... unasyn dc'd and po augmentin started.. cont on ox. F/E: fb + as noted.. repleted with Kcl, MG per med sheets. TF's reinstituted... now at 10cc/hr ... goal is 40cc/hr.. Discussion r/e peg for long term feeding.. Pt to have swallow study tomorrow... pending results of this, pt to decide r/e PEg. Access: IV team in to eval for PICC... state that arm is too edematous at this time.. if unable to place will need hickman. CV: no active issues. social: pt's daughter in to visit.. discussion held with team/pt/... pt statign would want to be reintubated... no cpr. A/P: pt with adequate abg'd, but cont with secretions although less.. cont to follow o/n.. line tomorrow for long term abx.. may diurese tonight. ||||END_OF_RECORD START_OF_RECORD=16||||46|||| NEURO: PT APPEARS A@OX3...APPROPRIATE WITH FAMILY, FOLLOWING COMMANDS. AFEBRILE. RESP: REMAINS ON FACE TENT 40% WITH O2SATS 96%. LUNGS COARSE THROUGHOUT, RECIEIVNG LASIX IV FOR DUIRESIS. ABG WNL. CV: SR ON MONITOR, VSS PER L RADIAL ALINE. NO AFIB NOTED. S1S2 ON AUSCULTATION. ANASARCA NOTED ALL AROUND. GI/GU: FOLEY OUTPUT DROPPED OFF, FOLEY IRRIGATED WITHOUT DIFF. WILL MONITOR OUTPUT. ABD S,NT,D...TOLERATING TF'S, RATE INCREASED TO 30CC/HR...NO RESIDUALS. WILL FOLLOW. TODAY; HCT DOWN TO 25...RECIEIVING ONE UNIT PRBC'S. L PICC PLACED, PLACEMENT OKAY PER XRAY; WILL PULL TLC AFTER BLOOD INFUSED. ||||END_OF_RECORD START_OF_RECORD=16||||47|||| Neuro: Awake, calling out at times, remains difficult to understand with weak voice, upper airway congestion Resp: Sats 92-96% on 40% cool neb face tent, BS coarse throughout, required N-P suctioning x4 overnight for thick tan sputum, has weak cough, at times can cough up to back of throat, can use Yankauer suctioning CV: Stable, remains in NSR, no ectopy noted, continues on Diltiazem 30mg via NGT q6hrs GI: Tol TF's at now 40ml/hr with minimal residuals. Blue dye in feeds, no evidence of aspiration overnight. Incont scant amt soft brown stool GU: I/O neg ~700ml/24hrs after lasix dose given on day shift, continues with u/o >60ml/hr Skin: No change in hip wound, Duoderm intact on back area Social: Telephone update to pt's daughter, [**Name (NI) **] overnight ||||END_OF_RECORD START_OF_RECORD=16||||48|||| D:PT AWAKE AND ALERT AND FOLLOWS SIMPLE COMMANDS APPROPRIATELY. CONVERSING WITH FAMILY IN FEW WORD SENTENCES. REMAINS ON 40% FACE TENT WITH ABG=7.35/49/87/28/0. SUCTIONED WITH DIFFICULTY VIA R NARE FOR COPIOUS AMTS OF THICK TAN SPUTUM AND THEN THICK YELLOW SPUTUM. THIS AFTERNOON PT ABLE TO COUGH AND RAISE TO BACK OF HIS THROAT THICK TAN SPUTUM. COARSE BS BIL ON AUSCULTATON. MAX TEMP=96.9 AXILLARY. SBP 160-179. AND RR 18-26. TUBE FDGS OF PROMODE INCREASED TO 50CC'S/HR WITH MINIMAL RESIDUALS. GOAL RATE FOR TUBE FDGS IS 60CC'S. PT STILL WITHOUT GAG AND THIS WAS VERIFIED BY SPEECH SWALLOW THERAPIST WHO RECOMMENDS THAT PT WILL NEED PEG. HCT STABLE AT 31.5 . K+ 3.6 AND REPLACED WITH 20 MEQ KCL VIA NGT. PT IS A DNR BUT WOULD BE REINTUBATED. PT EVALUATED AND SCREENED BY [**Hospital 138**] REHAB AND [**Hospital1 139**]. PT MAY BE TRANSFERED WHEN BED AVAILABLE TO REHAB AS EARLY AS MON. ||||END_OF_RECORD START_OF_RECORD=16||||49|||| Resp Care Note: Pt requires frequent NT suct for mod to large amt th beige sput. Lung sound prior to suct rhonchi improving w/ sx. Pt currently in NARD on cool mist aerosol @ .4FIO2. Cont to encourage deep breathing and coughing. ||||END_OF_RECORD START_OF_RECORD=16||||50|||| PT CONT TO DO WELL EXTUBATED. NASAL TRACHEAL SX X 1 FOR LRG AMT OF THICK TAN SECRETIONS. O2SAT'S IN HIGH 90'S. LUNG SOUNDS VERY COARSE THROUGHOUT. TUBE FEEDS TOL WELL VIA NGT. SM RESIDUALS. ABD DISTENDED BUT SOFT, BOWEL SOUNDS PRESENT. NO STOOL TONIGHT. HEPARIN INJ GIVEN AND PT OOZING BLD FROM SITE MOST OF NIGHT. U/O ADEQUATE. FAMILY UPDATED. ||||END_OF_RECORD START_OF_RECORD=16||||51|||| D: PT ALERT AND ORIENTED. FOLLOWS SIMPLE COMMANDS. ON INITIAL ASSESSMENT O2 AT=89%. ON 40% FACE TENT. SUCTIONE NASLLY VIA L NARE FOR MODERATE AMT OF THICK CREAMY YELLOW SPUTUM AND O2 SATS NOW 96-98%. COARSE BS BIL. CONTINUES ON PROMODE TUBE FDGS VIA NGT WITH MINIMAL RESIDUALS SO RATE NOW INCREASED TO GOAL RATE OF 60CC'S/HR WITH NO SIGNS OF ASPIRATION. INCONITNNENT OF MOD AMT OF LOOSE BROWN STOOL. AWAITING FAMILY'S CONSENT TO PLACE PEG AND ALSO AWAITING PALCEMENT AT [**Hospital 138**] REHAB OR [**Hospital1 139**] REHAB. VSS. UO ADEQUATE. WILL CONTINUE WITH PRESENT MEDICAL TX. WILL CONTINUE TO UPDATE FAMILY AS NEEDED AND OFFER EMOTIONAL SUPPORT. PT IS A DNR BUT WOULD BE REINTUBATED IF RESP STATUS WERE TO WORSEN. ||||END_OF_RECORD START_OF_RECORD=16||||52|||| Neuro: Awake and alert most of the day. Asked to get up OOB and stayed up for 2hrs or so and was most comfortable in the chair. Otherwise he has been restless, calling for me to reposition him frequently. I explained to him that it is not possible to repeostion him as frequently as he is asking and that every two hours would be the most frequent turn that is reasonable. His speech is very diffucult to understand since his voice is weak and he is congested in the upper airway. Resp: Still requires close monitoring of his resp status for need to suction him. He is on 40% TM and his sats were best while in the chair. He was suctioned twice today for thick blood tinged yellow sputum. Lungs are coarse. RR in the 20's. O2 sat 96% most of the day but were 100% while in the chair. Cardiac: Remains hypertensive in the 150's to 190's. Up with activity. Cozaar was increased to 50mg QD and extra 25mg was given as requested by the physician. [**Initials (NamePattern4) 140**] 70-80's. GI: Two small stool today. Tolerates goal rate tube feeds. GU: Adequate UO via the foley. Social: I spoke to pt's son via the phone today. Also MD updated pt's daughter and spoke to the ppt and to her about the need for PEG next week. ||||END_OF_RECORD START_OF_RECORD=16||||53|||| Resp Care Note: Pt required NT suct for mod th brn sput. Pt placed on FIO2 .4 via cool mist aerosol via face tent with stable O2 sats. Cont aggressive pulmonary toilet. ||||END_OF_RECORD START_OF_RECORD=16||||54|||| PT CONT TO STAY EXTUBATED ON FACE MASK. LUNG SOUNDS VERY COARSE THROUGHOUT, COUGHING AND ABLE TO RAISE SECRETIONS TO BACK OF THROAT AT TIMES. NASOTRACH SX Q4/HR FOR THICK TAN SECRETIONS. O2 SAT'S IN HIGH 90'S. PT'S VITAL SIGNS STABLE, AFEBRILE. RESP RATE REGULAR. NO SOB. TUBE FEEDS CONT AT 60/HR MINIMAL RESIDUAL. BOWEL SOUNDS PRESENT AND PASSING SM AMT'S OF SOFT GREEN STOOL. PT HAS BEEN VERY ALERT AND TALKING. SLEPT VERY LITTLE DURING THE NIGHT. NO CHG IN R HIP DECUBITUS. DSG CHG' NO SIG SIGNS OF IMPROVEMENT. FAMILY CHECKED IN AND UPDATED. ||||END_OF_RECORD START_OF_RECORD=16||||55|||| CV: STABLE WITH DILTIAZEM. RESP: ENT CONSULTED FOR HOARSENESS. FAILED SWALLOW STUDY YESTERDAY SECONDARY TO INABILITY TO BALL FOOD TO BACK OF MOUTH. AT 1800 ABG= 58/42/7.45...CHANGED TO NRB, NT SUCTIONED, SAMPLE SENT. PLAN: WILL REDO ABG CONT CPT Q4 HOURS. CONT NT SUCTIONING PRN GI/GU: FOLEY BAG CHANGED AND CULTURE SENT AS URINE DARKENED LATE TODAY. TOL GOAL RATE PROMOD WITH FIBER AT 60CC/HOUR. FREE WATER BOLUSES D/C'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 141**] N ATTEMPT TO MAKE HIM ABOUT 500CC (-). ID: AFEBRILE. OXACILLIN (D#17 OF 6WEEKS) AND AUGUMENTIN (D#7 OF 14). HE HAS MULTIPLE DENTAL ABCESSES THAT DENTAL HAS ASSESSED AND DOES NOT FEEL WILL SEED... OMF (ORAL MAXILOFACIAL SURGERY) DOES NOT HAVE O.R. PRIVELAGES, THUS HE WOULD NEED TO LEAVE [**Hospital1 2**], HAVE SURGERY AND RETURN. DSD TO RT HIP DECUBITUS. ||||END_OF_RECORD START_OF_RECORD=16||||56|||| Resp Care Note: Pt requires aggressive pulmonary toilet. Pt NT suct for copious th beige sput. Lung sounds bilat rhonchi clearing significantly after suct. Pt currently w/ O2 Sat ~ 95% breathing comfortably in NARD. Cont aggressive pulmonary toilet. ||||END_OF_RECORD START_OF_RECORD=16||||57|||| Systems Review: Resp: LS coarse bilat throughout. Aggressive CPT maintained throughout shift. Received CPT q4h with NT suctioning. Pt with large amts of tan thick secretions. O2 sats have been 94-97%, with rr in the 20's. ABG 63/47/7.39/30/2 on 40%CN. No further ABG's obtained, due to A-Line falling out with turning. CV: VS have remained stable. Neuro: extremely difficult to understand due to pt being very weak, he has not been able to expectorate any secretions. ID: Afebrile, on IVABX. Sputum cx sent. GU; +fluid status by 12am, 330cc's + by 6am. Skin: Right hip decub drsg [**Name5 (PTitle) 94**] per protocol. GI: Small amts green stool. +bs, tolerating TF's with minimal residuals. TF's held ~1hr with CPT and sxning. ||||END_OF_RECORD START_OF_RECORD=16||||58|||| MR [**Known patient lastname **] HAD AN IMPROVED DAY TODAY. INITIALLY Q2 HOUR NT SUCTIONIGN. BUT HE WENT FROM 12NOON TO 1700 WITH SATS >95%. REMAINS ON 40% FT. NO IMPROVEMENT IN VOICE YET (ENT CONSULT FOR VOICE ON HOLD). THE CT REVEALE D INCREASING IN SIZE D/T ??HYPOALBUMINEMIA. POSSIBLE PLAN INCLUDES CT GUIDED TAP...[**First Name8 (NamePattern2) 142**] [**Last Name (NamePattern1) 143**] (RESIDENT) WORKING ON THIS. HE HAS BEEN TIRED TODAY, SLEEPIING INTERMITTANLY AND AWAKENING APPROPRIATELY WHEN I GO IN ROOM OR CALL HIS NAME. GI/GU: STOOLS X3 TODAY. TOL GOAL PROMOTE WITH FIBER. SKINL RT HIP WOUND WITH TAN BASE. DSD WITH WOUND JELLY APPLIED. ID: OXACILLIN D18 OF 42. AND AUGUMANTIN DAY8 OF 14. AWAITING SPUTUM AND URINE SENT YESTERDAY. PICC SINCE [**04-26**] SOCIAL: I HAD AN EXTENSIVE DISCUSSION WITH DTR [**Name (NI) 132**] AND HER HUSBAND RE: [**Name2 (NI) 144**], TRACH, HIS HOSPITAL STAY, A REHAB STAY, MANY QUESTIONS WERE ASKED AND ANSWERED FROM BOTH SHE AND I... THIS INFO COMMUNICATED IN DETAIL TO DR [**Last Name (STitle) 145**]. PLAN: FAMILY MEETING TOMORROW AFTERNOON , PENDING A TIME FROM RESUMING ATTENDING DR [**Last Name (STitle) 146**]. ----THIS TIME MUST BE DECIDED UPON DURING ROUNDS SO RN AND FAMILY CAN BE AVAILABLE. FAMILY IS COMING IN THE EARLY AFTERNOON ADN ARE AWARE THEY MAY HAVE TO WAIT. ||||END_OF_RECORD START_OF_RECORD=16||||59|||| Systems Review: CV: Has been hemodynamically stable. BP 90's-120's, HR 70's SR, no ectopy. Received 20meq KCl last eve. AM labs drawn, awaiting results. Resp: Aggressive pulmonary toilet cont's. Secretions thick and tan. Attempting to suction less this shift due to trauma and discomfort. LS coarse throughout. ID: IV oxacillin, per ID, to con't until [**06-09**] to complete 8wk coarse. Aumentin for oral infx. Will need oral surgery consult.. F/E: Just about even at present. Heme: Hct up this am to 34.2 after receiving 2nd unit PRBC's. Social: Son from [**Name2 (NI) 147**] called last eve. Wanted to know what meds pt was on and if steroids or inhalers/nebulizers would help.. He had spoken to a friend who suggested this. I told him that the MD's were aware of the meds. He said he has a good relationship with his sister, who has been updating him frequently. He is in agreement with her decisions and wants what is best for the pt. Also he was unclear whether or not pt would benefit from a trach. I asked him if his father would want this aggressive tx and he stated that if it gave him some quality of life, he believes he would. He is aware of the family meeting scheduled for today, and expects to be updated by sister. ||||END_OF_RECORD START_OF_RECORD=16||||60|||| NPN 7a-7p: Review of Systems: RESP: Cont on 50% CSM, with weak, nonproductive, thickly congested cough. NT sx q 3-4 hrs for thick tan secretions. LS with exp wheezes, bronchial at bases... L thoracentesis done via bedside US for 900cc pleural fluid. RR 16-24. Sputum spec growing out yeast. Remains npo. Seen by Speech and swallow therapist who is to return to discess speach excercises with pt to strengthen voice... to be seen by eNT to evaluate vocal chords. ID: pt hyothermic this shift.. now on bearhugger with slow improvement. team aware.. in light of hypothermia, pt fully cx'd... sutum, blood with fungal isolator (peripheral), urine. cont on IV OX... po augmentin dc'd. F/E: pt with marginal UO this shift.. ? d/t No input, as TF's off for thoracentesis.. 250cc NS fluid bolus up over one hr... await effect. Lytes wnl. fluid bolus neg 600 today, + 2L yesterday... pt with peripheral edema throughout, + scrotal edema. GU: pt with yeast growing in urine... foley changed o/n... pt with intermittent BRB via foley.. irrigated with NS to clear. GI: pt with blue/green stool d/t dye in TF's... Butt bag placed as buttocks excoriated d/t frequent stooling. ab softly distended, BS + with + umbilical hernia. Integument: Skin care CNS to be paged tomorrow am to observe wound to R hip during dressing change... cont lined with yellow dead tissue.. dressing process unchanged. duoderm intact to upper back. wax placed to metal rod in boken tooth, R upper gumline. Social: family meeting held, attended by pt's daughter, son in law, Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 148**], and this RN.. Dr. [**Last Name (STitle) **] explained to family that if pt wants to cont. aggressive treatment, then a trach and PEg are recommended at this point... pt lethargic this afternoon, but when arouses, family to return to be present for discussion intern to have with pt... Pt prefers daughter to be present when he makes decisions about his care... also, pt would be reintubated at this point, but otherwise DNR. A/P: follow cx.. will follow MS/hypothermia carefully.. no further abx changes at this time. page skin care cns in am, and call family when pt more alert, in order to have discussion. ||||END_OF_RECORD START_OF_RECORD=16||||61|||| Pt awake, looking a little uncomfortable at 8PM. Unable to guess what the problem was so I turned him to the right at 9PM and he has looked more comfortable since then. RR 16-20. On 40% mask his sats have been 98%-100% most of the evening. UO was 20cc/hr early in the shift. Urine is grossly bloody, no clots noted. Last UO at 10PM was up to 50cc/hr. An order was written for 250cc NS bolus if UO drops below 30cc/hr for two consecutive hours tonight. Pt is on the tube feeds at goal rate. Vital signs are stable. Family was not present this evening. ||||END_OF_RECORD START_OF_RECORD=16||||62|||| PT SLEPT OFF AND ON DURING THE NIGHT MAINTAINING GOOD O2 SAT'S AND GOOD VITAL SIGNS. PT AFEBRILE. U/O LOW FOR 2/HRS 250CC NS BOLUS X 1. U/O PICKED UP SLIGHTLY. TUBE FEEDS TURNED OFF AFTER MIDNIGHT, SX BLUE TUBE FEED OUT OF TRACHEA WHEN NASOTRACH SX. PT'S LUNG SOUNDS COARSE THROUGHOUT. FOLEY CATH DRAINING BROWN URINE WITH OCC CLOTS. HIP DSG CHG'D NO CHG IN APPEARANCE. PT' HAS GENERALIZED THIRD SPACING, WITH SCROTAL EDEMA. FIB REMOVED DUE TO LEAKAGE. PERIANAL AND PERINEAL AREA VERY REDENED. MICONAZOL POWDER AND SKIN CREAM APPLIED. PT SEEMS ORIENTED BUT CONT TO SCREAM OUT AT TIMES. ||||END_OF_RECORD START_OF_RECORD=16||||63|||| NPN 7a-7p: S/O: Cont with copious secretions via nts, blue tinged still. changed to 6L o2nc with sats 98%, rr 20.kept npo/npgt... Most likely to have interventional radiology to place a post pyloric tube for feeding. NO trach per pt/family at this point. Currently with ns with 60meq kcl up over 10 hrs via midline... UO very poor all am.. team aware and 250cc ns fluid bolus given. Urine also very bloody... 3way foley placed and irrigated for 1200cc.. now urine clear and yellow... has order for maintenance ivf once K repletion compelte.. cont with frequent loose stools. C-diff sent x 2.. after 3rd cdiff, can give lomotil. Skin on bottom very broken and excoriated... barrier cream applied. Daughter spoke at length with rn and md's.. many ?'s answered. a/P: await feeding tube placement.. cont skin care, follow uO. needs one more c-diff and sputum spec with next sx. cont support to pt/family. ||||END_OF_RECORD START_OF_RECORD=16||||64|||| Resp Care Note: Pt required NT suct for large amt th white. Lung sounds rhonchi w/ significant improvement after suct. Cont with aggressive pulmonary toilet. ||||END_OF_RECORD START_OF_RECORD=16||||65|||| PT ALERT AND ORIENTED CONT TO MAINTAIN GOOD 02SAT'S AND GOOD VITAL SIGNS. LUNG SOUNDS CONT TO BE COARSE AND WHEEZY AT TIMES. NASOTRACH SX X 2 DURING THE NIGHT FOR THICK THICK TAN/YELLOW SECRETIONS. PT RUNNING VERY LOW TEMPS. PT CONT TO HAVE WORSENING THIRD SPACING GENERALIZED ESP IN SCROTUM. SCROTUM SUPPORTED WITH TOWEL. PT IV FLUID CONT AT 60/HR BUT U/O RUNNING ABOUT 20-25/HR. CONT OOZING SM AMT'S OF BLUE/GREEN STOOL. PERIANAL AREA VERY REDENED AND EXCORIATED, IMPROVING WITH DESITIN OINT. PT SCHEDULED FOR PEG PLACEMENT, PT HAS BEEN NPO, NGT PLACED TO SX DRAINING SM AMT'S OF BILIOUS/BLD TINGED MATERIAL. DAUGHTER CALLED DURING NIGHT AND UPDATED. PT CONT TO BE DNR BUT WILL BE REINTUBATED IF NECESSARY. ||||END_OF_RECORD START_OF_RECORD=16||||66|||| D: PT A&O AND FOLLWS SIMPLE COMMANDS. O2 AT 6L/M NC WITH O2 SATS>90%. COARSE BS BIL AND PT NASOTRACHEALLY SUCTIONED X1 FOR THICK TAN SPUTUM. COARSE BS BIL. PT REMAINS NPO FOR PEJ PLACEMENT TO BE DONE TODAY. RECEIVING D 5 1/2 NS AT 60CC'S HR AND HOURLY URINE IS MARGINAL. PASSED MEDIUM SIZED GREENISH BLUE SOFT STOOL AND DESITIN OINTMENT APPLIED TO EXCORIATED BUTOCKS. R HIP DRSG CHANGED AND APPEARANCE OF THE WOUND IS UNCHANGED. PT'S DAUGHTER AT BEDSIDE AND UPDATED. CASE MANAGEMENT CALLED TO BEDSIDE PER DAUGHTER'S REQUEST. ||||END_OF_RECORD START_OF_RECORD=16||||67|||| Neuro: Pt awake and alert. Sometimes speech is difficult to understand. Today was talking about making a phone call but it was difficult due to his poor speech. Pt wanted to get up OOB but did not due to the PEG placement procedure. He is very stiff, requires full lift and assist with all ADL's. Cardiac: One dose of diltiazem held today due to HR in the 50's. BP stable 120-140. Pt was given a dose of 20mg IV lasix today. Has had good effect. Resp: Had to go back to the 50% face tent due to pt desating and not coming up after suctioning. I suctioned him twice. Large amt secretions initially but small amt in the evening. Lungs are decreased and coarse. RR in the 20's. Current sat 95%. GI: Had a J-tube inserted in radiology today and tolerated this well. We can use it for meds and give him his tube feeds at half the normal goal rate until tomorrow afternoon when we can increase it back to the goal rate. Currently on promote w/fiber at 30cc/hr. The site is draining moderate to lrge amts serous drainage and the dressing was changed by myself twice. I caled the radiologist who inserted the tube and she feels as long as the bleeding is not grossly bloody and just clear to serous that it is probably due to his generalized body edema and may drain for a while. I have the Gastric port hooked up to gravity drainage and the j-port has the tube feeds. Gastric drainage is golden/yellow clear bile. Pt stooled three times today, green loose. GU: Foley draining drk urine at first but now clear yellow since he got the lasix. I did run the irrigant for a while but have it off now trying to get an accurate I+O. Skin: Unchanged. Buttocks are red and excoriated and I have been using triple cream ordered by team. Social: Pt's daughter was in most of the day. Pleased at pt's progress today and will call later tonight. ||||END_OF_RECORD START_OF_RECORD=16||||68|||| PT ALERT AND ORIENTED. WEARING FACE MASK AND O2SAT'S IN THE HIGH 90'S. ABD DSG FOR PEJ TUBE DRY AND INTACT. GASTRIC PORT DRAINED 175CC BILE. TUBE FEEDS INF AT 30/HR WITH LOW RESIDUALS. PT CONT TO BE INCONT OF SM AMT'S OF LIQ GREEN STOOL. PERIANL AREA CONT TO BE VERY REDENED AND EXCORIATED. DESITIN OINT APPLIED AND SEEMS TO BE HELPING. PT RECEIVED LASIX ON EVENING SHIFT AND PT CONT TO DIURESE LRG AMT OF DILUTE URINE. PT CONT TO HAVE MUCH DIFF COUGHING AND RAISING SECRETIONS. HIP DSG CHG AS ORDERED NO CHG IN APPEARANCE OF WOUND. DAUGHTER CALLED AND WAS UPDATED. ||||END_OF_RECORD START_OF_RECORD=16||||69|||| D: ALERT WHEN AWAKE BUT VERY LETHARGIC TODAY AND SLEEPING IN LONG NAPS. COARSE BS BIL. SUCTIONED X 2 NASOTRACHEALLY FOR THICK TAN SPTUM AND O2 SATS93-98%. REMAINS ON 50% OPEN FACE TENT BECAUSE PT RECEIVING MORE MOISTURE WITH THIS MODE. PT'S DAUGHTER AND SON AT THE BEDSIDE. RECIVING PROMODE WITH FIBER AT GOAL RATE NOW OF 60CC'S/HR VIA NEW PEJ. PEJ DRSG CHANGED FOR [**Name5 (PTitle) **] AMT OS SEROUS DRAINAGE. POS BOWEL SOUNDS AND PT HAS HAD 2 EPISODES OF SM AMTS BLUE STOOL. UO ADEQAUTE VIAFOLEY CATH . R HIP DRSG CHANGED AS ORDERED AND NO CHANGE IN APPEARANCE. PT HAS REQUIRED LESS SUCTIONING TODAY AND DOES NOT NEED ICU NURSING CARE THOUGH HIS RESP STATUS WILL NEED TO BE MONITORED CAREFULLY.. CONITNUE TO OFFER EMOTIONAL SUPPORT TO FAMILY ||||END_OF_RECORD START_OF_RECORD=16||||70|||| PMICU Nursing Progress Note: Resp/CV: Desat to 85% on 100% shovel mask. NT sx for min thick tan secretons. 5L NC added w/ O2 sats remain > 94%. Dropped sats again later in evening--required NT sx x 3 times for large amt of thick tan secretions with sats eventually >94%. Hemodynamically stable. GI/GU: 200cc output from gastric drainage. Cont on tf's at goal. Stool x 6 sm amts blue/grn. Buttocks excoriated, cream applied. U/O poor. ||||END_OF_RECORD START_OF_RECORD=16||||71|||| PT/RSD Re-consult received, pt known to physical therapy department. At this time we are unable to progress pt's mobility as he is NWB secondary to bilateral pelvic fractures. Will re-evaluate status on [**05-08**], deferred rx today as pt unstable this am. Pager: #[**Pager number 135**] Time: 10:00am ||||END_OF_RECORD START_OF_RECORD=16||||72|||| D: PT THIS AM TALKING AND RECOGNIZED HIS CAREGIVER, [**Name (NI) 149**]. O2 SAT=93& SO PT NASOTRACHEALLY SUCTIONED FOR LG AMT OF THICK YELLOW TO TAN SPUTUM. COARSE BS BIL. O2 SATS AFTER SX'ING WERE 96%. TURNED PT AT 0930 FOR BACK CARE AND TO CHANGE R HIP DRSG. ALARM SOUNDED AND SBP DOWN TO 84 WITH HR 50 AND O2 SAT=93%. MD'S CALLED TO BEDSIDE. PT NOT RESPONDING. NS BOLUS OF 500CC'S GIVEN. O2 REMAINED AT 100% FACE TENT WITH 6L/M NC. HR THEN DROPPED TO 41 AND SBP DROPPED TO 74. R RADIAL ALINE PLACED AND ABG AT THE TIME=7.15/96/81/35/1. PT'S DAUGHTER CALLED AND AFTER DISCUSSION WITH DR. [**Last Name (STitle) 150**] ,DAUGHTER AND MYSELF AS WELL AS PHONE CONVERSATION WITH PT'S SON IN [**Name2 (NI) **], THE DECISION WAS MADE TO KEEP PT COMFORTABLE. O2 SATS DROPPED TO A LOW OF 62% AND SBP 70'S. THIS AFTERNOON WITHOUT INTEVENTION PT'S HR HAS RETURNED TO THE 50'S AND SBP 90'S. O2 SATS HAVE REAMINED 90-94%. PT HAS MINIMAL CORNEAL REFLEX AND DR. [**Last Name (STitle) 151**] HAS SPOKEN TO PT'S FAMILY AND THEY UNDERSTAND HIS GRIM PROGNOSIS. PT HAS RECEIVED 2 MG IVP MSO4 X3 AND WILL START MSO4 GTT IF MSO4 NEED INCREASES. UO HAS ALSO DROPPED TO MINIMAL AMTS SINCE HYPOTENSION. FAMILY HAS REMAINED AT THE BEDSIDE. PT CMO AND AWAITING THE ARRIVAL OF HIS SON. ||||END_OF_RECORD START_OF_RECORD=16||||73|||| addendum to above note: pt's son [**Name (NI) 152**] arrived and dr. [**Last Name (STitle) **] met with famil. minimal corneal reflex to r and absent to l. unresponsive. family witnessed md's exam and aware of his status. o2 nc removed but continues with open tent mask. shortly after son arrived hr down to 43 and sbp 70's o2 sats dropped to 79-81%. mso gtt initated at 2 mg /hr and will continue to titrate as needed to keep pt comfortable. ||||END_OF_RECORD START_OF_RECORD=16||||74|||| Pmicu Nursing Note: Pt expired on [**05-06**] at 1:17am. Family in attendance. Drs' [**Name5 (PTitle) 153**] and [**Name5 (PTitle) 154**] pronounced. ||||END_OF_RECORD START_OF_RECORD=16||||75|||| Pt's urine output has steadily been declining. 15-20cc's/hr House officer notified. Will con't to assess. ||||END_OF_RECORD START_OF_RECORD=16||||76|||| Chart re-reviewed this afternoon. Events noted. No further PT needs at this time, will defer further treatment. Time: 6:00pm Pager: #[**Pager number 155**] ||||END_OF_RECORD START_OF_RECORD=17||||1|||| Per report from [**Hospital 30**] Hospital: 83yo male admitted to hosp [**04-02**] with SOB and CHF requiring intubation. Pt r/i for MI. Pt extubated [**04-13**]. Over past few pt has had worsening respiratory status requiring BIBAP. Over past 24hrs pt increasingly agitated and was given Ativan. Pt also c/o chest pain and found to have EKG changes. Given SL NTG x6 and started on NTG gtt which is currently at 50mcg. Pt given Lopressor and Lasix. CKs again elevated. HCT down from 30 > 28 to 26 today. Last K+ 3.7 this morning Recent vitals: BP 100-120/50-60s HR 60s 1st AV block. PAD 22-26, afebrile. Last ABG 176/71/7.29 on Bipap with 90% FIO2 PMH: CHF, CAD, CABGx4, RI, nephrectomy for CA, CVA, HTN, prostate CA, depression, O2 dependent, psoriasis ||||END_OF_RECORD START_OF_RECORD=17||||2|||| Pt accepted in transfer from [**Hospital 30**] Hospital. Pt lethargic, mumbling incomprehensible words. MAE. Neuro: Soft wrist restraints applied due to pt being slightly restless. MAE. Nods head to questions but is generally lethargic. Resp: On bi-pap 10/5 with initial ABG showing PO2 169, PCO2 69, pH 7.35. Lungs are decreased with crackles at bases. CXR shows ?CHF. Given 80mg IV lasix at 6PM. O2 on bi-pap will be weaned down according to sat and they plan to insert a-line this evening. Cardiac: Pt comes to uys with swan with PAP 60/20 CVP 5. Unable to wedge catheter. Team is aware and will check placement via CXR. Until then I will not due any CO readings. BP 90-110. HR 60-90. IV's: Pt has left subclavian triple lumen catheter with a port saved for TPN. TPN on hold for tonight. His left shoulder has a lipoma which is old, it is not infiltrated central line. GI: NPO due to lethargy and bi-pap. +BS, small amt stool under him at transfer. GU: Foley draining sedemented urine. Skin: Anal rectal area very excorieated, red and sore. Barier cream applied. Social: Pt has a wife who is in a nursing home and a daughter and son who are very devoted. Lopie Certusi cell# [**Telephone/Fax (2) 156**] Home# [**Telephone/Fax (2) 157**] work# [**Telephone/Fax (2) 158**] ask to [**First Name8 (NamePattern2) 159**] [**Doctor Last Name 160**] [**First Name4 (NamePattern1) 161**] [**Known patient lastname 162**] (son) cell# [**Telephone/Fax (2) 163**] (try 1st) secondly try pager [**Telephone/Fax (2) 164**] Home [**Telephone/Fax (2) 165**] Office [**Telephone/Fax (2) 166**] Both [**Doctor Last Name 160**] and [**Last Name (un) 161**] are his appointed Health Care Proxy. Copy of this is in the chart. ||||END_OF_RECORD START_OF_RECORD=17||||3|||| CCU NURSING PROGRESS NOTE 7P-7A NEURO: PT AGITATED MUCH OF NIGHT WITH PERIODS LETHARGY. DIFFICULT TO ASSESS NEURO STATUS. FOLLOWS SIMPLE COMMANDS. UNABLE TO UNDERSTAND SPEECH, GRUNTING SOUNDS ONLY. GIVEN ATIVAN SEVERAL TIMES WITH LITTLE EFFECT. MEDICATED WITH DILAUDID FOR EXCORIATED BOTTOM WITH GOOD EFFECT ON AGITATION. CV: HR 10-100'S SR/AFIB. HR 70'S WHEN IN AFIB, HEMODYANAMICALLY STABLE. STARTED ON HEPARIN AT 1000 UNITS/HR. PTT 44.9. INCREASED TO 1100 UNITS/HR AT 0530. CONVERTED TO NSR WITHOUT INTERVENTION. NO VEA NOTED. BP 100-110/40, MAPS 60-70'S ON IV NTG INCREASED TO 70MCG/MIN FOR DESIRED MAPS. UNABLE TO WEDGE CATHETER. HO AWARE. ? TOO FAR OUT PER CXR. HAS NOT BEEN ADVANCED. PAP'S ^^ 68-76/30-37. CVP 14-17. CO 5.4 CI 2.51 SVR 1007 MIXED VENOUS SAT 54. GIVEN IV LASIX 120MG X2 WITH FAIR U/O. -800CC THUS FAR LOS. PT UNABLE TO VOICE COMPLAINTS. CK #1 89 TROPONIN >50. K3.6 REPLETED WITH 40KCL IV OVER 2HRS. REPEAT K 4.1 HCT 26.9 HGB 8.7 PULM: LS CLEAR, DIMINISHED AT BASESS. ON BIPAP OVERNIGHT [**07-02**] FIO2 65% WITH O2 SATS 95-98%. ^RR 30'S WITH AGITATION. ATTEMPT TO PLACE ALINE UNSUCCESSFUL. DIFFICULTY FITTING BIPAP MASK CAUSING ^AGITATION. CHANGED TO NRB AT 6AM, SATS 99%. ? CHANGE TO AEROSOL MASK TODAY AND WEAN FIO2 AS TOLERATED. GI/GU: REMAINS NPO AT PRESENT. NO OGT/NGT. ABD SOFT, HYPOACTIVE BS. FOLEY DRAINING YELLOW URINE ~100CC/HR. BUN 84 CRT 2.3 TODAY SKIN: COCCYX/BOTH BUTTUCKS EXCORIATED WITH SCATTERED OPEN AREAS. PT CONSTANTLY MOVING AROUND IN ?BED TRYING TO GET OFF BOTTOM. MEDICATED WITH DILAUDED IV WITH EFFECT. PT TURNED SIDE TO SIDE. PROTECTIVE OINTMENT APPLIED TO AREA. WILL NEED AIR MATTRESS TODAY. SOCIAL: SON AND DAUGHTER VERY SUPPORTIVE. STAYED WITH PT MOST OF NIGHT. SLEPT IN WAITING ROOM OVERNIGHT. ACCESS: RIGHT IJ PA LINE. LEFT SUBCLAVIAN TRIPLE LUMEN PLAN: FULL CODE. WILL BE INTUBATED IF NEEDED. CURRENTLY OXYGENATING WELL ON NRB. WEAN O2 AS TOLERATED. ? OBTAIN ABG TO CHECK CO2. MONITOR HEMODYNAMICS. ?TEAM TO ADVANCE PA CATHETER TODAY. CONTINUE DIURESIS. ? ? SKIN CARE CONSULT. NEEDS AIR MATTRESS. ?NUTRITION PLAN. SUPPORT FAMILY. ||||END_OF_RECORD START_OF_RECORD=17||||4|||| s: "all over" in reply to where does it hurt? o: pls see carevue flowsheet for complete vs/data/events resp: when pt calm rr 14-20, nonlabored. attempted to support pt off bipap this am but sats dropped and pt req nt sxn'ing and was placed back on bipap at prev settings. has one other episode of desat this afternoon on bipap. had congested cough and sats dropped to 80s and pt restless and agitated with rr to 30s. req nt sxn'd. each time pt was sxn'd for sm amts of rusty to bldy secretions. sats improved with this. awaiting team to draw abg. sats generally 95-98%. cv: has remained in sr, rate 75-90. no vea. k 3.8. bp 95-130/60-70. iv ntg titrated up to decrease preload from 70 to 100mcg. goal sbp >100/ . heparin at 1100u/hr. ptt 78. pap 65-75/30-36. cvp 11-18. mv sat 72. co 9.6, ci 4.7 with svr 400. gu: responding poorly to iv bolus of lasix, last given at 3am 120mg. started lasix gtt at 6mg/hr at 11am. increased to 8mg/hr at 1:30pm with goal uop 150-200cc/hr. fluid balance approx 200cc neg from mn. cr stable at 2.3, bun 84. gi: remains without ngt currently. unable to initiate po med or feeds d/t ms and resp status. ordered for tpn tonoc, has port on tlc saved for this from gsh. abd is soft, hypoactive bs. smearing greenish, ob- stool. heme: hct stable at 26.9. no plans to transfuse currently. will follow bid. inr 1.2 ms: lethargic but arousable this am. has had some periods of agitation, pulling at mask vent, iv's, monitor. requires soft wrist restraints. more alert this afternoon. can follow commands to squeeze hand. moving all extremities equally. has not req ativan or pain med this shift. would pursue haldol if agitation cont to factor into resp decompensation. skin: has difuss superficial rash across buttucks. some sm areas open and excoriated. barrier cream applied after cleansing with aloe foam cleanser. pt placed on 1st step mattress. social: pt's dtr and son left for home this am after being updated by dr [**Last Name (STitle) 167**]. they can be reached on the cell phone, # is in green chart(nsg admit note). a: tenuous resp status, alt ms. p: follow sats. check abg. follow hct. replete k. begin tpn this eve. cont to follow need for sxn'ing and neb tx. assess response to lasix gtt and titrate to goal uop. support to pt and family. ||||END_OF_RECORD START_OF_RECORD=17||||5|||| INITIALLY PT. ON 100% NRB BECAUSE OF INCREASED AGITATION WITH BIPAP LAST NOC. PLACED BACK ON BIPAP B/C OF INCREASING EPISODES OF DESATS, AS LOW AS 74%. SETTINGS 10/5/65%-100%, TOLERATED UNTIL EARLY AFTERNOON, THEN PT. BEGAN TO DECOMPENSATE ABG 7.35/66/55 ON [**07-02**] BIPAP 65% 02. ATTEMPTS TO CORRECT ABG FUTILE, SEDATED AND INTUBATED. PLACED ON 600X12/5/65%. TOLERATING WELL AT THIS POINT ABG AND CXR PENDING. ||||END_OF_RECORD START_OF_RECORD=17||||6|||| n-lethargic, sedated with propofol s/p intubation, arouses appropriately to tactile stimuli r-progressive dyspnea-visibly struggling to breath-pa02 only 55-co2 66-ph 7.35 on bipap therefore-intubated repeat abg on ac 600 x 12 65% +5peep 79-65-7.35 therefore ^tv to 700, brb sx via ett- very wheezey/tight breath sds- alb/atrovent mdi's, pip's remain 45, hct 26.9 this am now 22 transfusing first of 2uprbc's presently- brb less via ett- ptt was 79 on 1100u/hr heparin now dc'd d/t bleeding reportedly patient has restrictive and obstructive pulm process-pulm consulted, chf also component-lasix drip ^10mgs/hr with 120mg bolus with only marginal diuretic response(240cc)/repeat bolus of 120mgs lasix given with initiation of blood-uo only 10cc past 2hours cv-hr 60-70, map's>60- iv ntg dc'd peri-intubation d/t bp-it was started d/t ^right sided filling pressures but pa #'s unchanged with ntg-also found pa to be pulled back to rv and cordis slipped back therefore line dc'd, l sc cvl remains and cvp-18 gi-ogt placed, tpn initiated gu-lasix drip with marginal uo, repeat creat tonight afebrile family in and updated a/p-resp compromise req intubation-oxygenation/ventilation remain sub-optiaml-adjusting vent prn, fluid volume status tenuous-follow closely, assess s/sx bleeding-transfuse ||||END_OF_RECORD START_OF_RECORD=17||||7|||| S: Orally intubated and sedated. O: PLease see carevue for VS and objective data. CVS: Hemodynamically stable with HR noted to be in Afib at a rate of 58-70's, EKG down, team assessed. no vea noted, K+ 3.5 given add. 40meq IV KCL, with repeat K+ 4.0, am pnd. BP ranges 88-130/40-60. IV NTG remains off, to start ace-inhibitor when BP allows. Resp: Remains orally intubated and mechanically ventilated with vent changes and abgs as per flow. Present settings A/C 600x12, 65% 5 peep. Most recent abg 130/52/7.42/35/8/98%. Lungs remain coarse throughout with good air movement. Suctioned q 2-3 hours for bloody to blood tinged, tan sputum. Repeat Hct after 1 unit PRBC 27.1, without further transfusion at present, am Hct pnd. IV Lasix drip titrated to 15mg/hour with hourly u/o response 40-160cc/hour. MN I/O 100cc neg, LOS 1600cc neg. U/O dropped overnoc to 40cc/hour, attempted 120mg IV Lasix bolus with fair response as per flow. CXR done post intubation and NGT placement, in good polacements as per teams report. TLC in good place. GI: GU: TPN conts at 41cc/hour, NGT in good placement with minimal bilious drainage, U/O via foley, light yellow urine with sediment. Loose brown stool x1, quaic pos. BS hypoactive. ID: afebrile Neuro: Sedated on IV Propofol, titrated as per flow, presently at 21.6 mcg/kg/min. Pt. responding to verbal and tactile stimuli with facial grimaces, and pulling at left soft, hand restraint. Attempting to reach for ETT. Not following commands. No movement of LE noted. PERL. Wife in to visit with 2 grown children. Pt. responsive with movement of hands L>R. Soft hand restraints remain in place. Skin: Buttocks and coccyx reddend and excoriated, cleaned and turned frequently. Destin lotion applied. Of noted, just below site of L SC TLC, Pt's own skin fold at level of armpit to shoulder is large, soft, boogy tissue, with permenant crease under skin. Team in to assess. All three port of TLC with good blood return and flush easily. CXR confirmed good placement of TLC. A: improved oxygenation and ventilation with intubation, mod. response to IV Lasix. Hct improved after one unit PRBC. P: Cont to monitor hemodynamics and rhythm, ? restart Amiod. po in setting of Afib. Cont with aggressive pulmonary toileting and duiresis, ? increase Lasix drip or continue boluses. Follow up with am labs, ? restart Heparin if Hct stable in setting of PAF. To start ace-inhibitor when BP allows, ? hydralazine instead of Captopril as ordered with increasing creat. Assess neuro status. Comfort and emotional support to Pt. and family ||||END_OF_RECORD START_OF_RECORD=17||||8|||| S/O: REMAINS INTUBATED CV: HR AF IN 70'S INITIALLY, CONVERTED TO SB WITH PR INTERVAL .22 AT 10A. SBP 80'S-130'S. K 3.8 40 KCL GIVEN PO, RECHECKED. CAPTOPRIL STARTED AND INC TO 12.5 MG AT 1600, WILL CONT TO INC WITH EACH DOSE UNTIL 37.5 MG TID. CVP 12-18. 500 CC NEG SO FAR TODAY, LASIX DEC TO 10 MG/HR AT 1600 B/C OF NEG FLUID BALANCE AND LOW SBP. GOAL IS TO KEEP EVEN TODAY. HEP SC STARTED TODAY, WILL HOLD ON IV HEP UNTIL TOMORROW DEPENDING ON HCT. RESP: VENT CHANGES PER CAREVUE, ABG IMPROVED WITH PO2 80'S AND PH 7.39. SUCTIONED Q4H FOR THICK BLOOD TINGED SPUTUM, SPEC SENT. PER PULMONARY, CXR IMPROVED FROM YESTERDAY, WILL NOT BRONCH TODAY. LS COURSE THROUGHOUT. ID: AFEB TODAY, WNL NL. GI: OGT CLAMPED, BILIOUS DRAINAGE, PH 4 AND CLEAR. SMALL STOOL IN AM, REC'D 1U PRBC THIS AM, HCT PND. NO EVIDENCE OF OVERT BLEEDING. BS HYPOACTIVE. TPN CONT AT 41CC/HR. GU: LASIX GTT DEC IN PM, BLACK SEDIMENT IN URINE. MS: RESPONDS NON-PURPOSEFULLY TO PAIN, PROPOFOL INC X2 TODAY B/C OF AGITATION AND DIFFICULTY VENTILATING WHEN PT MORE AWAKE. SKIN: PINK, SCALEY PATCHES ON SCALP AND DIFFUSELY ON REST OF BODY. DAUGHTER IS BRINGING IN SHAMPOO AND LOTION PT USES AT HOME. NO OVERT BREAKDOWN ON COCCYX BUT EXCORIATED. BARRIER CREAM APPLIED AND PT TURNED FREQ. A/P: FOLLOW SBP CLOSELY AS PT APPEARS DRY. ASSESS FOR SX OF BLEEDING, AWAIT LAB RESULTS. CHECK ABG AT 1800. CONTINUE SKIN PROTOCOL THAT PT USES AT HOME. ||||END_OF_RECORD START_OF_RECORD=17||||9|||| S: orally intubated and sedated O: please see carevue for VS and objective data. CVS: Hemodynamically stable with HR 50-60's Afib, team aware. No vea noted. BP ranges 90-120/40-50, with drop into the mid 70's/30 after 25mg po Captopril dose. Dr. [**Last Name (STitle) 168**] notified, responded to 250cc NS bolus as per flow. CVP 10-15. Resp: Remains intubated and mechanically ventilated with vent settings and improved abg as per flow. PO2 improved to 122 (60's) after NS lavage and suctioning a moderate size blood tinged plug. Suctioned q 3-4 hours for blood tinged, thick sputum. IV Lasix drip initially at 5mg/hour, titrated to off secondary to I/O 400-500cc neg. and team's goal was for I/O to be even. Remains off with I/O running approx. 400cc positive overnight after NS bolus for low SBP. GI:GU: TPN conts at 41cc/hour. Foley to drainage yellow urine with brown flecks of sediment, U/O as above. BS active. Loose golden mucous stool x2. NGT in good placement with minimal residuals. Neuro: Remains sedated on Propofol drip at 21.6 mcg/kg/min. Titrated/held briefly when SBP low. Moving UE L>R, soft hand restraints in place. Not moving LE. PERL. Intermittently following simple commands, ie: open eyes, but not squeezing hands. +gag,+cough. ID: afebrile Skin: Buttocks and coccyx remain red and excoriated, desitin lotion applied, turned q 2 hours. Skin care provided with Pt's lotions from home for psoriasis. A: Stable, improved oxygenation after aggressive pulmonary toileting, drop in SBP after increased Captopril dose P: Cont to with aggressive pulmonary toileting. Follow up with am abg and labs, monitor I/O closely, CXR in am. Check with team regarding Captopril dose for am. Skin care/turning frequently. Comfort and emotional support to Pt. and family ||||END_OF_RECORD START_OF_RECORD=17||||10|||| S/O: CV/FLUIDS: CAPTOPRIL 25 MG GIVEN THIS AM IN DIVIDED DOSES AND AT 1600 IN ONE DOSE. SBP STABLE, HIGHER TODAY AT 110-150'S. ASA STARTED. PT 700CC POS BY 1500, LASIX 120 MG GIVEN IV X1 WITH GOOD DIURESIS. FREE WATER BOLUS STARTED Q4H X24H. NA 148. HR 50'S-70'S SR WITHOUT VEA. EKG UNCHANGED. RESP: WEANED TO 20 PS AND 7.5 PEEP AT NOON TODAY. INITIALLY RR IN 30'S AND TV IN 300'S. PROPOFOL INC SLIGHTLY AND RR DROPPED TO 20'S WITH TV INC TO 400'S. ABG X2 STABLE, OXYGENATION BETTER ON THE SECOND ABG. SUCTIONED X4 FOR SMALL RUSTY SPUTUM, BLOOD IS CLEARING WELL. LS CRACKLES AT BASES, CLEAR UPPER LOBES. ID: AFEB, URINE CS PND. GI: STARTED TF AT 20CC/HR, REPLETE WITH FIBER. RESIDUAL AT 1600 50CC. WILL FINISH TPN AND THEN D/C. STOOL MORE FREQ TODAY, GOLDEN COLOR, OB POS. RECTAL CATHETER ORDERED. GU: DIURESING WELL AFTER LASIX BOLUS. CREAT/BUN CONT TO RISE. SEDIMENT STILL IN URINE. SKIN: BUTTOCKS, BACK AND ARMS WITH PATCHY SCALEY REDDENED AREAS. CREAM FROM HOME APPLIED FREQ. SMALL PIN-POINT OPENINGS ON COCCYX AREA. WILL INSERT RECTAL TUBE WITH NEXT TURN. HAIR WASHED WITH TAR SHAMPOO AND MOST OF SCALES REMOVED. ALINE AND TLC SITE D/I. MS: PROPOFOL INC SLIGHTLY TODAY FOR INC RR, HR AND SBP. NODDING HEAD TO QUESTIONS AT TIMES. MOVES LEFT HAND WELL BUT RIGHT HAND MOSTLY LIMP. A/P: CHECK HCT AND K THIS PM. FOLLOW FLUID BALANCE, WANT EVEN FOR TODAY. D/C TPN AFTER BAG FINISHED. FOLLOW RESIDUAL TF AND INC AS TOL. PT NEEDS DIETARY CONSULT IN AM AS TO GOAL AMOUNT. FOLLOW ABG'S ON PS, RETURN TO A/C IF PT TIRES. TITRATE PROPOFOL FOR COMFORT. ||||END_OF_RECORD START_OF_RECORD=17||||11|||| Respiratory Care: Patient remains intubated on mechanical support. Vent settings Psv 20, Cpap 7.5, Fio2 50% with flowby 6/3. Bs decreased bilaterally. Sx'd for moderate amounts of thick rusty sputum. Albuterol/Atrovent MDI's given Q4hr. Pt. sedated. Spont vols on above settings 400's with RR 22-24. O2 sats 94-96%. No further changes made. Continue with Psv as tolerated. See Carevue for Abg's. ||||END_OF_RECORD START_OF_RECORD=17||||12|||| CV: HR 60-70'S SR NO VEA, BP 120-140/50-70, TOLERATED CAPTOPRIL 37.5 W/ NO CHANGE IN BP. RESP: NO VENT CHANGES MADE. SX Q 1-2 HR FOR MOD AMTS THICK RUSTY SPUTUM. GI: TOLERATING REPLETE W/ FIBER, W. RESIDUALS >20CC, RATE INC TO 30CC/HR. 1 MED LIQ BM. RECEIVING 250CC FREE WATER BOLUSES FOR ^ NA. 150 AT MN. GU: FOLEY DRAINING CL YEL URINE W/ SM AMTS BLACK SEDIMENT. 100-200CC/HR, CURRENTLY ~ 200CC NEG. HEME: 2ND UNIT PRBC COMPLETED AT 8PM, F/U HCT AT MN 35. NEURO: REMAINS ON PROPOFOL 26 MCG/KG/MIN,. APPEARS COMFORTABLE, RESPONDS TO STIMULI. SOCIAL: FAMILY IN TO VISIT MOST OF EVE. ||||END_OF_RECORD START_OF_RECORD=17||||13|||| pls see caevue flowsheet for complete vs/data/events s: orally intubated o: pt remains sedated and ventilated. id: afeb. wbc 11.8. no abx. neuro: sedated with propofol at 28.8mcg/kg/min, has req occ sm bolus with sxn'ing, interventions. nonpurposeful responses to stimuli in general. will occ nod head to ?s appopr, follow simple commands. cv: sr with rate 50-70s. no vea. bp 90-140/40-50. dropped to high 80s after captopril dose of 50mg, resolved without intervention. k 4.1. ca 8.0. ionized ca 1.07. mg 2.1. po4 5.3. will discuss w/ team repleting calcium. resp: cont on ps 20, peep 7.5. 50%. tv avg around 500. rr 10-16. sxn'd q2-4hrs for thick drk brwn rusty secretions in mod amts. occ plug noted. bs with scatt cxs. plan for ct of chest today for further eval. last abg: 7.37/53/89/31/2. sats 95-100%. gi: abd soft, distended, hypoactive bs. residuals 20cc. replete w/ fiber advanced to 40cc/hr. goal 50cc. smearing soft green stool. no real bm. gu: uop 50-80cc/hr. no diuresis. goal even. currently 200cc+ from mn. na 150. free water boluses changed to q6hr and pt started on d5w ivf at 50cc/hr. cr 2.4, bun 103. heme: hct 35.9. inr 1.1. prophy: cont on sq heparin. zantac changed to protonix. access: tlc in l sc. r rad aline. status: full social: dtr [**Name (NI) **] in contact by phone, plans visit this eve. a: stable. cont hypernatremia. p: pulm toilet. advance tf as tol. follow rhythm, hemodynamics, volume status. support to pt and family. ||||END_OF_RECORD START_OF_RECORD=17||||14|||| resp note - pt remains intubated and mech vetilated, weaned to ps 17 peep 7.5 40% fio2, abg 7.39 - 49 - 69 - 31 - Spo2 93%. ||||END_OF_RECORD START_OF_RECORD=17||||15|||| RESP NOTE:PT REMAINS INTUBATED AND VENTILATED WITH NO REMARKABLE CHANGES IN RESP STATUS.B/S DIMINISHED BILAT WITH SX FOR SMALL AMOUNTS PALE/YELLOW SECRETIONS T/O THE EVENING.MDI"S GIVEN AS PER ORDER,NO RESP DISTRESS NOTED,ABG"S AVAILABLE IN CAREVUE. ||||END_OF_RECORD START_OF_RECORD=17||||16|||| s: remains orally intubated and sedated o: pls see carevue flowsheet for complete vs/data/events id: afeb. wbc 9.9(11.8). no abx. neuro: remains on propofol at 28/mcg/kg. fairly lightly sedated. arousable but nonpurposeful. grimaces to pain. coughs. min movement of extremities. cont with soft wrist restraints for safety. cv: converted to aflutter this am. rate has been in the 50s-60s. has occ dropped trans to 40s with up to 2 sec pauses. bp in general has been stable but lower overall. 90-105/40 via r rad aline. ausc is sig lower. has at times dropped bp to the 80s but trended back up >90 without intervention. captopril dose held today per bp parameter. k 4.2. resp: ps weaned down today. on 17ps, 10peep, 40%. abg: 7.42/42/62/28/2. sats 93-95%. occ drops to 88-90 but improves with sxn'ing. sxn'd for mod amt thick tan, occ bld tinged secretions q2hrs. ps further decreased to 15 at 2:30pm. tv avg 400cc, rr 18-24. abg to be rechecked. gallium scan planned. pt to be injected this afternoon and undergo scan friday. gi: replete increased to 50cc/hr at 3pm after min residuals on 40cc/hr. abd dist, hypoactvie bs. sm amt loose, golden stool. ob neg. na 143(150). ivf dc'd. cont on free water boluses. gu: attemtping diuresis with min effect. rec'd 180mg iv lasix this am. will give diuril and lasix when avail from pharmacy. uop 50-60cc/hr. currently 1300cc+from mn. uop with sm amt drk brwn/black sediment. bun 105(103), cr 2.5(2.4). heme: hct 33.6(35.9). skin: applied mycostatin powder to scrotum/groin area. triamcinolone cream to affected areas on bottom/legs. pt has some min bld drg from 4th toe on r foot. toe nail is loose. no erythema. remains on 1st step mattress. social: dtr has called, will visit tonoc. a: aflutter, bp lower. poor response to diuresis. tol ps wean. p: diuril/lasix this afternoon. assess response. follow abg and tol of ps wean. follow hemodynamics. skin care. support to pt and family. ||||END_OF_RECORD START_OF_RECORD=17||||17|||| S/O: DIURIL AND LASIX GIVEN IV WITH 140-160CC/HR U/O. URINE CONT WITH DARK SEDIMENT. SATS UNCHANGED. CAPTOPRIL HELD FOR SBP IN 80'S AT TIMES, WILL TRY AT MN AFTER DIURESIS. ABG SENT AFTER PS DEC. PT CONT SEDATED WELL ON PROPOFOL, OCC NEDS TO QUESTIONS. A/P: FOLLOW DIURESIS, ATTEMPT CAPTOPRIL AT MN. ||||END_OF_RECORD START_OF_RECORD=17||||18|||| PT. INITIALLY ON PSV/CPAP 15/10/40%. EXPERIENCED SOME TACHYPNEA RR 40-45 WITH VOLUMES 300MLS. INCREASED PS TO 18, ABG AFTER CHANGE 67/48/7.39 WITH RR 20'S VT 400-500'S. BS: COARSE TO MILD RHONCHI REQUIRING Q2 SXNING FOR BROWN OCC. BLOOD TINGED SPUTUM. PT. TOLERATING CURRENT SETTINGS WELL AT THIS TIME ||||END_OF_RECORD START_OF_RECORD=17||||19|||| ccu nursing progress note 7p-7a neuro: sedated on propofol increased to 30mcg/kg/min. moving upper extremities spontaneously at times. cv: hr 50-60's aflutter. no vea noted. bp 100-110/40's. captopril 25mg given at mn. tolerated well. given lasix 180mg iv at 3am. no increase in u/o noted. pt remains positive today. pulm: ls coarse, diminished at bases. o2 sat 92-98% on vent. ps increased from 15 to 18 for ^rr and decreased tv. pt tolerating ps 18 better. peep 10 fio2 40%. tv 400's. am abg 74/41/7.42/28/1. sx q2hrs thick tan/yellow secretions. gi/gu: abd soft, distended. +bs. loose mucousy brown stool x1. guiac negative. speciman sent for cdiff. tube feedings changed to replete WITHOUT fiber r/t unavailability of replete with fiber. cont at 50cc/hr, no residuals. u/o 50-80cc/hr. no increase noted with lasix given. noted to have pus draining from penis around catheter. id: afebrile. not on abx. skin: psoriasis all over. coccyx raw and excoriated. pt turned and repositioned. on 1st step overlay mattress. plan: cont pulmonary toilet and wean vent as tolerated. await results gallium scan. monitor hemodynamics. transferred to micu team yesterday. ||||END_OF_RECORD START_OF_RECORD=17||||20|||| resp note - pt. weaned to ps13 peep 5 40% fio2, tol ok at this time,spon rr 15 - 20, spon tv 400 - 500 cc abg 7.38 47 72 95% ||||END_OF_RECORD START_OF_RECORD=17||||21|||| n-sedated with propofol drip r-psv 13/10 peep fio2 40% tv's-450-540 rr teens, small amt sx's stable oxygenation/ventilation when sedate-does become tachypneac and loses tv's when aggitated from suctioning and when lighter on propofol abg 79-45-7.38-28-0 cv-afib/flutter 50-60 bp 90/40 range , na corrected, kcl repleted gi-tf changed to ultracal at 70cc/hr-large liq stool gu-qsuo-lasix 180 at 12noon with fair response-just becoming negative now-will need more lasix to achieve neg 1-2l goal afebrile, hct stable>34 psoriasis/yeast rx with powders/creams family phoned and updated a/p-tolerating psv wean today-assess fluid vol balance and contiunue to diurese, cont all current supports ||||END_OF_RECORD START_OF_RECORD=17||||22|||| O: For complete VS see CCU flow sheet. ID: Pt afebrile. RESP: Pt remains intubated on 40% c-pap 10 PEEP/13 PS with tital volumes ~45-500 and last gas on that setting 84/ 49/ 7.38/30. He required suctioning ~Q2-3 hrs for thick lt yellow sputum. Breath sounds are course. CV: Pt remains in a-flutter with hr of 50-6o and BP ranging 90-115/40s. GU: Pt had only fair response to increased lasix dose at 6pm and he remains positive 200cc for the day. GI: Pt tolerating tube feeds with minimal residual. He had minimal liquid stool out through rectal bag. SEDATION: Pt remains on propofol at 30/mic kilo. He rouses a little with suctioning. He does not follow commands. A: Poor diuretic response. P: Keep careful I & O. Suction prn. Check for TF residual. ||||END_OF_RECORD START_OF_RECORD=17||||23|||| ccu nursing progress note 11p-7a neuro: sedated on propofol at 30mcg/kg/min. arousable to stimuli. requiring propofol boluses with agitation. cv: hr 60's abib/aflutter. no vea noted. bp 86-120/40's. bp dropped to 80's systolic after captopril and later with lasix x1. resolved without intervention. given lasix 240mg x1 for goal -1 liter. pulm: ls coarse, decreased at bases. sx q2-3hrs small amt yellow/white secretions. o2 sat 94-98% on ps 13 peep 10 fio2 40%. tv 400-450. rr 22-28. am abg 74/48/7.41/31/4. gi/gu: abd soft/distened. hypoactive bs. on ultracal at 70cc/hr. residuals 60cc and 120cc. held x2 hrs for 120cc residual. rectal bag draining small amt liquid brown stool. foley draining mod amt yellow urine with sediment. skin: pt with psoriasis, receiving various powders and creams from home. pt has area ecchymosis on left side of abdomen. ? from constantly trying to scratch area. hydorcortisone cream applied. ? effect. on 1st step overlay mattress. turned side to side. plan: wean vent as tolerated. cont diuresis. check tube feed residuals. communication with family. await results gallium injection/scan. ||||END_OF_RECORD START_OF_RECORD=17||||24|||| resp. care note: No vent changes made this shift. Vent settings are psv+cpap 13/10 40%. Pt suctioned for a moderate amount of thick tan secretions. Mdis given as ordered. Plan is to continue vent support at this time. for further information please refer to carevue charting. ||||END_OF_RECORD START_OF_RECORD=17||||25|||| SYSTEMS REVIEW: NEURO: SEDATED ON PROPOFOL; MOVING LEFT ARM ON BED AT TIMES; RESPIRATORY: VENTED; ON CPAP WITH PRESSURE SUPPORT; FIO2 40%; RR 18; O2 SAT 95%. CV/HEMODYNAMICS: IN SB - SR WITHOUT ANY ECTOPY FOR MAJORITY OF NIGHT; APPROX. 0400- APPARENT BLOCKED PAC'S; DOPAMINE TAPERED TO OFF AS OF 0400- MAP> 60 ENTIRE WEAN; GI: ON ULTRACAL TUBE FEEDINGS AT 70 CC/HR; TOLERATING WITHOUT EXCESS RESIDUAL; FIB IN PLACE- PASSING THICK STOOL ID: AFEBRILE; ON OXACILLIN Q 4H. SOCIAL: SON AND DAUGHTER VISITING IN EARLY EVENING; RECEIVED UPDATE ON CONDITION AND PLAN IF CARE. ||||END_OF_RECORD START_OF_RECORD=17||||26|||| Pt. initially on 13/10 in am. On rounds it was decided to lower peep to allow for larger VT's given pt.s restrictive component. However pt. was transported to nuclear med. for gallium scan, showing tracheal malacia.Pt. on ac 550x12/5/50% during procedure, sedated with propofol. After procedure pt. sedation decreased, placed on simv until ventilatory drive returned. Now on PSV 15/7.5 with RR 20s Spo2 >95.ABG pnd, tolerating current settings at this time/ ||||END_OF_RECORD START_OF_RECORD=17||||27|||| n-sedated on propofol infusion, arouses to tactile stimuli r-weaned back to psv 15/peep 7.5 with stable oxygenation/ventilation-thick large amount of secretions cv-sb-50's-60, map's>60 off dopa, gi-tf's at goal, stooling gu-poor diuretic response to lasix afebrile on oxy gallium skan revealed tracheal malasia daughter updated skin yeast/psoriasis-creams/powders a/p-vent dependent-continue all current supports ||||END_OF_RECORD START_OF_RECORD=17||||28|||| Pt remains intubated on PSV+CPAP 13/10 FIO2 40%. TV 440-480, RR 20-30. ETT sx'ed for large amt tan secretions. Sputum Cx sent. B.S. coarse t/o. Albuterol MDI given Q4hr as ordered, no increase in air entry noted or increase in TV after tx. Awaiting for Atrovent MDI from Pharmacy ordered Q4hr. No changes in vent mgt this shift. ||||END_OF_RECORD START_OF_RECORD=17||||29|||| s/o: pls see carevue flowsheet for complete vs/data/events cv: aflutter all shift with rates in the 50-60s. occ pvc. bp 110-120/50 via r rad aline. resp: ps 15/peep 7.5, 40%. rr 18-24. tv avg 400-450cc. sxn'd q2hr for lrg amt thick tan secretions. last abg: 7.38/59/62/36/7. gi: lrg residuals at 11pm. held for sev hours. resumed at 70cc/hr at 2am. abd soft, +bs. gi asp green, ob -. has some stool in bag, unchanged overnoc. gu: 400cc+ at mn. rec'd 2.5 zaroxyln/200mg iv lasix with cont uop 100-150cc/hr. ms: cont on propofol. grimaces to pain/sxn'ing. social: family visited last eve. updated. a/p: follow uop. cont to diurese. follow renal fxn. ||||END_OF_RECORD START_OF_RECORD=17||||30|||| patient weaned from PS 15 to 10 this evening without difficulty.BS diminished , ambued and suctioned for copious amount of rusty looking sputum. SPT VT on PS 10= 360mls. On flovent ,ventolin ,and atrovent.Patient does not have atrovent in room.I called the Pharmacy and RN faxed order and paged pharmacist, but medications are still not received yet; please follow up. ||||END_OF_RECORD START_OF_RECORD=17||||31|||| ccu nursing progress note 7a-7p neuro: sedated on propofol at 35mcg/kg. responds to noxious stimuli. cv: hr 50-60's afib/flutter. occ pvc's noted. bp 110-130/50's via right radial aline. pulm: remains intubated. ps decreased from 15 to 10 today. tolerating thus far. peep 10 fio2 40%. tv 350-400 rr 12-20's. abg on ps 10 64/58/7.40/37/8. sx q2-3hrs thick tan sputum. o2 sats 92-98%. gi/gu: abd soft, distended. hypoactiv bs. not tolerating tube feedings. ultracal with >100cc/residuals this am. held for most of morning. resumed at 35cc/hr. started on reglan today. sm amt liquid brown stool via rectal bag. foley draining ~100cc/hr yellow urine with sediment. bun 112 crt 2.4. diuresis held today. skin: receiving nystatin powders/creams prn. on 1st step overlay mattress. turned and repositioned. id: afebrile. sputum sent last night revealed gram + rods, gram - rods, gram + cocci in pairs. on oxacillin q4hrs. await culture results. plan: cont wean ps as tolerated. cont abx. check sputum culture. goal to keep pt even today. advance tube feeds as tolerated. ||||END_OF_RECORD START_OF_RECORD=17||||32|||| Respiratory Care: Patient remains intubated on mechanical support. Vent settings Psv 10, Cpap 7.5, Fio2 40% with flowby 6/3. Spont vols 400's with RR low 20's. Bs rhonchi bilaterally. Sx'd/lavaged for moderate amounts of thick tan sputum. Albuterol/Atrovent MDI's given q4hr. Flovent MDI bid. Pt. weaned to 10cm Psv yesterday and tolerating well maintaining adequate vols. No further changes made. Continue with Psv and slowly wean as tolerated. ||||END_OF_RECORD START_OF_RECORD=17||||33|||| s/o: pls see carevue flowsheet for complete vs/data/events resp: on ps 10, peep 7.5, fio2 40% overnoc. rr 18-24, tv avg 400cc. sat >95% overnoc. pt req freq sxn'ing for thick tan secretions in mod amts. around 5am pt became tachypneic to the 30s. tv avg 350-400. req freg sxn'ing for some thin white secretions. appeared agitated. picking at anything near his l hand, grimacing, shaking. attempted to gently go up on propofol after a bolus without much effect. abg obtained: 7.44/55/57/39/10. sat 90%. intern called and examined pt. fio2 increased to 50%. repeat abg: . attempted to further increase propofol for vent mgmnt and pt comfort. bolused and ^'d to 40mcg/kg/min with min effect. rr cont in the 30s. tc at time drop to 280-320 range but gen remain close to 400. cont to require freq sxn'ing q20-30min this am. bs scatt coarse, occ crackles. cv: hr 60s, up to 80s this am with agitation. remains in aflutter. occ pvc noted. bp 120-130/ up to 150-170/60-70 w/ agitation. gu: uop 60-80cc/hr. 1.2l neg at mn. 200cc+ from mn. no diuresis. gi: abd soft, distended. +bs. residual <20cc at 10pm and tf increased to 50cc/hr. id: tmax 99.1 po. cont on oxacillin. neuro: resting comfortably most of night. agitated this am. moving arms. picking at wires/tubes, shaking. attempting to ^ propofol to manage. social: dtr and son visited last eve. plan to visit today with their mother. access: has l sc tlc. r rad aline. status: full code. a: agitation and hypoxia/tachypneia p: pulm hygiene. adjust vent parameters as indicated. sedation for pt comfort/safety and vent management. update and support to family. ||||END_OF_RECORD START_OF_RECORD=17||||34|||| Patient went to CT Scan this evening.Fully sedated prior to departure; placed on A/C 550*8-50%-7.5P. Patient remains on the preceeding settings for now ,but will soon change back to PSV.%Sat at moment is 97%;no recent ABG drawn. 7:58 AM ABG 7.44-52-69-36-(9). ||||END_OF_RECORD START_OF_RECORD=17||||35|||| ccu nursing progress note 7a-7p neuro: pt originally sedated on propofol, dose varying throughout day. increased for ct scan then weaned to off and pt started on ativan. ativan titrated for comfort to 3mg/hr. pt sedated most of day with periods agitation. cv: hr 50-60's. started day in aflutter. approx 1030 bp down to 80/40, noted pt to be in nsr/sb 50-60's. ekg done. ho notified. given iv bolus 250cc with some effect. propofol decreased at that time. bp ^90-100's systolic. again approx. 3pm bp down to 80 systolic again, given 2nd iv bolus 250cc with effect. pt currently with bp 130-140/70's, hr 70's nsr. no vea noted. pt remains positive today +1300cc. goal to maintain even/positive. pulm: ls coarse, diminished at bases. o2 sats 92-98% on vent ps 15 peep 7.5 fio2 50%. goal was to wean ps today but pt placed back in AC for transport to CT scan today and returned back to PS 15 approx 6pm. allowing pt to rest at present. ?will wean tonight or begin in am. abg this am on 50% fio2 7.44/53/60. sx q2-3 hrs thin white/thick tan secretions. pt sputum culture +pseudomonas, ho notified. currently on oxacillin q4hrs. gi/gu: abd soft/distended. hypoactive bs. low residuals via ogt this am. tolerating ultracal increased to 70cc/hr. on reglan qid. no stool this shift. foley draining qs yellow urine with sediment. id: afebrile. + sputum culture as noted above. await possible abx change. skin: psoriasis unchanged. creams and powders as ordered. 1st step overlay mattress. access: left subclavian triple lumen with large erythema area surrounding line. ho notified this am and reviewed on rounds. seen on ct scan. ? reason for swelling. triple lumen to remain in at present. plan: titrate ativan for sedation. cont pulm management and wean vent as tolerated. abx for pseudomonas in sputum. await ct results. family visited and updated. monitor bp to maintain maps >60. ||||END_OF_RECORD START_OF_RECORD=17||||36|||| NSG NOTE CARDIAC/RESP: INITIAL RATE AND RHYTHM. NSR WITH HR 70-80'S. BP 130-140/50-60. PT HAD RARE PVC;S AND PAC'S NOTED. AT 0100 PT CONVERTED TO WIDE COMPLEX TACHYCARDIA, WITH HR 100-1112. EKG COMPLETED AND HOUSE STAFF NOTIFIED. EKG SHOWING NEW LBBB WITH ST DEPRESSION IN V1-V2,I,AVR. BP 164-170/80-90. ALSO HAD RALES NOTED IN BILAT BASES. O2 SATS DOWN TO 88%. PT RECEIVED LASIX 200MG IV,LOPRESSOR IV (BY HO) TOTAL 10MG. PT COUGHING AND AGITATED. SUCTIONED WITH LAVAGED X3 FOR THICK TAN/YELLOW PLUGS. INITIALLY ON CPAP 50%,PEEP 7.5.IPS 15. PT NOW PLACED ON AC 60% 550X12,PEEP 7.5, ABG 75,54,7.42,36,8. ALSO RECEIVED INHALERS. 0500 DROPPED O2 SATS 88%. SUCTIONED FOR THICK TAN. FIO2 INCREASED 60% IPS TO 20. BS EQUAL, BUT COURSE. 0500 PT DROPPED BP TO 77/60. CVP TRANSDUCED @ 10. NS 250CC BOLUS PER ORDER. STARTED ON DOPAMINE 5.0 MCG/KG/MIN WEANED DOWN TO 2.2 MCG AT PRESENT. BP 115/55. HYPOTENSION ? R/T SEDATION/LOPRESSOR COMBINATION. NEURO: PT MOVES L ARM AND HAND ONLY. UNABLE TO FOLLOW COMMANDS. DOES NOT OPEN EYES. INITIALLY ON ATIVAN GTT AT 3 MG,HOWEVER INCREASED TO 9.0 MG DURING HYPERTENSIVE EPISODE. INCREASE HAD LITTLE EFFECT. PT STARTED ON DILAUDID GTT ( ALLERGY TO MS04) WITH GOOD SEDATION EFFECTS. CURRENTLY ON DILAUDID 0.5 MG/HR AND ATIVAN 7.0 MG GI: TF ULTRACAL AT GOAL RATE 70CC/HR RESIDUALS 15-25CC/HR. REMAINS ON REGLAN. RECTAL BAG INTACT. GUIAC NEG LIQ BROWN STOOL. HO AWARE. ABD SOFT DISTENDED. HYPOACTIVE BS. GU: RECEIVED LASIX 200MG DURING ABOVE EPISODE. WITH FAIR DIURESIS. URINE IS CLOUDY/YELLOW. ID: PT INITIALLY ON OXICILLIN. DURING TACHYCARDIC EPISODE TEMP WAS 102.1 HO AWARE. PT NOW HAS PSEUDOMONIS PNEUMONIA. PT PAN CULTURED. TYLENOL PR GIVEN. OXICILLIN D/CD AND PT STARTED ON CEFTAZIDINE AND PIPERCILLIN. IV: PT HAS L SUBCLAVIAN TRIPLE LUMEN. ON INITIAL ROUNDS NOTED THAT LATERAL TO THE IV INTO THE L AXILLA AREA VERY EDAMATOUS FROM LOWER SHOULDER INTO AXILLA AND L BREAST. AREA OUTLINED. HOUSE STAFF NOTIFIED AND INTO ASSESS AREA. PT HAD SWELLING ON DAYS. NSG CONCERNED ABOUT INFUSING CURRENT IV MEDS INTO LINE. I SPOKE WITH HOUSE STAFF REGARDING SITE AND STATUS OF LINE. PT HAD CT SCAN ON DAYS. HOUSE STAFF AND RADIOLOGY ASSURED NSG THAT THE AREA WAS SOFT TISSUE SWELLING. LINE PLACMENT ADEQUATE AND NO HEMATOMA NOTED. I CALLED IV THERAPY TO ALSO COME AND ASSESS. I ATTEMPTED TO INSERT IV PHERP. UNSUCCESSFULL. IV NURSE UNSUCCESSFUL AS WELL. ORDER GIVEN TO CON'T TO USE L SUBCLAVIAN LINE,BUT TO NOTIFY STAFF FOR FURTHER INCREASE INSWELLING. PLAN IS TO U/S AREA IN AM ? THROMBUS. SKIN: PSORIASIS AREAS NOTED AND TREATED. SOCIAL: SON AND DAUGHTER IN TO VISIT ON EVES. A: RHYTHM CHGS ASSOCIATED WITH RESP COMPROMISE AND LABILE BP P: CXR IN AM U/S L SHOULDER CK CYCLE CON'T ABX SLOW WEAN DOPAMINE ||||END_OF_RECORD START_OF_RECORD=17||||37|||| Resp Care pt required further ventilation tonight and increased peep d/t tachypnea/desaturation/febrile....now on ac mode...refer to flow sheet for settings. borderline oxygenation on 60% and 10 peep...received lasix. frequent suctioning for tan to bld tinged sputum. admin albuterol/atrovent q4h. c/w full ventilation...did not tolerate psv mode last night despite increasing levels. ||||END_OF_RECORD START_OF_RECORD=17||||38|||| s: orally intubated and sedated o: for vs and objective data please refer to flow sheet section ID: low grade fever continues. antibx changed per team / id consult to cover pseudo in sputum. ( oxacilin, ceftadizine/ levaquin) awaiting urine culture results. cv: remains in afib thru eve, somewhat higher rate 0f 70 - 80 with occas pvc. last k 3.5 from am . Conts to be dopa dependent at 5 mcg/ kg. Attempted to wean by one drop at a time but sbp drop with turning/ some interventions. Pa line placed by team. See team note for opening numbers.thru eve cvp 10 - 12. pad's 24 - 27. co 6.5/ ci . resp: remains vented. setting 60%/ 550 / 12 with rare spon breaths. lungs with coarse sounds at bases. snx q 2 - 3 hours for thick tan with old blood streaks. gi: tf restarted at 8 pm at a rate of 30cc/ hr. abd firm / distended. bs hypoactive. reglan give as scheduled. stool in incontince bag/ drain is brown. loose. Daughter and son in this eve to visit and discuss plan of care with team. Both children find this overwhelming . They plan to give current plan 24 - 48 longer to change infection and dopa dependence then re assess. a: conts to be dopa dependent , vent setting un changed. low grade fever conts. p; cont with current plan, weaning dopa and / or vent when appropiate, cont with antibx as ordered, cont to provide info and emotional support to family ||||END_OF_RECORD START_OF_RECORD=17||||39|||| Resp Care remains vented ac 550x12x.6/10 peep with abg 7.39/58/75/+7. sxning thick tan. coarse bs. sedated. inhalers given as ordered. no vent changes made this shift.c/w full vent support. ||||END_OF_RECORD START_OF_RECORD=17||||40|||| ccu nursing progress note 11p-7a neuro: sedated on ativan 5mg/hr and dilaudid .5mg/hr. pt responds to noxious stimuli. pt moves left arm when agitated, no movement of right arm noted. not opening eyes or following commands. cv: hr 60-80's afib/flutter. frequent pvc's and short runs aivr noted. bp with maps >60. pt started on levo at 3mcg/min and dopa titrated to off. CO via thermodilution done before levo started/dopa weaned co 5.90 ci 2.74 svr 922. unable to wedge pa line. am co via fick method co 6.1 ci 2.84 svr 721. pulm: ls coarse, diminished at bases. o2 sats 95-98% on AC 500/12 peep 10 fio2 60%. am abg 75/58/7.39/36/7. sx q2-4hrs thick tan/blood tinged secretions. rarely overbreathing vent. gi/gu: abd soft, distended, hypoactive bs. tube feeds with >120cc residuals at 1am. pt noted to have bile stain around mouth. tube feeds shut off for night. con't on reglan. ?needs further stool management. rectal bag on without stool output. foley draining 40-60cc/hr clear yellow urine. id: afebrile throughout night. con't on iv oxacillin, ceftaz, and levo for +pseudomonas in sputum and + u/a. wbc ^19.7 today. access: left subclavian triple lumen with erythema area marked around shoulder/breast area, no increase in swelling noted. triple lumen dc'd and tip sent for culture. pt had right IJ cordus with PA line placed yest. site benign. right radial aline intact. skin: psoriasis unchanged. nystatin creams and powders applied. on 1st step overlay mattress. plan: con't pulm management. await blood cultures. cont abx. levo to maintain maps >60. family in last night and udated. had meeting with md's, con't current treatment at present. pt full code. ||||END_OF_RECORD START_OF_RECORD=17||||41|||| CCU NURSING PROGRESS NOTE 7A-3P NEURO: Pt not responding to tactile/verbal stimuli. Conts on Ativan and dilaudid gtts for sedation. RESP: LS coarse. Sxn'd for thick tan sputum. Peep decreased to 7.5 with repeat improved:119/45/7.46. CARDIAC: BP 110-120's on levo gtt. PAPs 50/20's CVP 6-8 SVR 1058 C.O. 4.46 and C.I. 2.07 (done by thermodilution). Levo weaned back down to 2mcg/min. GI: Decreased aspirates this am, therefore Ultracal tube feeds restarted at 15cc/hr. Will reassess and advance as tolerated. Hypoactive BS. Brown soft stool in rectal bag. Conts reglan qid. GU: foley draining clear yellow urine ~50cc/hr. Pt is ~40cc negative this afternoon. ID: Pt afebrile on IV abx. STATUS: Pt's daughter called and stated that they understand that he is very ill and would like to continue as a full code for a few more days to see if the abx make a difference. Team aware. ||||END_OF_RECORD START_OF_RECORD=17||||42|||| RESPIRATORY CARE NOTE PT REMAINES VENTED ON A/C 550 X 12 6O% 7.5 PEEP. PT TOL CURRENT SETTINGS WELL. PT rxd x 3 with albuterol and atROVENT MDI. BS COARSE BILT. SXND FOR MOD AMOUNTS OF THICK TAN SECRETIONS. BS ESSENT CLE4AR POST SXN. WILL CONTINUE TO SUPPORT AS INDICATED AND RX AS ORDERED. ||||END_OF_RECORD START_OF_RECORD=17||||43|||| s/o: for a complete set of vs and objective data please refer to flow sheet section ID: afebrile. antibx regieme unchanged. CV: hr 70 - 80's afib / flutter with rare pvc's noted. maps 50- 60's. Levo decreased to 1.9 mcg/ kg. pad's 27 - 29. cvp slightly higher than previously at 10 - 12. RESP: vent settings remain at 60% / 550 / 12 and 7.5 peep with rare spon breaths. sxn x 2 for thick tan secretions. lungs with clear upper lobes and diminished lower lobes. sats 97- 99%. NEURO: remains unresponsive to verbal or tactile stimulation. ? movement of l hand. ativan and dilaudid ggts cont at same rates. GI: tf cont at 15cc/ hr. minimal residual at 4pm. reglan continues . no futher stool in rectal bag. abd soft but distended. a/p: currently tolerating slow wean of levo, afebrile, secretions cont to be thick/ moderate amounts, tolerating lower dose tf at present ||||END_OF_RECORD START_OF_RECORD=17||||44|||| Patient remains intubated and mechanically vented. Vent checked and alarms functioning. Settings A/C 650 *12 60% 7.5 peep. ABG 7.37/61/70/37/7. Please see respiratory section of carevue for further data. Patient appears comfortable on current settings. Plan: Continue mechanical venilation. Respiratory status stable on current vent settings. ||||END_OF_RECORD START_OF_RECORD=17||||45|||| ccu nursing progress note 7p-7a neuro: sedated on ativan 5mg/hr and dilaudid .5mg/hr(allergy to mso4). pt not opening eyes or following commands. frequently moves left hand when stimulated. noted pt to move right hand this am when agitated. cv: hr 60's afib. occ pvc's noted. maps generally >60. levo titrated to off approx 1am. CO done via thermodilution with levo on CO 5.5 CI 2.58 SVR 562. CO off levo 4.05 CI 1.88 SVR 909. PAP's 50-65/24-28. unable to wedge pa line. cvp 15-17. pulm: initially on AC 550/12, 60% fio2, peep 7.5 abg 7.37/61/70. changed to 650/12 with abg 7.51/41/24. decreased fio2 50%. repeat abg pending. sats 95-98%. sx q2-4hrs thick tan secretions when bagged and lavaged. ls coarse, decreased at bases. gi/gu: abd distended, hypoactive bs. tube feeds with 5-15cc residuals. ultracal increased to 25cc. con't to have no stool output via rectal bag. on iv reglan. ? needs further stool management. foley draining 20-40cc/hr clear yellow urine. id: low grade temps via pa line. con't iv oxacillin, ceftax, and levo for pseudomonas in sputum and urine. blood cultures pending. social: family in to visit last eve. updated on pt's condition. plan: once pt's cardiac/ID condition stable, plan to begin weaning vent further. 1153 Pt remains intubated, vent supported. Changed to SIMV this shift, in hopes of normalizing ABG. Pt remains sedated, on dobutamine. Current vent settings: SIMV/PS 650/10/50% 5psv 7.5peep. ABG currently 101-51-7.42. See flowsheet for further pt data. Plan: Maintain vent support. ||||END_OF_RECORD START_OF_RECORD=17||||46|||| n-sedated with ativan drip/dc'd dilaudid d/t no gastric motility/^gastric outputs r-abg's running resp alkalosis-changed vent to simv 10 x 600 50% 7.5 peep pip's 28 , abg's now with ph 7.42, thick sx's cv-afib 50's now afib 90's with addition of dobutamine ^4mcg's in hopes of improving forward flow and thus uo-co/ci/svr-6/2.8/698 which is slightly higher than this am, uo slighty improved to 60cc/hr weaned off all vasopressors overnoc gi-^gastric outputs/tf's dc'd, opiates dc'd, remains on prevacid/reglan gu-qsuo creat stabilized 2.5-2.7 afberile on oxy/levo/ceftaz for staph/pseudomonas daughter phoned-family making funeral arrangements-considering withdrawl of life support-nneds to have family meeting to discuss a/p-remains vent dependent/infected/compromised card/renal status, support family ||||END_OF_RECORD START_OF_RECORD=17||||47|||| RESPIRATORY CARE: PT. WITH 7.5 ORAL ETT AT 24 LIP. CONTINUES ON A/C 12/650/.50/7.5 WITH STABLE ABG. ALBUTEROL/ATROVENT/FLOVENT MDI'S GIVEN. [**First Name11 (Name Pattern1) 169**] [**Name7 (MD) 170**], RRT ||||END_OF_RECORD START_OF_RECORD=17||||48|||| S- INTUBATED, NOT RESPONSIVE O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- HEMODYNAMICS STABLE CURRENTLY= HR- 90- AFIB. SOME SWITCHING INTO BUNDLE/IDOVENTRICULAR RHYTHM TRANSIENTLY- NO CHANGE IN BP. BP- 150/60'S. HIGHER WITH STIMULATION/SUCTIONING. PA- 70/32- 60/29 CVP- 15-16. UNABLE TO PCW. CO/CI/SVR- 8.4/3.9/638- IMPROVED ON 5 MG DOBUTAMINE FROM PREVIOUS READING. RESP- REMAINS INTUBATED- COARSE BREATH SOUNDS- SUCTIONED FOR MODERATE AMT THICK YELLOW/TAN SPUTUM. O2 SATS- HIGH 90'S. REMAINS ON 50/650/10 IMV. NO DIURESIS THIS SHIFT- I/O EVEN. GU- SEE ABOVE- UO- 50-60/HOUR. TRANSIENT INCREASE TO 100/HOUR FOR COUPLE OF HOURS AT TIME OF DOBUTA DOSE INCREASE. ID- AFEBRILE-= CONTINUES ON ANTIBX AS ORDERED. GI- VERY HYPOACTIVE SOUNDS- OG TUBE CLAMPED, ACCESS FOR MEDS- NPO - TUBE FEEDS ON HOLD. NO STOOL THIS SHIFT. MS- PT SEDATE ON 5 ATIVAN, REMAINS OFF DILAUDID/PROPOFOL- MOVING EXTREMITIES EVER SO SLIGHTLY. NO NEED FOR EXTRA BOLUS SEDATION CURRENTLY. A/P- PT WITH END STAGE RESP FAILURE CURRENTLY REMAINS WITH STABLE HEMODYNAMICS OFF PRESSORS/AFEBRILE ON ANTIBX AND WITH ADEQUATE OXYGENATION ON CURRENT VENT SETTINGS. CONTINUE TO CLOSELY OBSERVE HEMODYANAMICS/OXYGENATION- PRESSORS/ADJUST VENT AS NEEDED ACCORDINGLY. ANTIBX/SEPSIS TREATMENT. CONTINUE NPO/ILEUS EVAL. REGLAN QID. SEDATION/COMFORT/SKIN CARE. CONTINUE TO WORK WITH FAMILY AS TO LONG AND SHORT TERM PLAN OF CARE. ||||END_OF_RECORD START_OF_RECORD=17||||49|||| s/o: pls see carevue flowsheet for complete vs/data/events cv: remains in afib. hr 70-90s, occ pvc noted. k 3.6 repleted with 40meq iv. bp 110-150/50-60 via r rad aline. noted this am that levophed was infusing instead of dobutamine. levo was dc'd, bp tol well and dobutamine was restarted at 5mcg/kg/min. pt tol well. co improved to 7.0. on rounds decision made to wean off dobutamine. dec rate to 2.5mcg and co and uop remained unchanged. turned off at 2:30pm. bp has actually come down slightly off dobut but is stable. uop unchanged thus far. pap 57-65/26-31. cvp 12-16. unable to wedge cath. resp: pt began to overbreath imv rate at times to mid 20s. spon tv on 5 ps only 150-220. so pt changed to a/c. 650 x10. 50% and 7.5peep. rarely overbreathing. bs coarse. sxn'd q2-3hrs for thick tan secretions in mod amts. last abg:7.40/54/78/35/6. sat 94-98%. gi: abd soft, distended, hypoactve bs. min aspirates. no stool. restarted ultrcal at 10cc/hr this afternoon. if high residuals cont may replace rij [**Last Name (un) 171**]/pa with tlc for tpn. gu: uop 60-80cc/hr. essentially even from mn. cr 2.3(2.5), bun 77(87). will likely dose with lasix this eve. heme: hct stable at 31.5(31.0). ms: cont on ativan at 5mg/hr. moves hands occ. has a cough. grimaces with interventions. id: afeb. wbc 16.0(12.6). cont on oxacillin, ceftaz and levo. skin: has new pressure sore on coccyx. rectal bag had peeled back revealing open are in fold. bag removed as some of skin is macerated and has had no stool for sev days. area cleaned with ns. dsd applied. pt remains on 1st step mattress. position changed q2hrs and prn. social: dtr [**Name (NI) **] called and discussed with me her and her brothers concerns re: their father's lack of progress. she states she is ready to withdraw and "let him go" but her brother is "having a really hard time re: removing the ventilator... it would be like killing him he feels". she will be in this eve and the team is ready to update her and to obtain a dnr order. a: tol dobut wean. cont to req vent support. resuming tf. alt skin integrity. p: check co, follow uop/hemodynamics of dobutamine. cont pulm toilet. advance tf if absorbing. skin care. provide info and support to family. ||||END_OF_RECORD START_OF_RECORD=17||||50|||| RESPIRATORY CARE: PT. WITH 7.5 ORAL ETT 24 LIP. A/C 10/650/.50/7.5 WITH STABLE ABG. SX THICK TAN. MDI'S INCLUDE VENTOLIN/ATROVENT/FLOVENT. ||||END_OF_RECORD START_OF_RECORD=17||||51|||| S- INTUBATED CV- VS REMAIN STABLE OFF DOBUTAMINE GTT- CO SLIGHTLY LESS- SEE FLOWSHEET FOR OBJECTIVE DATA. RESP- REMAINS ON SAME VENT SETTINGS- BREATHING IN SYNCH AT RATE OF 10- AWAIT ABG RESULTS. SUCTIONING FOR THICK YELLOW/TAN SPUTUM. COARSE BREATH SOUNDS. DIURESED WITH 200 LASIX- GOOD U.O- PAD 28-26. I/O (-) 700CC AS OF 5 AM SINCE [**14**] AM. GU- SEE ABOVE. GI- STARTED ON LOW DOSE TUBE FEED--30-40CC RESIDUALS- HYPOACTIVE BOWEL SOUNDS- VERY GRADUAL INCREASE IN TUBE FEEDS- 20CC/HOUR. NO STOOL THIS SHIFT. ID- AFEBRILE- REMAINS ON ANTBX X 3. SKIN- SMALL COCCYX BREAKDOWN- WET TO DRY DSG- NO SIG DRAINAGE FROM AREA- APPEARS CLEAN. MS- PT SEDATE, NON REPSONSIVE ON 5 MG ATIVAN. SOCIAL- SON/DAUGHTER MET WITH MICU RESIDENT TO CLARIFY PLAN OF CARE. WISH TO PROCEED WITH TRACH AS NEEDED, AND SUPPORT VENTILATION AS WELL AS BP WITH PRESSORS- NO SHOCK/CPR. MUCH DISCUSSION WITH FAMILY , SUPPORT, INFORMATION, TEACHING. A/P- PT WITH RESP FAILURE AND SEPSIS CURRENTLY REPSONDING TO LASIX. AFEBRILE; STABLE HEMODYNAMICS OFF PRESSORS. CONTINUE TO CLOSELY MONITOR VENTILATION/HEMODYNAMICS. WATCH FOR ANY FURTHER FEVER/HYPOTENSION. SEDATION, SUPPORT, SKIN CARE/PULM TOILETING. DISCUSS PLAN FOR TRACH/LONG TERM PLACEMENT/WEANING PLAN. SUPPORT FOR FAMILY. ||||END_OF_RECORD START_OF_RECORD=17||||52|||| PATIENT WEANED FROM CMV TO CPAP WITH PRESSURE SUPPORT +20 SPONT VT 600CC , MIMUTE VOL 6+ LITERS. SATS HIGH 90'S, HR 60'S RR LOW 20'S. BBS CLEAR WITH SOME SUCTIONING. ABG PENDING ON CPAP WITH PS MODE. ||||END_OF_RECORD START_OF_RECORD=17||||53|||| pls see carevue flowsheet for complete vs/data/events s/o: id: afeb. cont on oxacillin, ceftaz and levo for pseudomonus cv: hr 60s afib. bp 110-140/50-60. no pressors or inotropes. co 5.4/ci2.5 svr 780 via td. by fick co 8.4, mv sat 71. pap 50s/22-26. cvp 11-13. cath does not wedge. resp: changed to ps. weaned down to 16 with tv 450-500, rr 12-16. cont on 7.5 peep and 50%. last abg was on 20ps: 100/51/7.42/34/6. sat 94-99%. sxn'd q 1-2hrs for thick tan secretions in mod amt. bs scatt coarse, dim at bases. gi: advancing tf. now at 40cc/hr with low residuals. no stool as of yet. gu: no diuresis this shift. uop 50-80cc/hr. approx 700cc neg from mn. ms: sedated on ativan, decreased to 4mg/hr. min response, none purposeful. social: dtr called, will visit this eve. a: stable p: follow abg with weaning ps. advance tf. ?d/c pa line. ||||END_OF_RECORD START_OF_RECORD=17||||54|||| NSG NOTE CARDIAC: REMAINS IN A-FIB,RATE CONTROLLED HR 50-70. NO VEA NOTED. BP STABLE 100-120/40-50. HAD SHORT EPISODE OF HYPERTENSION. BP 170/90 ? ASSOCIATED WITH PAIN/ANXIETY. RECEIVED DILAUDID IV WITH GOOD EFFECT. BP DOWN WITH MAP'S AROUND 60. PAD'S 22-27,CVP 13. CO 4.84,CI 2.25,SVR 860. OFF ALL PRESSORS RESP: INITIALLY ON CPAP/PS 16,50%,7.5 PEEP VT 460. 2100 BECAME TACHYPNEIC RR-32. VT DOWN TO 330. O2 SATS 94%. SUCTIONED FOR THICK WHITE SECRETIONS,BUT NO SIGN CHG IN RESP STATUS. HOUSE STAFF NOTIFIED. PT CHG TO AC OVERNOC. 650X10,50%, PEEP 7.5 APPEARS MORE COMFORTABLE WITH IMPROVING SATS. BS COURSE BILAT. NEURO: GRIMCES ONLY.TWITCHES. UNABLE TO FOLLOW COMMANDS. MOVES L HAND ONLY.UNABLE TO OPEN EYES. PUPILS 2MM EQUAL/SLUGGLISH. REMAINS ON ATIVAN GTT 5.0MG GU: U/O SLOWING. RESPONDED WELL TO LASIX 200MG IV WITH U/O >200CC/HR. GI: TF INCREASED FROM 40CC TO 50CC,HOWEVER PT HAD HIGH RESIDUALS > 100CC. TF OFF. PT IS ON REGLAN. BS HYPOACTIVE. GIVEN DULCOLAX SUPP WITH POOR RESULT. PT HAS LG AMT'S OF HARD STOOL NOTED ON ADM OF SUPP. GIVEN SS ENEMA, WITH POOR RETURN. ABD IS SOFT,BUT DISTENDED. RECEIVED SENNA TABS ALSO. LABS: REPEAT HCT 29. HOUSE STAFF NOTIFIED. SKIN: PER FLOW SHEET. REPOSITIONED Q1-2HR. ID: AFEBRILE. REMAINS ON LEVO/CEFTAZIDINE/OXICILLIN A: STBALE/UNABLE TO TOL TF/IMPACTED. P: TRACH NEXT WEEK TO D/C SWAN CON'T PER NSG JUDGEMENT P: ||||END_OF_RECORD START_OF_RECORD=17||||55|||| S/O: CV: VSS, PA'S 30'S-50'S/20'S-30'S. CVP 7-12. NOT ABLE TO WEDGE. TEAM TO PULL SWAN TODAY. REMAINS IN AF, RATE 60'S-70'S. NO VEA. KCL 40 MEQ GIVEN AT 1400. GOOD DIURESIS TO 200 MG LASIX GIVEN OVERNIGHT. PT 1400CC NEG. WEIGHT DOWN TO 94.2 KG. RESP: TOL PS WEAN FROM 1400 TO 1800 WHEN RR INC TO HIGH 30'S, SATS DEC TO 94% AND TV DEC TO 300'S. PT SUCTIONED, SAT UP IN BED BUT DID NOT IMPROVE. ABG SENT AND BACK ON A/C. SUCTIONING SCANT WHITE TO YELLOW SECRETIONS. LUNGS COURSE BILAT. ID: AFEB, ABX CONT. GI: CRITICARE TF RESTARTED AT 30CC/HR. LOW RESIDUALS SO FAR. PT HAD SOME LIQUID STOOL AND THEN DISIMPACTED FOR SOFT FORMED STOOL AT 1800. HYPOACTIVE BS, REGLAN CONT. GU: CLEAR YELLOW URINE, DEC TO 30-40CC/HR AFTER DIURESIS. SKIN: COCCYX AREA WITH SOME OPEN AREAS, OOZING BLOOD. KEPT CLEAN FOR NOW. WILL INSERT RECTAL TUBE IF STOOL IS LIQUID ENOUGH. PSORIASIS CREAM APPLIED FREQ. ATIVAN CONT AT 5MG/HR. PT ONLY MINIMALLY RESPONSIVE TO STIMULI, MOVES RIGHT HAND OCC. NO NEED FOR DILAUDID. A/P: FAILED WEAN AGAIN, ? TRACH ON MONDAY. TOL TF SO FAR. BOWELS STARTING TO MOVE. CONT WITH LACTULOSE AND PULM TOILET. ASSESS SEDATION LEVEL. ||||END_OF_RECORD START_OF_RECORD=17||||56|||| NSG NOTE CARDIAC: REMAINS IN A-FIB RATE CONTROLLED AT 64-73. RARE PVC'S NOTED. CVP 9-15,PAD'S 16-23. MAP'S 60-75. RESP: RESTING OVERNOC ON AC 50%,650 X 10,PEEP 7.5 CON'T TO SUCTION AND LAVAGE FOR WHITE THIN- THICK SECRETIONS. BS COURSE BILAT. 02 SATS 100%. 100,47,7.44,33,6 GI: TOL CRITICARE TF,RESIDUALS 15-50. BOWEL SOUNDS PRESENT. CON'T TO HAVE HARD STOOL ALTERNATING WITH LIQ BROWN STOOL. STOOL NOW SEEMS TO BE MORE LIQ IN CONSISTENCY. WILL CONSIDER RECTAL TUBE IF CONTINUES. GU: U/O ADEQUATE NEURO: NO SIGN. CHGS. GRIMCES ON OCCASSION. MOVES ONLY L HAND. UNABLE TO OPEN EYES OR FOLLOW COMMANDS. LABS: K+ 3.8 RECEIVED 40MEQ KCL. REPEAT K+ WNL ID: AFEBRILE. CON'T ON TRIPLE ABX A: BOWEL ISSUES RESOLVING/STABLE P: PLAN TRACH/PEG FOR MONDAY ATTEMPT CPAP TRIAL AGAIN TODAY MAY D/C SWAN CON'T PER NSG JUDGEMENT. ||||END_OF_RECORD START_OF_RECORD=17||||57|||| S/O: CV: VSS, AFEB. PAD'S 30'S-40'S AND CVP 6-12. SWAN TO BE D/C'ED TONIGHT. CONT IN AF RATE 60'S-70'S. 40 KCL GIVEN AT 1600 FOR K 3.8. RESP: SUCTIONED Q4H FOR THICK YELLOW SPUTUM. ON PS AT 1400, TV IN 400'S-500'S. SATS IN HIGH 90'S, RR 18-28. PT SEEMS COMFORTABLE. NO ABG SENT. ID: ABX CONT, PT AFEB. GI: INC TF TO 60CC/HR, RESIDUALS 30-40CC. STARTING 250CC FREE WATER BOLUSES. REGLAN CONT. NO STOOL FROM RECTAL TUBE. GU: POS 500CC FOR TODAY, TEAM FEELS THAT PT IS AT HIS DRY WEIGHT OF 94.5. SKIN: NYSTATIN CREAM ON SKIN FOLDS. STAGE 2 BREAKDOWN ON COCCYX COVERED WITH DUODERM. MS: ATIVAN DEC TO 4MG/HR AFTER PERIODS OF APNEA AT BEGINNING OF WEAN. GRIMACING TO PAIN ONLY, NO PURPOSEFUL MOVEMENT SEEN. PUPILS EQUAL AND REACTIVE. TURNED FREQ. SPOKE TO DAUGHTER ABOUT PT'S CONDITION. A/P: TOL PS WEAN BETTER TODAY. CHECK ABG IF PT TIRES AGAIN. ? TRACH AND PEG EARLY THIS WEEK. FOLLOW RESIDUALS WITH FREE WATER BOLUSES. ASSESS MS, ? IF CAN WEAN ATIVAN FURTHER. ||||END_OF_RECORD START_OF_RECORD=17||||58|||| Respiratory Care: Pt on cpap+ps at biginning of shift. Was changed over to full vent support at 8:00pm to rest over night. vent settings are AC 650*10 50% 7.5 peep. BS rhonchi bilat,sxn'd reg sm to moderate thick yellow secreations. plan to change back to cpap+ps 15/7.5 on 7a-7p shift and wean as tollerated. ||||END_OF_RECORD START_OF_RECORD=17||||59|||| NEURO: REMAINS SEDATED ON ATIVAN GTT. WILL OPEN EYES TO PAIN. NOT MOVING EXTREMITIES, NO PURPOSEFUL MOVEMENT. COUGH AND GAG STRONG. CV: A-FIB. HR 75-80 NO VEA NOTED. BP STABLE SEE FLOWSHEET FOR DATA. RESP: COARSE BREATH SOUNDS THROUGHOUT ALL LUNG FIELDS. SUCTIONING Q1-2 HRS FOR THICK YELLOW SECRETIONS. NEEDS SALINE LAVAGE TO LOOSEN SECRETIONS WITH GOOD EFFECT. RESTED OVERNIGHT ON AC 650X10, 50%, PEEP 7.5. GI: BM X3 LIQUID BROWN STOOL WITH SOME FORMED STOOL. MUSHROOM CATH INSERTED THIS AM AS STOOL MORE LIQUID. TUBE FEEDING HELD FREQ OVERNIGHT FOR HIGH RESIDUALS > 120CC. TF OFF AT PRESENT. CONT ON REGLAN IV. GU: FOLEY TO GRAVITY. URINE GOOD AFTER GIVEN LASIX 200 MG IV. CLEAR YELLOW URINE. SEE I/O FLOWSHEET FOR DATA. WILL HOLD FREE WATER BOLUS FOR NOW AND WILL DISCUSS ON ROUNDS. SKIN: CONT WITH SEVERAL SITES OF PSORIASIS, [**Last Name (un) 172**] APPLIED. BUTTOCKS REDENED, PROTECTIVE CREAM APPLIED. HEELS REDENED, PT ON AIR MATTRESS. TURNED Q2HRS FOR PRESSURE RELIEF. SWAN GANZ CATH D/C'D, TRIPLE LUMEN INSERTED OVER WIRE. POSITION VERIFIED BY CXR. ||||END_OF_RECORD START_OF_RECORD=17||||60|||| CCU NURSING PROGRESS NOTE 7A-7P NEURO: PT SEDATED ON ATIVAN AT 4MG/HR. OPENS EYES TO PAINFUL STIMULI. NOT FOLLOWING COMMANDS. OCCASIONALLY MOVING LEFT ARM SPONTANEOUSLY. CV: HR 60-70'S AFIB. OCC PVC'S NOTED. BP 110-130/50'S. PULM: LS COARSE. CHANGED FROM A/C TO PS THIS AFTERNOON. PS 15 PEEP 7.5 FIO2 50%. ABG STABLE. TV'S 500'S. SATS 98-100%. SX Q2-4HRS THICK YELLOW/TAN SECRETIONS WITH LAVAGE. GI/GU: NOT TOLERATING TUBE FEEDS. CURRENTLY ON CRITICARE AT 10CC/HR WITH MINIMAL RESIDUALS. STARTED ON TPN THIS EVENING AT 41CC/HR. MUSHROOM CATH IN PLACE WITH SM AMT LOOSE STOOL. CON'T ON IV REGLAN. HYPOACTIVE BS. FOLEY DRAINING 40-100CC/HR CLEAR YELLOW URINE. -1500CC THUS FAR TODAY. ID: AFEBRILE. CON'T IV ABX AS ORDERED. SKIN: NYSTATIN LOTION AND CREAMS PRN. ACCESS: TRIPLE LUMEN AND ALINE PLAN: PLAN TO HAVE ANOTHER FAMILY MEETING ? WHEN. PT IS FAILURE TO WEAN OFF VENT R/T CHRONIC LUNG DISEASE. NEEDS PEG/TRACH IF FAMILY DECIDES TO PROCEED IN THAT DIRECTION. CURRENTLY DNR STATUS. HEMODYNAMICALLY STABLE. ||||END_OF_RECORD START_OF_RECORD=17||||61|||| Patient remains intubated and mechanically vented. Vent checked and alarms functioning. Settings: Patient initially on PS 15/7.5 but was changed back to A/C 650*10 50% 7.5 peep to rest. BS Coarse. Combivent/flovent given as ordered. Please see respiratory section of carevue for further data. Plan: Will Continue mechanicall ventilation. ||||END_OF_RECORD START_OF_RECORD=17||||62|||| Resp Care changed from ac to psv mode this a.m. generating same Ve with reasonable volumes,resp rate. admin combivent q4h. sxned for sm amts thick white. refer to flow sheet for further data. ||||END_OF_RECORD START_OF_RECORD=17||||63|||| ccu nursing progress note 7a-7p neuro: sedated on propofol at 5mg/hr. opens eyes to painful stimuli. not following commands. minimal spontaneous movement of upper extremeties. cv: hr 50-70's afib. occ pvc's noted. bp 100-150/50's. tolerating captopril 12.5 mg. pulm: ls coarse, diminished at bases. o2 sats 98-100% on vent. switched from ac to ps this am. currently on ps 15 peep 7.5 fio2 50%. tv 500's. abg 7.41/54/97/35/7. lavaged and suctioned for thick tan secretions. sample sent for culture and gram stain. less secretions today. gi/gu: abd soft, hypoactive bs. mushroom cath with small amt liquid stool. tube feeds (criticare) increased to 30cc/hr. no residuals. con't on tpn at 41cc/hr. foley draining clear yellow urine >30cc/hr. skin: seen by skin nurse today. duoderm removed from coccyx, skin "looks better" according to skin rn. new duoderm applied. nystatin powder and creams applied, nystatin s&s applied to tongue for thrush. turned and repositioned. id: afebrile. con't iv oxacillin and levo. ceftaz dc'd today. plan: pt to receive peg and trach. ? when. communication with family. con't wean vent as tolerated ||||END_OF_RECORD START_OF_RECORD=17||||64|||| uneventful nite. VSS. suctioned for thick tan secretions. remained on PS 15/peep 7.5 all nite. tolerated well. NPO since midnite for PEG insertion today. see careview for vitals and assessment. ||||END_OF_RECORD START_OF_RECORD=17||||65|||| resp care remains psv mode 15/7.5 peep/50%. trach deferred until tomorrow. admin combivent/flovent. no further weaning until trach. sxning very thick yellow/tan sputum. transported to radiology for peg. c/w above as tolerates. ||||END_OF_RECORD START_OF_RECORD=17||||66|||| s: orally intubated, sedated on ativan gtt o: pls see carevue flowsheet for complete vs/data/events id: afeb. no changes to abx regime. cv: afib 70s. k repleted. bp 110-140/50-60 via l rad aline. captopril dose ^'d to 25mg, tol well. resp: cont on ps 15/7.5 peep. 50%. rr 10-18, tv 450-550. sxn'd for sm-mod amts clear to white secretions. bs scatt coarse. plan for trach placement at bedside [**05-10**]. kit in room. gi: npo. tpn infusing. g-j tube placed late this afternoon. cont at present with ogt as well. abd is dist, +bs, min o/p of stool this am and rectal tube removed. placed rectal bag this eve for liquid stool. sample sent for cdiff. skin: has 2 open areas on coccyx. cleaned with ns, covered with duoderm. had sm skin tear from removing prev duoderm(had gotten soiled w/stool). mod amt drk blood. pressure held, then dsd placed. other skin care problems at baseline with assortment of powders and creams applied. gu: good response to am lasix. ms: sedated on ativan. has not req additional meds. min response to stimulation. dispo: screening for rehab begun. social: case manager spoke with [**Doctor Last Name **] today to inform her of screening. no contact from family this afternoon. a: hd stable. p: ?begin tf tonoc. npo after mn for trach. skin care. d/c planning. ||||END_OF_RECORD START_OF_RECORD=17||||67|||| Respiratory Care Note Remained overnight on pressure support of 15/ 7.5 of peep 50%. Suctioning thick yellow sputum. Given Combivent and Flovent inhalers in line with vent. ||||END_OF_RECORD START_OF_RECORD=17||||68|||| Uneventful nite. Sx thick yellow secretions. remained on PS15/5peep overnite on 50%. sats 100%. For TRACH insertion this morning. PEG inserted yesterday, NPO since midnite. Nutrition: TPN. stooling liquid brown stool, rectal bag intact. foley patent >30cc/hr. Remains sedated on Ativan @ 5mg/hr. PLAN: Trach insertion this am. cont' to monitor VS. pt being screened for rehab. ||||END_OF_RECORD START_OF_RECORD=17||||69|||| resp note - pt. remains on psv 15 peep 7.5 50% fio2, tol ok at this time, spon tv 550 - 650 cc rr 14 - 18. ||||END_OF_RECORD START_OF_RECORD=17||||70|||| ccu nursing progress note 7a-7p neuro: sedated on ativan at 5mg/hr. opens eyes to stimuli. not following commands. no spontaneous movement noted. cv: hr 60-70's afib. no vea noted. bp 120-140/60's. pulm: remains on ps 15, peep 7.5, fio2 50%. tv 550's. rr teens. sats 97-100%. sx q2-4hrs thick yellow secretions. gi/gu: remains npo for possible trach today. j-tube intact. meds via ogt. small amt liquid stool. tpn at 56cc/hr. u/o 30-60cc/hr. to receive 200mg iv lasix. skin: creams and powders as ordered for psoriasis. on 1st step overlay mattress. plan: plan to have trach today. evaluated by several rehabs. awaiting acceptance and decision from family. family called and updated. ||||END_OF_RECORD START_OF_RECORD=17||||71|||| ccu nursing progress note addendum just spoke with md, pt will be trached tomorrow. ? time. con't npo for now. ||||END_OF_RECORD START_OF_RECORD=17||||72|||| (Continued) ll are very involved. wish to give him a chance to recover though apparently pt had prev expressed wishes, to his dtr at least, not to go through another trach/rehab scenario and pt has been in poor health for sev months. status: dnr. intubation to cont and trach planned for [**05-11**]. would use pressors. access: r ij tlc. ||||END_OF_RECORD START_OF_RECORD=17||||73|||| MR. [**Known patient firstname 173**] [**Known patient lastname **] is an 83 yr old male who presented to [**Hospital **] hospital from [**Hospital **] rehab [**04-02**] with sob/chf and nqwmi. during this stay he was started on abx for pneumonia, r/o'd for pe. req intubation for hypoxia/resp failure and was extubated [**04-12**]. he cont post extubation with hypoxia, resp distress. then he developed cp with new lbbb and elevated enzymes which led him to be transfered to [**Hospital1 **] [**04-18**]. pmh: cad, s/p cabg '[**97**](lima to d1, svg to dlad, svg to om1). chf ef 20-30%. paf. pulm: ?copd. restrictive lung dz. ?pulm fibrosis poss r/t methotrexate. had prolonged intubation(4+mos) after heart surgery. was o2 dep at prev rehab site, cpap as well. vasc: s/p cva. renal ca, S/P R NEPHRECTOMY, CRI. prostate ca. gerd, h/o gib. diverticulitis. djd of cervical spine. psoriasis. psoriatic arthritis. hpi: ekg changes/nqwmi felt secondary to unstable resp status. pt did not undergo cath. predominantly in afib with well controlled rate, amiodarone dc'd per pulm team d/t pt's resp status. req pressors and fluid last [**04-30**] with presumed sepsis from fever/pseudomonus in sputum. was then briefly on dobutamine for inotropic and diuresis support. -resp failure req reintubation [**04-20**] after trial of bipap. lung dz eval w/ gallium scan. diuresed for chf. began abx for psedomonus in sputum and bilat ll infiltrates [**04-30**]. -req 4u prbcs for hct to 22-25. no clear source. no egd performed d/t cardiac and resp issues. hct has remained stable for past 2 weeks. ros: neuro: sedated on ativan gtt at 5mg/hr for vent mgmnt and pt comfort. pt grimaces, opens eyes to pain. has no purposeful movements of extremities. does withdraw to painful stimuli. does not follow commands. id: afeb. wbc nml. started oxacillin [**04-26**] and completed [**05-11**]. ceftaz rec'd [**04-29**] - [**05-07**]. currently cont on levo 250mg iv qd since [**04-29**]. last sputum from [**05-08**] cont to note pseudomus but infiltrates have improved. cdiff [**05-09**] neg. cv: afib rate in the 70s. bp 110-130/60. tol captopril now at 37.5mg tid. also on asa and lipitor. resp: ps 15/peep7.5. 50%. tv 400-500, rr 120-18. bs scatt coarse. sxn'd for thick white to tan in sm amts. awaiting trach placement for [**05-11**]. gi: has had difficulty with tol tube feeds(lrg residuals) despite changing formulas, adding reglan, etc. g-f tube placed by ir [**05-09**]. have yet to resume tf as pt is an add-on for trach and is ordered for npo for past two days. is rec'ing tpn with lipids at 56cc/hr and tol well. has brown liquid stool with rectal bag intact currently. stool and aspirates have tested ob+ but no gross melena. gu: cr bumped >3 with hypotension +/- aggressive diuresis. has now returned to 1.5-1.7. responds well to 200mg iv lasix. skin: has stage 11-111 open areas at coccyx area. duoderm placed to keep covered. sm amt serosang drg. pt is on 1st step overlay mattress in icu. has not been oob since admit. social: pt's wife has a form of dementia and is residing in a nursing home. pt has 2 children who act as his official health care proxys. [**Name (NI) **] and [**Name2 (NI) **] ||||END_OF_RECORD START_OF_RECORD=17||||74|||| Pt remains on PSV 15/7.5 in NARD. Bedside trach planned. Combivent and flovent given as ordered. vent checked alarms on. Humidifier full. [**First Name8 (NamePattern2) 174**] [**Last Name (NamePattern1) 175**] RRT ||||END_OF_RECORD START_OF_RECORD=17||||75|||| s: remains intubated, now trached and sedated O: see flowsheet for objective data. VSS except for one hypotensive episode after captopril dose responding to IVB. Captopril dose reduced.Trach done and fentanyl/propofol boluses given, then became hypotensive to sbp 60 requiring 1l NS and neosynephrine boluses by anesthesia followed by atropine for HR 30's after neo bolus. now cont on neo gtt which has been titrated down over the hour. cont in Afib without VEA. cont on same vent settings of P.S and PEEP with good sats until trach, put on AC where he cont tonight. suctioned minimal white secretions. lungs with crackles/coarse at bases. u/o fair. PEG site D/I. OGT d/c'd with ETT. #8 portex trach inserted by Dr. [**Last Name (STitle) 176**] with minimal bleeding. pt. turned q2hr, FIB intact with minimal loose stool new TLC inserted over a wire by housestaff tip sent for Cx. BC x 2 sent as well. pt. grimacing to stimuli but not opening eyes or following commands. not moving extremities. cont ativan gtt at 5cc/hr large lipoma over left shoulder area outlined. daughter called, updated on condition cont TPN A: hypotensive after meds for trach P: cont pulm toilet, trach care, wean neo as tolerated follow ID status, resp status, ?transfer to [**Hospital2 **] [**Doctor Last Name 177**] tomorrow ||||END_OF_RECORD START_OF_RECORD=17||||76|||| NSG NOTE CARDIAC: REMAINS IN A-FIB,RATE CONTROLLED 56-77. NO VEA NOTED. BP STABLE AND NEO SUCCESSFULLY WEANED TO OFF @ 0500. MAP'S > 60 WITH ADEQUATE U/O NOTED. MN CAPTOPRIL HELD TILL NEO OFF. RESP: MECH VENT VIA TRACH (PLACED [**05-11**]). AC 100%,650 X 10,PEEP 7.5 ABG'S: 171,51,7.31,27,-1. VENT CHG TO AC ,60%,750 X 10,PEEP 7.5 WITH IMPROVING ABG: 174,48,7.34,27,0 HOUSE STAFF NOTIFIED AND NO FURTHER CHG MADE. BS COURSE BILAT. SUCTIONING BLOODY TO NOW BLOOD TINGE SECRETIONS. HAD 1 EPISODE OF COUGHING AND HAD SM-MOD AMT OF BLOOD DRAIN FROM AROUND TRACH SITE. REPEAT HCT 29.1 AND HOUSE STAFF MADE AWARE. GI/NUTRITION: TPN INFUSING AT 70CC/HR. FIB IN PLACE DRAINING LIQ STOOL BROWN. ABD SOFT/HYPOACTIVE BS NOTED. PEG CLAMPED AT THIS TIME. GU: U/O ADEQUATE 45-100CC/HR SKIN: TURNED Q 2/HR. DUODERM INTACT ON COCCYX. SKIN CARE AND CRM TO PSORIASIS AREAS NEURO: GRIMCES. MOVING L HAND ONLY. STILL UNABLE TO FOLLOW COMMANDS REMAINS ON ATIVAN 5.0MG. PUPILS 2MM EQUAL AND SLUGGLISH ID: AFEBRILE ON LEVOFLOXCIN A: STABLE POST TRACH P: SCHEDULED FOR REHAB TRANSFER ON OR PRIOR TO TUESDAY WEAN TO CPAP SETTINGS TODAY ||||END_OF_RECORD START_OF_RECORD=17||||77|||| S REMAINS TRACHED ON VENT AND SEDATED O; SEE FLOWSHEET FOR OBJECTIVE DATA. VSS OFF OF NEO, ABLE TO TOLERATE CAPTOPRIL DOSES. AM DOSE 12.5, PM DOSE 25 WITHOUT DROP IN SBP. REMAINS IN AFIB WITHOUT VEA. VENT CHANGED FROM AC TO PRESSURE SUPPORT AND PEEP WITH GOOD ABG'S AND SATS. RR TEENS TO 20'S WITH TV 400-500 AND MINUTE VOLUME AROUND 9L. NOW AT 12CM P.S. WITH 7.5 PEEP ON .4FI02 LUNGS REMAIN COARSE SUCTIONED THICK WHITE/YELLOW SPUTUM Q2HRS. TRACH SITE D/I WITH MINIMAL BLEEDING, TRACH CARE DONE. LOW GRADE TEMP ON ANTIBX, STOOL FOR CDIFF SENT (3RD SPEC). FIB INTACT, DUODERM INTACT ON COCCYX SKIN CARE DONE, TURNED Q2HR. DAUGHTER CALLED, UPDATED. REMAINS ON ATIVAN GTT WITH WAS DECREASED TO 4MG/HR. GRIMACING TO STIMULI, NOT RESPONDING TO NAME OR COMMANDS, MOVING EYEBROWS BUT NOT OPENING EYES. NOT MOVING EXTREMITIES. TUBE FEEDINGS RESTARTED, INITIALLY RESTARTED ON CRITICARE, NOW ON PEPTAMEN THROUGH PEG. RATE INCREASED TO 20CC. REMAINS ON TPN UNTIL GOAL RATE ATTAINED. PEG SITE D/I, URINE CLEAR TLC SITE D/I WITH TRANSPARENT DRESSING A: TOLERATING PRESSURE SUPPORT P: CONT PULM CARE, FOLLOW ID STATUS, FOLLOW HEMODYNAMICS, CONT TO INCREASE T.F, TO GOAL RATE AND THEN D/C TPN. TO GO TO [**Hospital 178**] ON TUESDAY PER CASE WORKER ||||END_OF_RECORD START_OF_RECORD=17||||78|||| Mr [**Known patient lastname 162**] received mech vented via trach. Vent settings A/C 750 Rate 10 Peep 7.5 FiO2 40%. Suctioned Trach for sm mod amt of yellow secretions. Breath sounds coarse. MDI's flovent and combivent given as ordered. Will cont to follow closely. ||||END_OF_RECORD START_OF_RECORD=17||||79|||| S: trached and sedated O: Please see carevue for VS and objective data. CVS: HR 60-90's Afib without vea noted. BP initially stable 106-120/50's, prior to MN dose of Captopril Pt. dropped SBP 68-70's, initially attempted 250cc NS bolus without sign. effect, restarted Neo 10-70mcgs/min. as per orders. Titrated to maintain MAP>60. Resp: Remains mechanically ventilated via trach, vent settings A/C 750x 10, 40% Fio2, 7.5 peep. Spont. RR 1-2 over vent. abg 159/43/7.31/23/-4 98%. Suctioned q2-3 hours for small amount, thick, yellow secretions. Trach care done, site D/I without bleeding noted. Lungs coarse. ID: Tmax 99.4 on antibxs. GI;GU: TPN conts at 52cc/hour. TF's Peptamen at 10cc/hour initially, increased by 10cc q 8 hour as ordered, via PEG, site D/I. Fecal incont. bag remains intact, draining brown, liquid stool. Foley to drainage clear, yellow urine. U/O 15-60cc/hour. Neuro: Remains sedated on IV Ativan at 4mg/hour. Pt. responding to turning and suctioning with facial grimaces and withdrawal of left arm. Not moving LE. or right arm. Not opening eyes. Pupils 2mm and sluggish. Not following commands. Strong cough and + gag. Skin: Coccyx with duoderm clean and intact. Turned q 2-3 hours, skin care provided. A: Hemodynamically labile, requiring Neo restart and titration. P: Cont to monitor hemodynamics, assess Pt's response to Neo. Hold Captoril. Cont to monitor resp. status., pulmonary toileting. Increase TFs as ordered. Follow up with am labs. Comfort and emotional support to Pt. and family. ||||END_OF_RECORD START_OF_RECORD=17||||80|||| Respiratory Care Note Pt remains on AC 750X10 40% 7.5 peep. No vent changes made this shift. Pt rxd with combivent and flovent mdi. Pt also sxnd for mod amount of thick yellow/clear secretions. Will continue to support patient. ||||END_OF_RECORD START_OF_RECORD=17||||81|||| S: TRACHED AND SEDATED O: PLEASE SEE CAREVUE FOR ALL OBJECTIVE DATA. CV: NEO WEANED AND D/C AT 16:00 W/ BP 95-112/38-58. HR 90'S A FIB W/ NO VEA. CAPTOPRIL HELD D/T HYPOTENSION. RADIAL A LINE VERY POSITIONAL. K THIS AM 6.4 (HEMOLYZED) K FROM ABG 4.5. RESP: NO VENT CHANGES MADE TODAY. SX Q 2-4 HR FOR SM AMTS THICK WHITE SECRETIONS. LUNG SOUNDS COARSE. GI: TF ^^ TO 50CC/HR VIA PEG. TPN COMPLETED.WILL BEGIN PROTONIX IN AM. CONTINUES T9O HAVE FOUL SMELLING STOOL ~100CC THIS SHIFT. SPEC SENT FOR OSMS AND FECAL LEUCOCYTES. GU: FOLEY DRAINING CL YEL URINE, CURRENTLY ~ 850CC + ID: CONT W/ LOW GRADE TEMP. WBC 13.7. STARTED ON CEFTAZADIME THIS AFTERNOON. SKIN: MOUTH W/ LG AMT THRUSH, NYSTATIN SWISH AND SWALLOW APPLIED. PSORIASIS ON BACK LEGS FACE UNCHANGED. OINTMENT APPLIED. MS: ATIVAN INFUSING AT 4MG/HR. PT ONLY RESPONSIVE TO PAINFUL STIMULI. SOCIAL: DAUGHTER CALLED THIS AFTERNOON, WAS UPDATED ON CONDITION. WILL BE IN THIS EVE. A: HEMODYNAMICALLY STABLE OFF NEO. CONT W/ LOW GRADE TEMP, DIARRHEA. P: MONITOR BP, RESTART CAPTOPRIL AS TOLERATED. FOLLOW TEMP CURVE, CONT ABX, ||||END_OF_RECORD START_OF_RECORD=17||||82|||| Pt received mechanically ventilated via trach. Vent settings A/C tidal volume 750 Rate 10 peep 7.5 FiO2 40%. Suctioned for mod amt of white/yellow secretions. Breath sounds coarse. MDI's flovent and combivent given as ordered. Will cont to follow. ||||END_OF_RECORD START_OF_RECORD=17||||83|||| NSG NOTE CARDIAC: REMAINS IN A-FIB,RATE CONTROLLED 73-90. HAD EPISODE OF HYPOTENSION. BP 81/30. NEO RESTARTED AND TITRATED TO 60MCG/MIN. ABLE TO WEAN OVERNOC DOWN TO 20MCG/MIN. BP NOW 125/42 VIA CUFF ON R ARM. A-LINE DAMPENED. CAPTOPRIL HELD.SUSPECT HYPOTENSION IS RELATED TO INFECTION. RESP: REMAINS MECH VENT VIA TRACH(PLACED [**05-11**]) AC 750 X 10 PEEP 7.5 O2 SATS 98-100%. SUCTIONED FOR WHITE THIN TO THICK SECRETIONS. BS COURSE BILAT. TRACH CARE COMPLETED. SITE APPEARS NL. NO BLEEDING NOTED. NEURO: NO SIGN CHG. UNABLE TO FOLLOW COMMANDS. MOVES L HAND OCCASSIONALLY. UNABLE TO OPEN EYES. ID: TEMP MAX 100-100.4 FOUL SMELLING STOOL(SENT FOR CULTURE [**05-13**]) PT STARTED ON FLAGYL. CON'T ON CEFTAZ. AND LEVOFLOX. GI: CON'T ON PEPTAMIN. INCREASED TO 60CC/HR WITH LOW RESIDUALS. PT PASSING LG AMT'S LIQ BROWN STOOL. ATTEMPTED USE OF MUSHROOM CATH. UNSUCCESSFUL. FIB REPLACED AND INTACT. GU: U/O> 60CC/HR SKIN: DUODERM REPLACED TO COCCYX. SEVERAL BROKEN AREAS NOTED. SEE FLOW. CLEANSED WITH NS. AND DUODERM APPLIED. NOTED L HEEL BLISTER,UNBROKEN. HEELS ELEVATED ON PILLOWS SOCIAL: FAMILY INTO VISIT ON EVES. BOTH RN AND HOUSE STAFF SPOKE WITH FAMILY (WIFE,DAUGHTER AND SON) REGARDING CURRENT STATUS. THEY ARE AWARE OF HIS GRAVE SITUATION,BUT WANT TO CON'T WITH CURRENT TREATMENTS. THEY WOULD LIKE TO HAVE A FAMILY MEETING THIS AM TO DISCUSS PT CONDITIONS FURTHER AND OPEN OPTIONS. PT IS DNR,PRESSORS ONLY AT THIS TIME. A: CRTICAL P: FAMILY MEETING CON'T TILL FURTHER OPTIONS ARE AVAILABLE AM LABS ||||END_OF_RECORD START_OF_RECORD=17||||84|||| Respiratory Care Note Pt remains on AC 750X10 40% 7.5peep. Pt tol current settings well. Pt txd with Combivent and Flovent MDI during shift. Pt sxnd for small/mod amount of thick tan secretions. Sample obtained and sent to lab...still pending. Will continue to support on current settings. ||||END_OF_RECORD START_OF_RECORD=17||||85|||| S/O: CV: SBP 68-110. NEO TITRATED UP AND DOWN, CURRENTLY ON 20 MCG. HR 70'S-80'S AF. K 5.0. CAPTOPRIL HELD. RESP: NO ATTEMPTS TO WEAN. REPEAT VBG SHOWED CO2 44 WITH PH 7.25, ? R/T SEPSIS. BREATHING 0-10 OVER VENT. PT INITIALLY WITH RR 40'S AND PARADOXICAL BREATHING AT 8A, BOLUSED WITH 2 MG ATIVAN X2 1/2 HOUR APART AND BREATHING SLOWLY DEC TO 10-16 WITH MUCH BETTER SYNCHRONIZATION TO VENT. SUCTIONED THICK TAN SPUTUM, SENT FOR SPEC. ID: TMAX 101.5 PO, URINE AND SPUTUM SENT. TYLENOL GIVEN X1 AND TEMP DOWN TO 100'S PO. BC FROM 2D AGO PND. ABX CONT. GI: NO STOOL TODAY PER RECTAL BAG. C DIFF NEG X3. TF INC TO 75CC/HR WITH GOOD ABSORPTION, TF OFF WHEN NEO > 40 MCG. GU: U/O SLOWED DURING AFTERNOON TO 30-40CC/HR. BUN 94, CREAT 1.9. URINE SL CLOUDY. MS: MOVES ARMS SMALL AMOUNT OCC, ONLY RESPONDING TO PAIN, NO ATTEMPTS TO COMMUNICATE OR PURPOSEFUL MOVEMENT. UNABLE TO ASSESS SKIN. FAMILY: CHILDREN AND WIFE IN FOR FAMILY CONFERENCE. SO FAR, SON SEEMS UNABLE TO AGREE TO STOP TREATMENT AND TURN TO COMFORT CARE. FAMILY STOIC, ABLE TO DISCUSS SITUATION KNOWLEGABLY. A/P: CONT WITH CURRENT PLAN. ||||END_OF_RECORD START_OF_RECORD=17||||86|||| ccu nursing progress note 7p-7a neuro: pt remains on ativan at 5mg/hr. opens eyes to painful stimuli. not following commands. cv: hr 60-70's afib. bp- maintaining maps >60 via nbp with neo, currently at 40mcg/min. left radial aline dampened, able to flush, unable to draw blood. pulm: ls coarse throughout. sx q2-4hrs thick tan blood tinged sputum. o2 sats 100%, trached on vent 750/10, 40% fio2, 7.5 peep. gi/gu: abd soft, distended. hypoactive bs. tube feeds off since neo titrated up. no stool this shift. rectal bag intact. foley draining clear yellow urine approx 50cc/hr. id: tmax 100.1 ax. con't on flagyl, ceftax, and levo. social: spoke with family re: plan of care. daughter stated plan was to withdraw care "Tuesday, Wednesday, or Thursday." states awaiting Rabbi to visit. currently DNR on neo. plan: con't wean neo as tolerated. con't abx. ?obtain abg today. communication with family. ? wean vent if pt tolerates. resume tube feeds once neo dc'd. ||||END_OF_RECORD START_OF_RECORD=17||||87|||| Respiratory Care Note Patient remained on assist/control overnight with no vent changes made. O2 sats 98-99% on 40% Fi02, no art. line so no abgs. Breath sounds are coarse with thick tan secretions. Getting Combivent and Flovent inhalers as ordered. ||||END_OF_RECORD START_OF_RECORD=17||||88|||| Daughter [**Name (NI) 160**] called this am, the family after much discussion have decided to make the patient comfort measures only, to stop all meds except mso4 and ativan, and to dec fio2 to 21%.They wish no further decrease in ventilation at this time. Currently pts hr 76, bp 68/40and sats are 79%. Pt requires suctioning at least q2hr. Son and daughter are with patient. ||||END_OF_RECORD START_OF_RECORD=17||||89|||| ccu nursing progress note pt comfort measures only. ativan and mso4 titrated for comfort. daughter and son at bedside throughout night. pt expired at 1046 pm. ||||END_OF_RECORD START_OF_RECORD=17||||90|||| add: dobutamine off. ||||END_OF_RECORD START_OF_RECORD=18||||1|||| Resp. care note: Cardiac arrest called To [**Wardname 43**] At 0455. Pt was found unresponsive; then went asystolic. Pt was ambued and suction was attempted. Pt's fen. inner cannula was completely occluded. Pt was stabilized and transferred to CCu-2. A nonfen. inner cannula was placed; then patient was placed on PB 7200. Vent settings AC 700/18/70% +5. ||||END_OF_RECORD START_OF_RECORD=18||||2|||| O: IN RESP DISTRESS ON [**Wardname **]; CODE CALLED; TO CCU- INNER CANNULA CHANGED FROM FENESTRATED TRACH; VENTILATING MUCH EASIER; BP 68; ON DOPAMINE TRANSIENTLY; NS FLUID BOLUS GIVEN; RIGHT FEMORAL TRIPLE LUMEN PLACED; A LINE IN PROCESS OF BEING PLACED; A: POST RESPIRATORY ARREST; INITIAL TREATMENT PHASE IN PROGRESS IN CCU. P: FLUID; DOPAMINE, LINES, DEFINTIVE TREATMENT. ||||END_OF_RECORD START_OF_RECORD=18||||3|||| 76 YR OLD RUSSIAN SPEAKING DIABETIC MALE ADMITTED TO [**Hospital1 2**] [**03-09**] C AMI, 3VD RX C CABG [**03-13**] . POST OP COARSE COMPLICATED BY 3 REINTUBATIONS ,VRE PNEUMONIA AND UTI .REQUIRED TRACH, PEG,DIALYSIS . WAS RESPONSIVE TO QUESTIONS AND SIMPLE COMMANDS THOUGH EEG SHOWED WIDESPREAD ENCEPHALOPATHY .CT SCAN NEG.HE WAS TO BE SENT TO REHAB TODAY BUT WAS FOUND UNRESPONSIVE AND ASYSTOLIC ON [**Wardname **]. DIFFICULT TO VANTILLATE, TRACH CHANGED TO NON FENESTRATED .EXTERNAL PACER TRANSIENTLY USED.RECIEVED EPI,ATROPINE,BICARB.ADMITTED TO CCU IN AFIB C BP 62/26. PRESENTLY IN SR, BP MAINTAINED OVER 100 SYS ON 1.9 DOPAMINE .NON RESPONSIVE. ||||END_OF_RECORD START_OF_RECORD=18||||4|||| RESP NOTE - PT. TRANSFERRED TO CT AND BACK WITHOUT INCIDENT, PLACED BACK ON THE VENT AC TV 700 RR 18 FIO2 40% 5PEEP SPO2 100% HR60 AT THIS TIME. ||||END_OF_RECORD START_OF_RECORD=18||||5|||| CV SR TO SB OCC PAC .WEANING DOPAMINE . PT IS USUALLY ON HYPERTENSIVE MEDS. RESP LATEST ABG 126/24/7.52/20 ,RATE ,TV DROPPED ,AC 600/40/16/5. SX FOR MOD TAN TO BLD TINGED .TRACH CLEAN . GI NOT TOL TF.[**Name Prefix (Prefixes) 179**] [**Last Name (Prefixes) **] GREEN P TUBE CLAMPED FOR MEDS . PLACED ON GRAVITY DRAIN. ENDO 15 NPH, 10U REG IN AM. 6PM BS 198, NO INSULIN GIVEN . PM NPH DOSE CUT TO 7 U GU ON HEMO TOMORROW , NO URINE ,POS 767 CC NEURO NON RESPONSIVE ,POSTUREING, MOUTHING OPENING EYES NOT FOCUSING.CAT SCAN NEG FOR BLEED SOCIAL WIFE, SON DISCUSSED SITUATION C ATTENDING , PT REMAINS FULL CODE FOR PRESEST.SOCIAL WORKER CALLED VS STABLIZING .NEURO CONDITION UNCHANGED SUPPORT FAMILY ||||END_OF_RECORD START_OF_RECORD=18||||6|||| PT. INITIALLY ON AC 600X16/5/40%, PT OVERBREATHING VENT X [**10-30**] WITH ABG 11/31/7.45. PLACED ON CPAP/PS 16/5/40% TOLERATING WELL. PT. HAD FEW EPISODES OF TACHYPNEA RR UPPER 30'S TO 40'S. AMBUED, LAVAGED AND SXN'D FOR OCC. THICK YELLOW MUCOUS PLUG, OTHERWISE PALE YELLOW IN MODERATE AMTS Q2.PLAN IS TO WEAN TO EXTUBATE TODAY. ||||END_OF_RECORD START_OF_RECORD=18||||7|||| S- INTUBATED/TRACHED O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- PT REMAINS HEMODYNAMICALLY STABLE OFF ALL PRESSORS. HR- 50'S SB, BP- 120-130/50 VIA RADIAL ALINE. NO ISSUES CURRENTLY. RESP- PT CURRENTLY TOLERATING PRESSURE SUPPORT MODE- ABG X 2 WNL. SUCTIONED FOR THICK WHITISH SPUTUM- NO PLUGS CURRENTLY. SENT SPECIMEN X 1. SPONTANEOUS TIDAL VOLUMES 480-550, RESP RATE 18-24. COARSE BREATH SOUNDS PERSIST. ID- T MAX- 102.6 AT 4 AM- TYLENOL/CULTURES. NEW ANTIBX STARTED 12 AM. GU- ANURIC. DIALYSIS CATHETER IN PLACE RT IJ.? SCHEDULE FOR DIALYSIS. GI- 75CC DRAINAGE VIA G TUBE. NPO FOR S.P EMESIS YESTERDAY. NO STOOL. VERY HYPOACTIVE BOWEL SOUNDS. SKIN- DSD ON RT HEEL/LEFT LOWER LEG AND DUODERM ON COCCYX. STERNAL SITE DRY. ALL DRESSINGS CHANGED, NO DRAINAGE CURRENTLY. MS/NEURO- PT REACTING TO STIMULI WITH GRIMACING, WITHDRAWING UPPER EXTREMITIES. PUPILS NONREACTIVE- TO VERY SLUGGISH. (+) COUGH. SEE FLOWSHEET. REPORTEDLY SLIGHTLY IMPROVED NEURO SIGNS FROM ADMISSION/EARLIER IN DAY [**05-11**]. NEURO TO CONSULT. SOCIAL- NO CALLS THIS SHIFT FROM ANY FAMILY MEMBERS. A/P- PT S/P RESP ARREST CURRENTLY TOLERATING PRESSURE SUPPORT MODE OF VENTILATION. NEUROLOGICAL DEFICITS PERSIST S.P ARREST. CONTINUE TO CLOSELY MONITOR CV/RESP STATUS. SUPPORT AS NEEDED. CONTINUE FEVER W.U- CONTINUE ANTIBX AS ORDERED. AWAIT CULTURE RESULTS. SKIN CARE/COMFORT/KEEP FAMILY AWARE OF PROGRESS/PLAN OF CARE. CONTINUE REGLAN/NPO UNTIL BETTER MOVEMENT IN GI TRACT. CONTINUE GRADUAL VENT WEAN AS PT TOLERATES. ||||END_OF_RECORD START_OF_RECORD=18||||8|||| resp note - pt. received on ps, unable to tol placed on ac tv 600 rr 16 40%fi02 5peep tol ok at this time. ||||END_OF_RECORD START_OF_RECORD=18||||9|||| NEURO MOVVES LEGS, POSTURES C ARMS, CHEWING . COUGHS HAS STRONGER GAG .SEEMS MORE REACTIVE TO STIMULI TODAY BP STABLE DURING DIALYSIS . SPIKED TEMP TO 102.2 .BP THEN 87 TO LOW 90S.DIALIZED FOR 1LITER 250 CC FLUID BOLLUS GIVEN CATHED FOR 100CC THICK GREEN FOUL SMELING URINE. SENT FOR C/S,A.TYLENOL GIVEN . SR NO ECTOPY TOL PEG TUBE BEING CLAMPED . MEDS GIVEN 5PM . STARTED DAY ON CPAP. FAILED TRACH MASK DUE TO SECRETIONS AND TACHYPNEA. REMAINED TACHYPNEIC ON CPAP ,AC .MEDICATED C 2 MGM MSO4.CURRENTLY ON AC 600/16/40/5.ABG 7.46/32/107 .SX THICK YELLOW, THIN BLOOD TINGED. SPEC SENT C/S. BS 150 TO 79. 7 NPH GIVEN THIS AM. RECHECK BS, HOLD EVE NPH IF LOW RESTART TF IF TOL MEDS TYLENOL FOR TEMP ||||END_OF_RECORD START_OF_RECORD=18||||10|||| S- NONRESPONSIVE/TRACHED O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- HEMODYNAMICS SOMEWHAT LABILE THIS SHIFT. INITIALLY- ISSUES WITH HYPOTENSION- SPB- 80/- GIVEN 250 NS BOLUS X 2. BP RANGE- 100-110/40-60. AT 4 AM- ACUTE INCREASE IN BP- 170-180. H.O AWARE- NEURO SIGNS CHECKED- NO ACUTE/SIGNIFICANT CHANGES PER H.O. STARTED PT ON 6.25 CAPTOPRIL FOR BP CONTROL. CURRENTLY- 140/60. HR- 50'S SB- 60 SR. NO VEA. GIVEN 40 KCL FOR K- 3.2. AM LYTES PENDING. RESP- TOLERATING SWITCH OF MODE TO A/C FROM CPAP LAST EVE. CURRENTLY- 40/700/16 A.C. SUCTIONED FOR MEDIUM AMT THICK WHITISH SPUTUM. COARSE BREATH SOUNDS. O2 SATS- HIGH 90'S. ID- TEMP UP TO 102.8-PAN CULTURED X 2 [**05-12**]. TYLENOL X 1. ADDED CEFTAZ AND ONE TIME VANCO DOSE. FLAGYL DECREASED TO BID FROM TID. ID APPROVAL FOR CEFTAZ OBTAINED. CULTURES PENDING. GU- ANURIC. S/P DIALYSIS [**05-12**]. GI- NO RESIDUALS VIA GT- STARTED TUBE FEEDS- CURRENTLY AT 20/HOUR. TOLERATING WELL- VERY SMALL AMT STOOL . MS/NEURO- SEE FLOWSHEET- NO CHANGE FROM [**05-12**] NIGHTS- A/P- PT S/P ARREST CURRENTLY WITH NEURO DEFICITS FUO LABILE HEMODYNAMICS CONTINUE TO CLOSELY MONITOR HEMODYNAMICS- FLUID/PRESSORS AS NEEDED. MONITOR NEURO FOR ANY SIGNIFICANT CHANGES. CONTINUE FEVER W/U- ANTIBX AS ORDERED. CONTINUE TO KEEP FAMILY WELL INFORMED RE: PLAN/PROGRESS. ||||END_OF_RECORD START_OF_RECORD=18||||11|||| resp care note: Pt continues to be ventilated on AC 600/16/40% +5. No ventilator changes made thiis shift. Pt suctioned for a moderate amount of tan pluggy secretions. Pt spiked a temp max of 104. plan is to hold vent weaning until pt's temp decreases. For further information please refer to carevue charting. ||||END_OF_RECORD START_OF_RECORD=18||||12|||| SPIKED TEMP TO 104 . TYLENOL GIVEN .CXR DONE .BLD CX RESENT . TEMP BROKE BEFORE ICE BLANKET APPLIED . PRESENTLY 100.8 RECTALLY . HYPERTENSIVE C STIMULATION,TOLERATING LOPRESSER, CAPTORIL . SR NO ECT. REPEAT HCT 29 . VENT AC 600/40/165/5 ABG 102/33/7.39/21. SX TAN/YELLOW . OVERBREATHING MACHINE P CPT , RESOLVED C 2 MG MSO4 . LESS REACTIVE TODAY ,PUPILS SM EQUAL NO REACTION . TOL TF MIN RESIDUAL, SM BR STOOL . BLUE FOOD COLORING ADDED TO TF . NO URINE. TO BE DIALYSED TOMORROW DUODERM ON COCCYX CHANGED ,PINK SEES TO BE HEELING 7 NPH , BS STABLE TYLENOL FOR TEMP ADVANCE TF AS TOL ||||END_OF_RECORD START_OF_RECORD=18||||13|||| SYSTEMS REVIEW: NEURO: ESSENTIALLY UNRESPONSIVE; AT TIMES MOVING LEGS ON BED; CV/HEMODYNAMICS: IN SB-SR WITHOUT ECTOPY; BP STABLE; HR AND BP RANGE REFLECTIVE OF LOPRESSOR AND CAPTOPRIL; ID: FEBRILE TO 103.4- TYLENOL GIVEN- DEFERVESCED; ON LEVOFLOXACIN QOD; ON CEFTAZIDIME POST EACH HEMODIALYSIS. ENDOCRINE: GLUCOSE IN ACCEPTABLE CONTROL; ON NPH INSULIN BID- COVERED WITH SLIDING SCALE; RENAL: ANURIC- ON HEMODIALYSIS; SCHEDULED FOR [**1992-05-14**] GI: ON NEPRO AT 30 CC; MINIMAL RESIDUAL- ATTEMPTING TO ADVANCE TO GOAL OF 45 CC/HR. RESPIRATORY: TRACH- ON 40% FIO2; RR SET 16 WITH 16 TOTAL BREATHS; O2 SAT 100% AT TIMES; SUCTIONED FOR SCANT SPUTUM. SOCIAL: FAMILY MEMBERS PRESENT IN EARLY EVENING. ||||END_OF_RECORD START_OF_RECORD=18||||14|||| Pt. initially on AC 600x16/5/40%, switched to PSV. Tolerated 18/5 with ABG's 88/77/7.44. Continued to wean down to 10/5. Pt tolerating well RR 20's with VT's 500-560's. Plan is to continue support, wean as tolerated. ||||END_OF_RECORD START_OF_RECORD=18||||15|||| ccu npn o- temp spike to 103.8, bld c+s sent from aline, straight cath for c+s of urine and sputum sent. abx added this pm. cv- cont. in sr, no vea. bp 103-180s. resp- weaned slowly to psv 10 with peep 5, 40%. abgs done, see flowsheet, sats 97-100. tv 400s, rr 20s. tolerated activity better today without increasing rr. sx'd q2-3hr for thick yellow via ett and orally. dialysis done in am, tol well, 1.4 liters off. s/p pt. gi- tol t/f, increased to 45cc/hr nepro with food coloring. no bm. peg connection occ. slips out, difficult to give meds, ho aware. skin- unchanged. cont. on 1st step mattress. repos side to back with skin care. social- wife visited, spoke to md [**First Name (Titles) **] [**Last Name (Titles) **] regarding pt's condition and updated. ||||END_OF_RECORD START_OF_RECORD=18||||16|||| Respiratory Care: Patient trached with 6.0 shiley trach. Vent settings Psv 10, Cpap 5, Fio2 40%, with flowby 6/3. Spont vols 400's with RR 20-30's. Bs decreased and slightly coarse bilaterally. Sx'd for sm amount of thick white sputum. Abg within normal limits. Patient appears comfortable on above settings. No further changes made. Continue with mechanical support and wean Psv as tolerated. ||||END_OF_RECORD START_OF_RECORD=18||||17|||| S- NONRESPONSIVE O- SEE FLOWSHEET FOR OBJECTIVE DATA. CV- HEMODYNAMICS REMAIN AT BASELINE.. HR- 50-60 SB/SR BP- 90-100/40-50. NO ISSUES WITH HYPOTENSION THIS SHIFT. RESP- TOLERATING PRESSURE SUPPORT. GOOD ABG'S- SEE FLOWSHEET . RESP RATE- 20-24, TV- 450-500. SUCTIONED FOR THICK WHITE SRUTUM. LUNG SOUNDS RHONCHI THROUGHOUT. ID- FEBRILE TO 103- COOLING BLANKET. STARTED MERIPEM ANTIBX. CONTINUES ON FLAGYL/CEF. BY THIS AM- T- 99. GI- TUBED FEEDS AT 45/HOUR. NO STOOL- HYPOACTIVE BOWEL SOUNDS. GU- NO U.O. S/P DIALYSIS [**05-15**]. NEURO- REMAINS UNRESPONSIVE- NEURO SIGNS UNCHANGED. MOVING ALL EXTREMITIES. PUPILS UNCHANGED/REFLEXES UNCHANGED. SKIN- COCCYX WITH DUODERM/ RT HEEL BLACKENED... A/P= PT REMAINS UNCHANGED NEUROLOGICALLY; REMAINS FEBRILE. HEMODYNAMICS STABLE CURRENTLY. CONTINUE FEVER W/U- ANTIBX AS ORDERED. MONITOR HEMODYNAMICS. SKIN CARE/PULM TOILET. ASSESS CLOSELY TOLERANCE OF PRESSURE SUPPORT. KEEP FAMILY AWARE OF PLAN OF CARE/PROGRESS. DISCUSS STATUS WITH FAMILY/MEETING. ||||END_OF_RECORD START_OF_RECORD=18||||18|||| NEURO: unchanged. Pupils remain 2mm unreactive. not responding to commands. had +gag and cough. opens eyes to stimuli. facial grimmacing to suctioning. wife in to visit w/ no change in status. CARDIAC: SB/SR 50-60s. SBP 90-110s. on Captopril 6.25 TID , Lopressor 12.5mg BID, tolerating. L radial Aline. R s/c quinton. 2 peripheral heplocks. plan for PICC insertion in am. ID: TMAX 101.8. tylenol 650mg PR x 1 given. some abx d/c'd today. remains only on meropenum. RESP: LS coarse/rhonchorous to bases. sx white/tan thick secretions small amts. Trach site intact. placed on PS 5/5 this afternoon, tolerating well... TV 4-500s, RR 8-12, sats 40%. ABG: 142/39/7.35/22/-3. sats 100%. ENDO: FS 200s. SSRI coverage. BID nph. GI/GU: anuric. last dialysis [**05-15**]. NEPRO 45cc/hr via PEG. hypo BS. no stool. SKIN: duoderm to coccyx, R calf dsg, R heel blackened, on air mattress and padded booties. PLAN: con't to monitor neuro status for any improvements. monitor FS. monitor temps. ||||END_OF_RECORD START_OF_RECORD=18||||19|||| Trached patient , failure to wean off mechanical ventilation. PS decreased to 5 from 10 ABG on PS 5=7.35-39-142-22. BS coarse , patient suctioned for minimal amount of creamy sputum. Full code will continue to follow. ||||END_OF_RECORD START_OF_RECORD=18||||20|||| Respiratory Care: Patient trached with 6.0 shiley trach. Vent settings Psv 10, Cpap 5, Fio2 40% with flowby 6/3. Spont vols 400's with RR 19-low 20's. Psv weaned to 5cm yesterday. Tolerated well x 2 1/2 hrs. RR increasing consistently to mid 30's with increased WOB. Psv increased to 10 to rest for the noc. RR decreasing to 20's. Bs faint crackles R base otherwise lungs clear. Sx'd for moderate amounts of thick tan/yellow sputum. No further changes made. Continue with slow Psv wean as tolerated. ||||END_OF_RECORD START_OF_RECORD=18||||21|||| Resp care no changes made overnoc...remains on 5/5/ with Ve 8.0 and rr low 20's. sxned thick clear/bld tinged sputum. c/w vent support.?try trach collar today. ||||END_OF_RECORD START_OF_RECORD=18||||22|||| micu npn o- afebrile. cv- unchanged. hr 40s-50s. bp 90s-150s/. aline dampens frequently. resp- cont. on vent 5/5 psv with rr 20s, tv 300s. sx'd for small tan/yellow via trach and large white orally, no gag. ?try trach mask today. for hd today. gi- tol. t/f at goal. needs laxative ?lactulose for constipation. ms- unchanged, no reponse to verbal stimuli, pupils nonreactive. social- wife called. ?[**Name2 (NI) 180**] meeting planned or to be planned for today. s. service consult for fx support. ||||END_OF_RECORD START_OF_RECORD=18||||23|||| Neuro status unchanged hr down to 36 at one point during dialysis, lopressor held, am dose captopril held, given at 16:00 at 18:00 sbp down to 60's, given 100cc ns and started on dopamine briefly, currently sbp 100/ vent on 5ps/5peep most of day. sx for mosd amt thick yellow sputum. had episode of plugging during chest pt, placed on ac for rest. Vomited very lg amt tf at noon, tf off, again vomited ~ 16:00, tf will remain off thru noc. dialysis today w/ 2000cc fluid removal, tolerated well. wife in to visit most of day, family meeting planned for 11:00 tomorrow. ||||END_OF_RECORD START_OF_RECORD=18||||24|||| NEURO: remains unchanged. unresponsive. only brainstem reflexes. +gag +cough. opens eyes to physical stimuli only, no tracking, not obeying any commands. occasional leg movements, abnormal flexion w/ coughs. pupils 2mm NR. given 2 doses of Fosphenytoin 400mg IV per neuro recommendations. no changes noted in neuro status this morning. CARDIAC: BP labile. dopamine titrated for MAP>60. HR sb/sr 40-60s. failed attempt at replacing aline last evening. RESP: placed back from AC to PS 12/5peep at 8pm. 40%. sats >96%. Sx for small amts tan thick to scant whitish thin secretions. Trach site intact. ID: afebrile. remains on meropenum. GI/GU: anuric, rec'd dialysis yesterday. NPO. pt vomited large amts of tube feed x 2 during the day yesterday, tube feeds on hold since. Peg intact in abd. FS 206 this am, SSRI held since pt rec'd full dose NPH last evening. PLAN: FAMILY MEETING @ 11am today to discuss pt condition and to discuss code status. attempt to wean off dopamine. needs PICC placement. monitor neuro status and VS. ||||END_OF_RECORD START_OF_RECORD=18||||25|||| Resp Care vented in psv mode however now requiring incr level of support. presnt settings 12/5/40%. volumes 400's with rr 20's. sxning initially for tenacious tan , now to clear tenacious. c/w psv as tolerates. attempt to wean further/cw lavage/sxn. ||||END_OF_RECORD START_OF_RECORD=18||||26|||| RESPIRATORY CARE NOTE PT CONTINUES ON CPAP 5 PEEP 12 PSV 40%. VT 460-550. RR 20'S. PT SXN FOR MOD AMOUNTS OF TAN THICK SECRETIONS. BS COARSE RHONCHI THAT CLEARED POST SXN. WILL CONTINUE SUPPORT AND WEAN AS TOLERATED. ||||END_OF_RECORD START_OF_RECORD=18||||27|||| Neuro: neuro status unchanged Cv: bp remains labile 72-150/40-50,requiring titration of Dopamine 2-15mcg/kg. Hr generally 50-60 sr w/ no vea, w/ periods of bradycardia to low 40's. Resp: Vent unchanged, PS12/Peep5. sx q 1-3hrs for thick yellow secretions. GI: TF remain off d/t lg amt emesis [**05-18**] and inability to measure residuals, no stool today GU: no urine, dialysis [**05-20**] Social: Family meeting today w/ wife, son and grandson, neurologist, pcp Dr [**Last Name (STitle) 181**]. Family has decided to maintain present level of care and have pt remain full code for another week. ||||END_OF_RECORD START_OF_RECORD=18||||28|||| Patient remains trached and mechanically vented. Vent checked and alarms functioning. Settings Cpap/PS 5 peep 12 ps. 40%fio2. volumes are around 400cc with respiratory rates in the teens. Patient looks comfortable on current settings. Please see respiratory section of carevue for further data. Plan: Continue mechanical ventilation. ||||END_OF_RECORD START_OF_RECORD=18||||29|||| A:UNCHGED. P:PICC PLACEMENT. DIALYSIS. CONTIN PRESENT MANAGEMENT. ||||END_OF_RECORD START_OF_RECORD=18||||30|||| Remains trached, vent supported. Decreased vent to 5PSV 5CPAP 40%. No ABG's this shift. See flowsheet for further pt data. Plan: Will follow. ||||END_OF_RECORD START_OF_RECORD=18||||31|||| RESPIRATORY CARE: PT. WITH 6.0 SHILEY TRACH. CONTINUES ON PS 5/.40/5 AND BREATHING COMFORTABLY. MAY TRY TRACH COLLAR IN AM. ||||END_OF_RECORD START_OF_RECORD=18||||32|||| micu npn o- afebrile po. cv- hr 50s-71 sr, no vea. bp 120-150s/. resp- weaned to 40% trach mask, tol well, no distress noted. rr 18-low 20s. sats 98-99. abgs- 112,42,7.38,26. l/s dim, coarse. sx'd for thick yellow via trach and orally- yellow/clear. gi- tol t/f, increased to 45cc/hr (goal). no vomiting. had scant amt new stool in rectal bag, rectal bag intact. dm- bs 200s, up to 248 this pm, given nph this eve with t/f at goal. also covered with reg. insulin. skin- unchanged, cont. with duoderm intact on coccyx, black heel on r (ho aware). repos side to side q3hrs with skin care. lines- picc dsg changed by iv rn, flushes per protocol. social- wife and friends in this pm, updated on pt's condition and changes by rn. ||||END_OF_RECORD START_OF_RECORD=18||||33|||| RESPIRATORY CARE: PT. WITH 6.0 TRACH IN PLACE. DOING WELL ON TRACH COLLAR .40 SINCE [**1992-05-20**] AM WITH RR 24-28 BPM. SX. THICK TAN SPUTUM. CONTINUE TRACH COLLAR .40 AS TOLERATED. ||||END_OF_RECORD START_OF_RECORD=18||||34|||| NEURO: remains unchanged. no improvements noted. pupils 2mm unreactive. unresponsive. brainstem function only. breaths off vent. gags, +cough. spontaneously opens eyes to stimuli, postures upper body when suctioned and moved. does not respond to commands. does not focus or look around. does not grasp hand. slight movement of legs at times. no purposful movement noted. on dilantin qhs. neuro on consult. CARDIAC: SR 60-70s. no ectopy noted. BP stable. aline patent. d/l PICC patent to L a/c. RESP: remains on trach collar 40%. sx q2-3h for thick tan secretions. sats 100%. RR 20s. GI/GU: anuric. for dialysis today. abd soft, +bs. stooling scant amts. rectal bag intact. +flatus. PEG intact, TF at goal @ 45cc/hr. no vomiting noted. SKIN: heels elevated off bed. turned and repo'd frequently w/ skin care. duoderm intact to coccyx. on air bed. PLAN: con't to monitor airway off ventilator. monitor neuro for changes. emotional support to family. ||||END_OF_RECORD START_OF_RECORD=18||||35|||| PT continues to wean on [**Last Name (un) 182**] collar 40% 12 lpm sats high 90's rr teens. goal: dc vent today. ||||END_OF_RECORD START_OF_RECORD=18||||36|||| Neuro status unchanged Remains hemodynamically stable Remains on trach mask at 40% w/ good abg. Sx q2hr for thick tan secretions. Dialysis this am, w/ 2000cc fluid removal, tolerated well sma mt brn liq stool draining from rectal bag. tf at goal wife in to visit all day. ||||END_OF_RECORD START_OF_RECORD=18||||37|||| o:neuro=unresponsive. pulm=sx freq for thick creamy tannish secretions. remains off vent-trach mask w sats upper 90's. gi=tf @ goal-45ml/hr. rectal bag in place. id=afebrile. labs=am sent. a:unchged. p:contin present rx plan. ?call-out. family mtg ?monday [**05-25**]. ||||END_OF_RECORD START_OF_RECORD=18||||38|||| S/O: CV: VSS, AFEB RESP: FIO2 INC TO 50% AFTER ABG SHOWED PO2 66. SATS CONT HIGH 90'S. CO2 AND PH MNL. RR INTERMITTANTLY HIGH TO LOW 40'S, OTHERWISE IN 20'S. LUNGS WITH COURSE SOUNDS THROUGHOUT. SUCTIONED Q2H FOR COPIOUS TO MOD AMOUNTS OF THICK WHITE SPUTUM. SPUTUM PROD DEC DURING COURSE OF DAY. WILL D/C A-LINE TOMORROW. GI: TOL NEPRO WITH PROMOD AT 45CC/HR, RESIDUALS <10CC. REQ SS REGULAR INSULIN SC. RECTAL BAG INTACT, VERY LITTLE STOOL PRODUCTION. MS: CONT UNRESPONSIVE TO NOXIOUS STIMULI. OCC SEE RIGHT ARM OR LEG MOVE. POS COUGH AND GAG. PUPILS CONT FIXED AT 4MM. NO SEDATION NEEDED. WIFE IN TO VISIT WITH SISTER, STATES SHE IS WAITING FOR HIM TO WAKE UP. STATES SHE UNDERSTANDS WHEN TOLD THAT PT PROBABLY WILL NOT WAKE UP. WANTS PT TO STAY IN ICU FOR A FEW MORE DAYS, IS FEARFUL HE WILL GET SICKER IF MOVED TO THE FLOOR. PLEASE CALL WIFE IF IT IS NECESSARY TO MOVE TO FLOOR. WIFE STATES SHE IS NOT SLEEPING OR EATING. ENCOURAGED TO GO HOME AND TAKE SLEEPER THAT SHE HAS TONIGHT. A/P: WIFE STILL IN DENIAL ABOUT PT'S PROGNOSIS ALTHOUGH SHE SEEMS TO UNDERSTAND INFORMATION GIVEN. WANTS PT TO STAY IN ICU. SUCTIONING DEC SOMEWHAT TODAY. CONT WITH FREQ TURNING AND PULM TOILET. ||||END_OF_RECORD START_OF_RECORD=18||||39|||| O:NEURO=UNRESPONSIVE. PULM=SX FOR LARGE AMTS THICK SECRETIONS. SATS UPPER 90'S. BREATH SOUNDS-COURSE THROUGHOUT. GI=TF @ GOAL. STOOLING-RECTAL BAG IN PLACE. ENDO=BS COVERED W SS. A:REQUIRING FREQ SX FOR THICK SECRETIONS. P:CONTIN PRESENT RX PLAN. ||||END_OF_RECORD START_OF_RECORD=18||||40|||| SEE NURSING TRANSFER NOTE AND CAREVUE CV: VSS, AFEB. RESP: SUCTIONED Q2-3H FOR THICK YELLOW SPUTUM. CLEARS EASILY, RR IN 20'S-30'S ON 50% NEB. TRACH SITE WITHOUT ERYTHEMA. INNER CANNULA CHANGED. GI: TOL TF AT 45CC/HR. RECTAL BAG CHANGED, SMALL AMOUNT OF LIQUID STOOL. POS BS, ABD SOFT. GU: NO U/O. SKIN: RIGHT HEEL WITH NECROTIC AREA 7CM X 6 CM. NEEDS PLASTICS CONSULT IN AM. PADDED LEG PROTECTORS ON PT. COCCYX REDDENED BUT INTACT. MS: NEURO STATUS UNCHANGED. MRS [**Last Name (STitle) **] HERE AND UPSET THAT PT WAS BEING TRANSFERRED, STATED THAT DR [**Last Name (STitle) **] HAD PROMISED HER THAT PT WOULD STAY IN CCU. TOLD ME THAT SHE WISHES PT TO BE DNR BUT WILL NOT TALK TO ANY HOUSE STAFF ABOUT THIS. A/P: STATUS UNCHANGED, READY FOR TRANSFER. ||||END_OF_RECORD START_OF_RECORD=19||||1|||| npn 7p-7a ccu admission note: pt is a 41 yo f who arrived from [**Hospital 183**] hosp hosp via medflight for further eval of ?heart failure. she was admitted there [**05-08**] after several er visits for c/o sob. she was initially being tx for copd exerbation then required intubation and swan placed which showed increased pa pressures & increased pcwp. echo done which showed biventricular failure w/hypokenesis w/ef 10-15% & ?clot in her ventricle. she was started on dobutamine & hep & was diuresed. attempts were made to wean from vent after diuresis but unsuccessful. she did r/i for mi she was sent to [**Hospital1 **] for further eval. pmh: dm smoker mitral regurg ros: neuro--pt rec'd ativan/fent/vec enroute to [**Hospital1 **], did begin to wake, moving all ext, given ativan 2mg iv x3 w/some effect on aggitation, propofol started which she had a good response to, will change to ativan gtt d/t ?elevated ck's/rhabdomyolysis. when well sedated she moves only to painful stimuli, she does not follow commands resp--conts vented, a/c-10, 500, peep 5, 40%, team attempting to place aline to follow abg's, sats 98-100%, breathing 2-4 breaths over vent, ls coarse throughout, sxn'd x2 for thick white secretions--spec sent off cardiac--hr 100-110's st w/occ-frequents multifocal pvc's, bp 94-120/40, initially on 7.5mcg dobutamine, weaned to 4.5mcg w/bp 97-107/50, pa present, cxr confirms placement, pa # 34-40/24-30, pcwp 12-14, co 6.3/ci 3.5, swan is in rij, skin around area reddened, broken down under teagaderm, ?skin reaction to tape or infection, team would like to resite line, ?if they still want swan, conts on hep gtt, initially at 1350u/hr increased up to 1550 after ptt subtherapeutic gi--abd soft/distended, (+)bs, green/bilious material, tf's had been stopped from transfer, restarted in ccu, replete w/fiber at 10cc/hr started tonight, gu--foley to gravity draining clear/cloudy urine, approx 40-50cc/hr, ua/c&s sent w/temp spike id--tmax 102r, team aware, did get tylenol for fever, bld cx x2 sent, ua/c&s, sputums sent, given tylenol w/min improvement in fever, to start vanco, team to resite line, ?if still will need swan skin--pt has ?allergic reaction w/red dry skin to area under teagaderm on r side of neck, also reddness to cheecks where ett appeared to be tapped, (+)yeast to perineum, nystatin powder ordered access--#20 l lower arm, rij swan, several attempts made at add peripheral access w/out success, team aware, pt does still required iv access social--pt is married but separated from husband, she has 5 children, oldest son [**Name (NI) 184**] was in to visit last night, unclear who is next of kin/ proxy o patient ||||END_OF_RECORD START_OF_RECORD=19||||2|||| resp. care note: Pt continues to be ventilated on AC 500/10/40% +5. Pt ambued today while swan was placed. Pt very agitated at times. Morphine and fent. added for sedation. pt suctioned for amoderate amount of secretions. Plan is to continue vent support until the pt is stable. for further information please refer to carevue charting. ||||END_OF_RECORD START_OF_RECORD=19||||3|||| NEURO: pt sedated on ATIVAN @ 3mg/hr + FENTANYL 75mcg/min. Pt rouses to stimuli and req'd freq boluses of fent and ativan during PA line and Aline insertions. Pt seemed to know brother and son when they visited this afternoon, pt calmer, looking at family at times. CARDIAC: SR/ST 90-120s, occ PVCs. New PA line inserted in L s/c. PAD 21-24. PCWP 17. unable to wedge new PAline this evening, HO aware. CVP 7-10....CO 7.6 ->7.3 , CI 4.04 -> 3.88, SVR 516 -> 570. Dobutamine drip weaned to off at noon and LEVOPHED gtt started, currently at 3mcg/min. Heparin off this afternoon for line insertion, restarted @ 4pm, next PTT due 10pm. L radial ALINE placed this evening. difficult to palpate pedal pulses. ACCESS: pt has 2 peripheral IVs (RLA, LLA), Lrad Aline, Ls/c PAline w/ VIP port. RESP: LS coarse, sx mod amts thin white to tannish secretions. sats >97%. AC 500x14, 5 PEEP, 40%. pm ABG: 148/46/7.38/28/1 GI/GU: foley patent, good u/o >30cc/hr. Abd soft, +BS. no stool. TF replete w/ fibre @ 30cc/hr, minimal residuals. ENDO: FS qid. on SSRI for sugars 300s. NPH bid. ID: TMAX 102rectal. Now monitored w/ core temps, currently 100.8. Tylenol 650mg PR x1 today. On Vanco q12h, and started on Levoquin. Old PAline tip sent for culture. BC results pnd. PLAN: con't to monitor hemodynamics and cardiac calcs. advance TF as tolerated. recheck PTT at 10pm. con't cycling CKs. titrate sedation as needed. ||||END_OF_RECORD START_OF_RECORD=19||||4|||| npn 7p-7a: ccu nsg progress note: neuro--on ativan/fent gtts, rates increased d/t pt becoming very aggitated and lifing head/shoulders off bed, also w/increased hr w/aggitation, ativan up to 7mg/hr, fent at 125mcg/hr, pt is arousable to name, opens eyes, follow simple commands, pt appears more comfortable this am resp--conts vented, a/c rate up to 12, tv 450, peep 5, 40%, last abg 74-41-7.44, ls decreased in rll, coarse throughout rest of lung fields, sxn'd q1-2hrs for thick white/tan secretions, sats 93-98%, overbreathing vent up to 6-7 breaths cardiac--hr 98-140's st, hr elevated w/aggitation and also d/t febrile, conts w/occ mulitfocal pvc's, conts on levo weaned to 2.5mcg, bp 88-128/50-70, pa numbers initially 57/30, pcwp 18, cvp 11, co 4.6, ci 2.45, svr 1061, when became tachy & hypotensive pa numbers--59/44, unable to wedge, cvp 12, co 3.4, ci 1.81, svr 1788, team aware, pt given fluid boluses which did improve bp & hr, rate to 110's, bp to 98-100/50's, conts on hep gtt, rate increased d/t subtherapeutic ptt, this am in range gi--abd soft, (+)bs, tol tf's at 30cc/hr, gu--foley intact, u/o initially 40cc/hr which improved w/ivf boluses endo--at mn fs 407, given 10u reg insulin, 5am fs 389, team aware, insulin gtt started at 5u/hr after given 8u sq id--conts febrile up to 102 core, given tylenol, temp down to 101.3, again given tylenol, conts on ivab, cx still pnd ||||END_OF_RECORD START_OF_RECORD=19||||5|||| S. REMAINS INTUBATED, SEDATED O. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA] CV: HR 116 ST DOWN TO 98 SR RARE TO FREQUENT PVC'S BP 108/69 DOWN TO 90/50'S W/LEVO DOWN TO 2MG/HR FROM 2.5M - PAP'S 51-59/27-33 CVP 10-13, RECEIVED LASIX 40MG IV W/~500 U/O AND PA DOWN TO 38/22 CVP 8 PCWP DOWN TO 21; CO/CI PRE AND POST LASIX/LEVO DECREASE 4.5/2.39 SVR 1156 TO 5.1/2.71 SVR 1004 ECHO DONE -RESULTS PND; HEPARIN REMAINS AT 1750/HR W/ PTT 99 RESP: REMAINS INTUBATED ON 40% AC 500X12 5 PEEP RR 12-18 - ABG POST DIURESIS 123/46/7.39/29/1, SUX FOR SM AMTS THICK YELLOW SPUTUM W/INSTILLATIONS ID: WBC'S UP TO 20 - CORE TEMPS 101.5-101.8 - RECTAL TEMPS TAKEN 103.2-103.4 - RECEIVED TYLENOL 650 PR Q 4HR, CONTINUES TO RECEIVE LEVO, VANCO, FLAGYL ADDED, RECEIVED FIRST DOSE; FULLY RE-CULTURED BC X2, URINE, SPUTUM SENT ENDOCRINE: REMAINS ON INSULIN GTT - INCREASED TO 8MG/HR PER TEAM - FS 125-184, FOLLOWING Q 1-2 HRS HEME: HCT IN AM DOWN TO 27, REPEAT PND GI: REPLETE W/FIBER INCREASED TO 45/HR W/MINIMAL RESIDUAL, (REPLETE NOW PROMOTE W/FIBER PER NUTRITION), NO STOOL, ABDOMEN SOFT, NON-TENDER, + BS GU: FOLEY DRAINING CLEAR YELLOW URINE, REMAINS 1 LITER POSITIVE FROM TODAY AFTER RECEIVING LASIX 40 IV MS: REMAINS SEDATED BUT ARROUSABLE, MOVES PURPOSEFULLY, DOES NOT FOLLOW COMMANDS, ATIVAN DECREASED FROM 7 TO 4 MG/HR, FENTANYL DOWN FROM 125 TO 75 MCGS/HR SOCIAL: HUSBAND CALLED THIS AM AS WELL AS A BROTHER [**Name (NI) 185**] AND A SISTER-IN-LAW; HUSBAND WILL TRY TO BE IN LATER TODAY OR TOMORROW A: IMPROVED CARDIAC OUTPUT, FILLING PRESSURES AFTER DIURESIS; HOWEVER BP NOW MARGINAL AFTER SMALL DECREASE IN LEVOPHED - REMAINS W/HIGH TEMP DESPITE ANTIBX, ? ETIOLOGY P: CONTINUE TO FOLLOW TEMPS, AWAIT CX'S, COOLING BLANKET ORDERED FOLLOW HEMODYNAMICS, CONSIDER CHANGING LEVOPHED TO INOTROPE, DIURESE AS TOLERATED PER TEAM; FOLLOW FINGER STICKS CLOSELY; ASSESS CHANGES IN MS, CONTINUE SUPPORTIVE CARE. ||||END_OF_RECORD START_OF_RECORD=19||||6|||| Pt. intubated and sedated. Today febrile tmax 103.2, diuresing today. Vent settings 500x12/5/40%. tolerating settings well, last abg 7.39/123/46. Pt. sxn'd occ. for sm. amts white thin.If fillings pressures are optimal may begin wean tommorrow. ||||END_OF_RECORD START_OF_RECORD=19||||7|||| CV: Remains on Levo, increased to 4ug for drop in BP to 81/, has since been 90's-low 100's/50-60, HR 90's NSR, began having increased ectopy when she was lighter, increased sedation, gave 2 GM of MgSO4 for Mg+ of 1.5 this AM, K+ 4.8 this AM. Ectopy has decreased again with sedation and MgSO4. CVP stable at 10, PAP 40's/22, PCWP 22, FICK CO 4.6, CI 2.45, SVR 1000. UO has dropped off to ~20cc/hr. Resp: no vent changes made, ABG: 107/40/7.46/29/4, LS course, bronchial at the bases. Suctioned x2 for sm amt white secretions. ID: remains febrile to 103 R, placed on cooling blanket and given tylenol per OGT, Core temp has started trending down. On IV Levo, Vanco and flagyl. Trough Vanco sent before 8PM dose. GI: On TF, low residuals, BS hypoactive, no stool. Endo: remains on Reg ins gtt, one gtt in bs to 67, dropped gtt to 1U and gave [**09-28**] amp D50, BS 1 hr later 190, increased gtt.(see flowsheet for details) Heme: HCT 27, holding. Sent Clot to BB. Neuro: was lighter at onset of shift, pulling at restraints, raising head off bed. Increased Ativan to 5mg and Fent back to 125ug. Has since been comfortable. Soc: calls received from a brother and another brothers wife, updated and asked them to appoint family spokesperson, they said that would be difficult d/t scattered family and some without long distance service. A: Remains febrile, pressor dependent, labile BS, filling pressures stable. P: cont close monitoring of hemodynamic status, follow BS closely on Ins gtt, continue measures to bring down fever. ||||END_OF_RECORD START_OF_RECORD=19||||8|||| npn 7p-7a: ccu nsg progress note: neuro--conts sedated on ativan/fent, ativan increased back to 6mg/hr after several boluses d/t aggitation, fent conts at 125mcg, pt does open eyes to name, occ appears to focus on you when talking to her, has purposeful movements, does not follow commands resp--ls decreased at bases, coarse throughout, ||||END_OF_RECORD START_OF_RECORD=19||||9|||| npn cont'd: resp--sxn'd for lg amt of thick white secretions q 1-2hrs, sats 98-100%, conts vented, no changes, abg wnl cardiac--hr 90's sr w/occ mulitfocal pvc's, conts on 4mcg levo w/bp 90-104/50, pa numbers 39-50/19-27, cvp 6, pcwp 20, given 20mg iv lasix at mn d/t increased pad's, pt did respond to lasix, pa numbers after lasix..co 5.6, ci 2.98, 40/19,, cvp 6, pcwp 18, conts on hep w/theraupetic ptt gi--abd soft/distended, (+)bs, conts on tf's, no residuals, no stool at this time gu--foley draining approx 40-50cc/hr id--conts febrile, rectal temp up to 103, rec'ing tylenol & ivab, temp down to 102.2r, endo--conts on insulin gtt w/fs 132-309, insulin gtt at 7u/hr ||||END_OF_RECORD START_OF_RECORD=19||||10|||| S. REMAINS INTUBATED, SEDATED O. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA CV: 10AM DECIDED ON ROUNDS TO ATTEMPT QUICK VENT WEAN - ATIVAN/FENTANYL OFF; VENT CHANGED TO PS 10, PT QUICKLY BECAME AGITATED, COUGHING AND BUCKING VENT, RR 30'S; SATS TO 89-91%; HR TO 130'S BIGEMINY, PAP'S TO 60/35; CO/CI 2.7/1.44 SVR 2104 - VENT CHANGED BACK TO REGULAR SETTINGS, SEDATION RESTARTED; HR DOWN TO 90-110 SR-ST, OCCASSIONAL PVC'S - K+ 3.7 - RECEIVED 40MEQ IV BP 85-109/60-70, LEVO CONTINUES AT 2.4-4.0 MCGS/KG TITRATED TO BP, PAP'S REST OF DAY 48-55/24-31 CVP 9-13, CO/CI 4.6-5.2/2.45-2.77 SVR 954-1183; RECEIVED 40 IV KCL AT 6 PM B/W UNITS PRBC'S - >400CC U/O THUS FAR; HEPARIN AT 1100U/HR CHANGED TO SC RESP: MOST RECENT ABG ON 40%/AC 500X12/5 PEEP 124/36/7.41/24/0 SUX Q1-2HR SM AMTS THICK WHITE SPUTUM, LUNGS COARSE AND DIMINISHED AT BASES GI: TOLERATING PROMOTE TUBE FEEDS AT 45/HR, MINIMAL RESIDUALS, NO STOOL HEME: HCT 25 IN AM RECEIVED 1 UNIT PRBC'S, 2ND UNIT HUNG AT 6 PM GU: FOLEY DRAINING CLEAR YELLOW URINE ENDOCRINE: INSULIN GTT CONTINUES AT 7U/HR FS 119-160 ID: TEMPS CONTINUE AT 102-102.4 R, 2 DEGREES HIGHER THAN CORE TEMPS, ANTIBX CONT AS ORDERED, CX'S PND MS: ATIVAN AT 6 MG/HR, FENTANYL 125MCGS, ARROUSABLE EYES OPENING, MAE BUT DOES NOT FOLLOW COMMANDS, OCCASSIONALLY GETS RESTLESS, COUGHING AND BUCKING VENT REQUIRING ATIVN BOLUS SOCIAL: HUSBAND AND [**Name2 (NI) 186**]. OTHER FAMILY MEMBERS IN TO VISIT TODAY A: FAILED QUICK WEAN W/SIGNIFICANT DROP IN CARDIAC OUTPUT W/STRESS CONTINUES TO NEED LEVO FOR BP P: CONTINUE FOLLOW HEMODYNAMICS, DIURESIS AS ORDERED, FOLLOW TEMPS, TYLENOL Q 4 HR, AWAIT CX'S, CONT SEDATION FOR COMFORT, Q 2HR FINGER STICKS, CONT SUPPORTIVE CARE. ||||END_OF_RECORD START_OF_RECORD=19||||11|||| Patient weaned to PS today , weaning trial aborted post episodes of hypotension and arrythmias. Hypersecreted, suctioned for copious amount of secrtion multiple times by RN and RT. Transfused with prbc. Patient back on A/c with FIO2 increased to 70. Now on 40% post ABG 7.37-49-247-29-99%. ||||END_OF_RECORD START_OF_RECORD=19||||12|||| Respiratory Care: Patient remains intubated on mechanical support. Vent settings Vt 550, A/c 12, Fio2 40% and Peep 5. PAP/Plateau 22/19. Bs coarse bilaterally. Sx'd for moderate amounts of thick white sputum. See Carevue for Abg's. Results within normal limits. No further changes made. Continue with mechanical support. ||||END_OF_RECORD START_OF_RECORD=19||||13|||| O: For complete VS see CCU flow sheet. ID: T-max 10.2R. Temp low grade. Viral cultures sent. She conts on abx. Went for CT of sinuses today.] CV: Pt has been hemodynamically stable on 3.2mic levo. HR has been in 70-80s NSR no ectopy. BP has been stable 99-116/50-60. PAP has varied widely between 45-66/22-32 with RA [**07-11**]. CO this afternoon ws 5.2/2.77 with SVR 1062. Sats wre 97/67. She was replaced with 2 amp of MgSO4 today. Plan is for cath tomorrow. RESP: Pt intubated with no vent changes today. She remains on 40% AC 500 X 12 with rare overbreathing, 5 PEEP. She has course breath sounds. BG on above settings was 111/ 45/ 7.40/ 29.She requires suctioning ~Q2-3 hrs for mod amts thick lt yellow sputum. GU: Pt had low urine output after last nights diuresis. She was 250 positive at 6pm and received 40mg IV lasix at that time. ENDO: Pt remains on insulin drip at 5 u/hr. She received finger sticks Q2 which ranged between 110 and 188. MS/SEDATION: Pt had many episodes of restlessness and aggitation today. She had great difficulty being still in CT and had to receive bolus of 10mg of ativan and 5mg of fentanyl. She is now on 8mg IV ativan/hr and 125mic fentanyl/hr. She intermittently obeys commands. She received rom and should be seen by PT to evaluate for foot drop. She may require splints. A: CT done/ativan increased/stable on neo P: NPO after midnight. Monitor for change. Decrease neo as tolerated. ||||END_OF_RECORD START_OF_RECORD=19||||14|||| Resp Care remains intub/vented pending cath. ac 500x12x.4/5 peep. sedated. sats stable. c/w vent support. ||||END_OF_RECORD START_OF_RECORD=19||||15|||| O: LOW GRADE TEMP; SEE FLOW SHEET SECTION FOR CLINICAL INFORMATION; SEDATED AND VENTED; ON IV ATIVAN AND IV FENTANYL; LEVO CONTINUES; IV INSULIN DRIP CONTINUES- TITRATED TO GLUCOSE RANGE; PAD RANGE ELEVATING- RESPONDING TO LASIX; A: CARDIAC STATUS UNDERGOING CONTINUED DIAGNOSTIC EVALUATION; P: FOR POSSIBLE CARDIAC CATH TODAY. NEURO: AROUSABLE, LETHARGIC; MOVING ALL EXTREMITIES; OPENS EYES SPONTANEOUSLY AND INTERMITTENTLY; SEDATED CV/HEMODYNAMICS: NO RHYTHM PROBLEMS OR BP PROBLEMS; A-LINE DAMPENING; BP RANGE REFLECTIVE OF ATIVAN AND FENTANYL; ID: WBC CONTINUES TO BE ELEVATED AT APPRROX. 18; ON FLAGYL, LEVOFLOXACIN; VANCOMYCIN REQUIRING RE-ORDER AND ID APPROVAL FOR CONTINUATION; GU: BRISK DIURESIS POST IV LASIX- ELECTROLYTES WNL; NUTRITION: TUBE FEEDINGS HELD POST MIDNIGHT FOR POSSIBLE CARDIAC CATH; ENDOCRINE: INSULIN DRIP CONTINUES EVEN POST TF DC AS GLUCOSE RANGE REBOUNDING SOMEWHAT; INSULIN TITRATED PER GLUCCOSE RESULTS. SKIN: EXCORIATED PERIANAL AREA REQUIRING MYCOSTATIN POWDER; DUODERM TO COCCYX AREA. PAIN/COMFORT: MODERATELY COMFORTABLE; RESTLESS, SOMEWHAT FRUSTRATED WITH EQUIPMENT. SOCIAL: NO VSITORS OR PHONE CONVERSATIONS OVERNIGHT. ||||END_OF_RECORD START_OF_RECORD=19||||16|||| S. REMAINS INTUBATED/SEDATED O. SEE CAREVUE FLOWSHEET FOR COMPLETE VS, OBJECTIVE DATA ID: TEMP TO 101.4 R AT 12NOON, ANTIBX D/C'D, WBC'S REMAIN 18.2, CX'S PND CV: HR 79-90'S SR, RARE PVC, 2 GM MGSO4 GIVEN FOR MG+ 1.5 BP 90-100'S/ A-LINE INTERMITTENTLY DAMPED, FOLLOWING NBP'S AS WELL, REMINS ON LEVO AT 4 MCGS; PA 37-45/20-23 PCW 17, CVP 8-13 CO 5.5/2.93 NO FURTHER DIURESIS THIS SHIFT 3:30 PM TO CATH LAB RESP: REMAINS ON SAME VENT SETTINGS W/ABG 88/46/7.42/31/4, SUX Q 2 HR THICK WHITE SPUTUM IN SM-MOD AMTS ENDOCRINE: INSULIN GTT REMAINS AT 2 U/HR WHILE NPO, FS 138-176 GI: NPO FOR CATH, NO STOOL, ABDOMEN SOFT, N-T, GD BS GU: FOLEY DRAINING CLEAR AMBER URINE IN SM AMTS, NEGATIVE 1200CC THUS FAR TODAY HEME: HCT 33.2, OG ASPIRATES NEGATIVE A: REMAINS FEBRILE - UNKNOWN ORIGIN CATH TO ASSESS CAD AS CAUSE OF LOW EF P: AWAIT PT FROM CATH LAB, CONT MONITOR HEMODYNAMICS MONITOR TEMPS AND RECX FOR SPIKE; CONT SUPPORTIVE CARE. ||||END_OF_RECORD START_OF_RECORD=20||||1|||| 80 year old male admitted through er with c/o SOB. Pt. recently diagnosed with "vasculitis" Wegners syndrome and was on cytoxin. At PMD [**05-02**] wbc low, and pt. stopped taking cytoxin. Pt. then began to experience SOB and was brought to Er. In Er WBC .2. CXR showed a diffuse interstitial process. BP was low in ER and pt. also in MAT and was treated with IVF, and lopressor. Brought to MICU for close observation. PMHX: COPD Wegner's syndrome Neuro: alert and oriented x3. Pt. resting comfortably without any complaints. Resp: on 50% VM, Lungs are coarse with crackles in both bases. Crackles thought to be related to pneumonia. Sat's in the 90's. ABG WNL (see careview), pt. is tachypnic with at resp. rate in the 30's. Initially c/o sob, however received neb treatment with good results. Pt. does need to be sitting up. CV: BP stable 90-105/50's with MAP >60, NSR with occ pac's. no further episodes of MAT as reported from ER. No c/o chest pain. GI: Active bowel sounds, will keep pt. npo in case of intubation. GU: Foley placed in Er, minimal urine output. given 1 liter NS in er, and additional 500cc upon arrival to floor. Urine output remains marginal, no maintence ivf ordered. Plan is to bolus if urine output does not increase. Social: lives with wife, follow by [**Hospital 187**]. Wife aware of pt's admission to MICU. Pt. on neutropenic precautions. ||||END_OF_RECORD START_OF_RECORD=20||||2|||| resp care pt was rx'd with albuterol/atrovent nebs q4h. bs with coarse crackles.minimal wheeze noted. rr initially in 30's and labored. placed on noninvasive mask ventilation with ps 10/peep 5/100%. abg 7.43/36/306, rr 24. initially tolerated very well with subj relief...then required ativan 30"minutes later...removed 2 hrs. later to allow pt a break...subsequent abg on nrb at 15 lpm 73.42/36/96 with rr 20's. cough has become weaker/congested...may need nts. further bipap to be done if evidence of fatigue..c/w nebs q4h. ||||END_OF_RECORD START_OF_RECORD=20||||3|||| NEURO: PATIENT A&O X3. MAE. FOLLOW COMMANDS. REQUIRED 1MG ATIVAM THIS AFTERNOON WHEN BIPAP MASK PLACED. THIS HAD GOOD EFFECT AS PATIENT KEPT MASK ON FOR TWO HRS AND SLEPT. NO COMPLAINTS OF PAIN VOICED OTHER THAN FATIGUE. CARDIAC: HR 113-180'S ST AND NO ECTOPY NOTED. BP 93-149/47-66. THIS AM WHEN PATIENT STRAINING FOR BM HR JUMPED TO 180 AND SATS DROPPED TO 88% WITH INCREASED SOB. EKG DONE SHOWED POSSIBLE COARSE AFIB/FLUTTER BUT NO OTHER ACUTE CHANGES. PATIENT GIVEN 40MEQ KCL AND 1GM MGSO4. ALSO GIVEN 500CC FLB BOLUS WITH NO EFFECT. WAS THEN GIVEN 5MG VERAPAMIL IV WITH EFFECT AS HR DROPPED TO 120'S AND PATIENT STARTED ON STANDING DOSE OF VERAPAMIL. STARTED ON D5.45NS AT 100CC/HR AT 530PM. RESP: INITIALLY ON 50% VENTI THIS AM BUT AFTER ABOVE MENTIONED EPISODE WAS CHANGED TO 100% NRB WITH GOOD EFFECT. REMAINED ON THAT FOR A FEW HRS BUT PATIENT TIRING AND CHANGED TO NONINVASIVE VENTILATION. PS 10/5 WITH 100%. RR WENT FROM 30'S TO 20'S AND PATIENT MORE COMFORTABLE. TV WER 400-500. ABG ON THIS WAS 306/36/7.43 AND PATIENT KEPT IT ON FOR TWO HRS AND CHANGED BACK TO NRB WITH SUBSEQUENT ABG 93/36/7.42. WILL REMAIN ON NRB AND WILL USE BIPAP IF FATIGUE SETS IN. SATS 88-99% WITH RR 23-40. LS HAVE HAD EXP WHEEZES AND GIVEN NEBS WITH GOOD EFFECT. ALSO COARSE RHONCHI WITH CRACKLES AT THE BASES. PATIENT NO WITH WEAK CONGESTED NONPRODUCTIVE COUGH. NEED SPUTUM FOR GRAM STAIN AND CULTURE. ALSO INDUCED SPUTUM FOR PCP. GI: HAS BEEN NPO EXCEPT MEDS AND H20. ABD SOFT NONTENDER NO STOOL. FS OF 172 AND 200 COVERED WITH 2U REGULAR INSULIN. GU: U/O 6-30CC/HR. YELLOW AND CLEAR. 500CC FLD BOLUS AND FOLEY IRRIGATION DID NOT INCREASE U/O. TEAM AWARE. U/A C&S AND LYTES SENT. ID: ON LEVOFLOXACIN, CEFTAZ AND BACTRIM. TMAX 100.6 AXILLARY. WAS APN CULTURED LAST EVENING. NEED SPUTUM SPEC. STARTED GCSF SQ TO IMPROVE WBC. SKIN: INTACT. ACCESS: #20 LLA, #20G RAC, LEFT ART LINE. SOCIAL: WIFE IN AND UPDATED. PATIENT IS A FULL CODE. ||||END_OF_RECORD START_OF_RECORD=20||||4|||| Resp Care Note: Pt receiving ALB/ATR via HHN via aerosol mask as per Carevue. Pt required NT suct w/ each Tx for mod to large amt th tan sput (obt sput). Lung sounds rhonchi/wheeze before suct improving significantly after suct. Pt has not required NIPPV to this point. Pt O2 sat 95%+ on NRB. ABGs stable @ present. Cont w/ aggressive pulmonary toilet. ||||END_OF_RECORD START_OF_RECORD=20||||5|||| Pt. remains in MICU with ?sepsis, pneumonia, and neutropenia. Neuro: alert and oriented x2. Pt. thought that he was at [**Hospital 187**], and that it was July. During the night he has had a few episodes of increased anxiety and frustration because "I can't sleep because I can't breath, and I am not getting better". When pt. agitated his resp. status declines. Dr. [**Last Name (STitle) 188**] aware, 1mg iv ativan given, and pt. slept comfortably most of the night. However this am, once again he is "frustrated". Resp: Received on 100% NRB. Pt. has been tachypnic throughout night. ABG earlier in evening on 100% NRB O2 97, pco2 37, ph 7.42. Dr. [**Last Name (STitle) 188**] aware. Pt's lungs are extremely coarse with crackles and wheezes. PT. does improve with neb treatments. Pt. coughing up sputum, yet not able to bring it up. Secretions can be heard at the back of his throat. Pt. NP suctioned x3 for thick, tan secretions. Sputum speciman sent. After NP suctioning, pt. does sound better and appears to be breathing better. This am pt. using accessory muscles to breath, and appeared to be working much harder than earlier in eveing. Audible wheezes heard, along with crackles. Sat's 94%. ABG done. PO2 86, PCO2 38, ph 7.38. Pt. then given neb treatment and np suctioned, and now appears better. CV: BP very [**Last Name (un) 189**], at 9pm BP decreased with low MAP and SBP in low 90's. HO aware, and pt. initially given a 250cc NS boluse with good increase in BP, pt. then dropped BP at MN with SBP in 80's, and MAP in low 60's. HO aware, and pt. given 500cc NS bolus. At this time urine output also noted to start to drop off. After initial bolus BP did not respond, and pt. was given and additional 250ccNS bolus. Initially Bp responded, however began to drop again, this time with urine output decreasing to 6cc/hr. Dr. [**Last Name (STitle) 190**] made aware. Pt. given additional 500ccNS bolus, and BP at this time stable, with a MAP in the 70's. HR NSR with occ PAC's, however pt. did have an episode of increased heart rate to 130, Dr. [**Last Name (STitle) 190**] aware, EKG done, unable to give 4am verapamil, due to pt's hypotension. HR resolved on own. AM labs sent, and results are pending. GI: Pt. being kept npo with sips of water in case of intubation. GU: Initally urine output marginal, however as shift has progressed urine output has declined to 6cc/hr. Dr. [**Last Name (STitle) 190**] aware. Despite fluid boluses urine output remains critically low. Dr. [**Last Name (STitle) 188**] and [**Doctor Last Name 190**] aware. Are monitoring urine output closely, and pt. has not picked up. Team is aware. Unable to do bath or aggresive adl's due to pt's resp. compramise. Pt. also refused, stating that he needed to breath. ACCESS: Pt. has two peripheral lines, and aline, should he require pressors will need central line. Dr. [**Last Name (STitle) 188**] and [**Doctor Last Name 190**] aware. See careview for further details. ||||END_OF_RECORD START_OF_RECORD=20||||6|||| REVIEW OF SYSTEMS- REMAINS ALERT AND ORIENTED X 3 THROUGHOUT THE DAY. RESP- ON 100% NRB THIS AM SATS 94% UP TO 100%. RESP LOW 20'S LABORED. CPT ORDERED AND DONE Q 4 HOURS. WITH CPT PATIENT IS ABLE TO TAKE DEEP BREATHS AND WILL COUGH. DID RAISE A SMALL AMOUT GOLDEN TAN SECRETIONS. WAS NASOTRACHEAL SUTIONED X2 AFTER CPT FOR THICK GOLDEN TAN SECRETIONS. SPUTUM SENT FOR CULT AND GM STAIN. ABG ON 100% NRB. 7.35/38/98/22. O2 WENAED TO 50% COOL NEB. SATS REMAIN AROUND 100%. ABG TO BE CHECKED AT 1600. VANCO AND BACTRIM ADDED TO LEVO AND CEFTAZ FOR BROADER COVERAGE. OF NOTE O2 SATS WITH POOR WAVE FORM. BEST PLACE TO OBTAIN O2 SAT IS RIGHT EAR. CARDIAC- HR MAINLY IRREG IN THE 1TEENS TO 120 RANGE. OCCASIONALLY UP TO 130'S WITH ACTIVITY. PATIENT OCCASIONALLY IN NSR FOR A FEW MINUTES THEN BACK INTO AN IRREGULAR RHYTHMN. BP DOWN TO 88/51 WHEN PATIENT SOUND ASLEEP. UP TO 124/57 WHILE AWAKE. DID RECEIVE 1 500CC NS FLUID BOLUS. PICC LINE PLACED IN RIGHT BRACHIAL BY IV NURSE IN CASE PATINET SHOULD BECOME HYPOTENSIVE AND NEED PRESSORS. CXR TO BE DONE. GU- UO 10-12 CC/HR THIS AM. AFTER FLUID BOLUS UO 14-20CC/HR. DR [**Last Name (STitle) **] AWARE. GI- REMAINS NPO IN CASE HE NEEDS TO BE INTUBATED. NUTRITION CONSULT DONE. IF STABLE CAN TRY BOOST PUDDINGS AND DRINKS TO GET GOOD AMOUNT OF CALORIES INTO PATIENT. SKIN- PATIENT HAS OLD WELL HEALED DECUB ON COOCYX. PATIENT TURNED FREQUENTLY AND EUCERIN APPLIED TO AREA. SOCIAL- PATIENT'S WIFE AND NEICE INTO VISIT THIS AM. UPDATED ON PATIENT'S CONDITION. OF NOTE NEICE IS TH ONE WHO CARES FOR THE PATIENT AT HOME. SHE IS VERY KNOWLEDGEABLE IN TERMS OF HIS CARE. ||||END_OF_RECORD START_OF_RECORD=20||||7|||| ACCESS- CXR DONE TO ASSESS PICC PLACEMENT. IV NURSE [**First Name4 (NamePattern1) 191**] [**Last Name (NamePattern1) 192**] CALLED AND SAID PER DR [**Last Name (STitle) 193**] PICC IN SVC AND OK TO USE. IV NURSE TO COME UP TO UNIT AND WRITE THIS IN THE PATIENT'S CHART. ||||END_OF_RECORD START_OF_RECORD=20||||8|||| CARDIAC- 2L OF D51/2 NS AT 100CC/HR FINISHED. DR [**Last Name (STitle) 194**] NOTIFIED OF WHAT TO DO WITH IV FLUIDS. RATE DECREASED TO 75CC/HR X 2L. ANXIETY- AT 1800 AFTER DOING CPT PATIENT PANICED THAT HE COULD NOT BREATH. SAT AT THE TIME 94%. RESP RATE 22. DR [**Last Name (STitle) 194**] [**Name (STitle) 195**] AND PATIENT RECIEVED 1MG IV ATIVAN ( PATIENT RECEIVED THIS LAST PM W/O COMPROMISE OF HIS RESP STATUS. WITH THIS IN APPROXIMATELY 10MIN PATIENT UCH CALMER. ||||END_OF_RECORD START_OF_RECORD=20||||9|||| RESP NOTE:PT PRESENTLY ON 50% COOL AEROSOL AND TOLERATING WELL WITH NO RESP DISTRESS NOTED.(SATS 98-100%)NT SX AS NEEDED DURING SHIFT FOR MOD AMOUNTS THICK TAN SECRETIONS.ABG"S AVAILABLE IN CAREVUE,HHN"S GIVEN AS PER ORDER,WILL CONTINUE TO MONITOR. ||||END_OF_RECORD START_OF_RECORD=20||||10|||| Assessment per flowsheet. Assessment unchanged from previous shift. Dr. [**Last Name (STitle) **] ordered lopressor to slow rapid heart rate. After 12.5 mg lopressor po heart rate continued to be rapid in rate of 120-130. An additional 12.5 mg po was given at midnight. Heart rate slowed to a Sinus rhythm in the 80-90's; however, SBP dropped to 75. 250 cc NS bolus given. Sbp responded quickly to fluids. Scheduled Xanax ordered to help control patients anxiety attacks. Pt did not experience anxiety attack on night shift. Breathing less labored at this time. Lungs sounds coarse with crackles throughout. Complete bed bath done. Pt tolerated well. ||||END_OF_RECORD START_OF_RECORD=20||||11|||| REVIEW OF SYSTEMS- NEURO- PATIENT REMAINS ALERT AND ORIENTED X3. RESP- SATS 93-100% DIFFICULT TO GET A GOOD WAVE FORM ON SAT. BS WITH AUDIBLE EXP WHEEZES AT TIMES. BS COARSE WITH CRACKLES [**09-28**] WAY UP. ATROVENT AND ALBUTEROL NEBS DONE Q4 HOURS AND Q2HOURS PRN. HE HAS REQUIRED Q2 HOUR TREATMENT TODAY. CPT DONE Q4 HOURS. HE HAS REQUIRED SUCTION CATHETER PLACED AT BACK OF THROAT TO ELLICIT A COUGH TO INDUCE SPUTUM. SPUTUM REMAINS THICK GOLDEN TAN COLORED. RESP IN THE 20'S. CARDIAC- HR INITIALLY IN THE 80'S. AS SHIFT PROGRESSED HR IRREGULAR 120-130'S. DR [**Last Name (STitle) 196**] UP AT 1615 AND PUSHED A TOTAL OF 15MG IV CARDIZEM. SBP IN THE 120'S PRE CARDIZEM AND REMAINED 120'S POST CARDIZEM. GI- TAKING BOOST PUDDING AND SHAKES. HAS TAKEN IN ABOUT 500 CALS THIS SHIFT. ABD SOFT DISTENDED WITH POS BS. GU- FOLEY PATENT DRAINING CLOUDY TO CLEAR YELLOW URINE AT 30-40CC/HR. CREAT 1.7 UP FROM 1.5 YESTERDAY. SKIN- SKIN INTACT. PITTING EDEMA IN FEET BILATERALLY. SOCIAL- WIFE AND NEICE IN TO VISIT TODAY. THEY WERE UPDATED ON THE PATIENT'S CONDITION. THEIR QUESTIONS WERE ANSWERED. ||||END_OF_RECORD START_OF_RECORD=20||||12|||| RESP NOTE:PT HAD A FAIRLY UNREMARKABLE DAY,HHN"S GIVEN AS PER ORDER,REMAINS ON 50% COOL AEROSOL,SATS MAINTAINED 95-100%.B/S REMAIN DIMINISHED BILAT BEFORE AND AFTER TXS WITH EXP WHEEZES PERSISTING.WILL CONTINUE TO MONITOR AND TX AS PER ORDER ||||END_OF_RECORD START_OF_RECORD=20||||13|||| Pt status unchanged from previous shift. Pt continues to have thick yellow secretions. Pt is unable to cough secretions up independently. Pt needs to be nasotrachial suctioned q4 hr. Lungs sounds coarse with crackles. Urine output 60-80cc/hr. Pt tolerating po meds well; however needs encouragement to drink boost shakes and puddings. Heart rate is irregular. Verapamil given. Heart rate ranges from 80-140 depending on pt's activity. ||||END_OF_RECORD START_OF_RECORD=20||||14|||| Resp Care Note: Pt cont to require aggressive pulmonary toilet w/ NT suct for mod to large amts th tan sput. Lung sounds rhonchi w/ wheeze improving to scat rhonchi after suct. Pt has narrowing R naris (pt has deviated septum cannot use L naris) do to frequent suct. Pt received ALB/ATR as per order & tol well. Pt currently in NARD on cont cool mist aerosol @ .5FIO2. ||||END_OF_RECORD START_OF_RECORD=20||||15|||| resp. care note: pt continues to require q4 hr mednebs, only able to nts, once t/o the shift pt nares are extremely traumatized. pt tried on nasal bipap, [**07-02**], unable to tolerate, placed then on full face mask bipap 10psv over 5 peep and fio2 of 50%$, pt tolerating well. pt needs a nasal trumpet, md aware, pt will infact need sedation to place trumpet. all is well at this time. ||||END_OF_RECORD START_OF_RECORD=20||||16|||| Respiratory: Most of day pt in respiratory distress..rr 20's.c/o fatique..Wheezing I/E most of day also.abgs poor..unable to suction pt d/t nasal swelling.. Attempted to orally suction..has no gag..old blood found in back of mouth..Very weak cough..non productive..Initially on nasal bipap..(pt is a mouth breather)...did fair..but he felt he couldnt breath on the mask..Issue of intubation discussed with team and family..On/off 100% cn and 100%nrb...Finally placed on masked ventilation..10/5.100% pt became agitated..required 1mgm ativan and wrist restraints..Wife and neice are with pt. Had improved abg..now becoming more acidotic..Plan per team is to avoid intubation and keep on bipap..if abg remain stable... Fluid: Extremities edematous..u/o 20-50cc hr..??if pt could use diuresis..is up several liters since admit.. GI: Pt has not been adequately fed since admit..now npo..no ng tube..would have to pass oral tube d/t nasal trauma from suctioning.. ??do this tonoc. Cardiac: With increase in rr distress..noted increased hr up to 120-130's..af..frequent VEA..couplets..no c/o cp.. BP 110-150/..new aline placed..(unable to draw blood from 1st one).. Neuro: With 02 off..pt confused and agitated..otherwise..cooperative..fatiqued..moving all extremeties..orientated/lethargic.. ||||END_OF_RECORD START_OF_RECORD=20||||17|||| Neuro: Pt. alert, but confused at times. Difficult to understand due to bipap mask. Pt. did have one episode of calling out, and agitated, and wanted mask off. Given 1mg iv ativan with good relief and pt. was able to sleep. RESP: received on masked ventilation via servo, changed to bipap machine, and pt. appeared more comfortable. On I=10, E=5, 10L. Lungs are coarse and decreased throughout, with occ. wheezes, sat's have been in the 90's. ABG with po2 44 eronous as mask had leak, fixed leak and abg WNL. See careview. PO2 150. Sat's have remained in the high 90's. No secretions, and weak cough. Goal is to keep pt. on bipap and use noninvasive ventilation if possible. CV: BP stable, however did have episode of increased hr to 140's, appearing to be afib. Dr. [**Last Name (STitle) 188**] aware. Pt. had been unable to receive po meds during day due to compramised resp. status. Verapamil po given and hr did not respond, 5mg iv verapamil ordered to bedside however not given due to hr decreasing on own. Pt. with occ pvc's. When hr in the 90's noted to be NSR. GI: Pt. npo except meds, abdomen firm and distended. When bipap mask off, pt. belching. No ngt at this time, HO aware. Pt. has not had any real nutrition since admission HO aware, ?tpn. GU: initially foley with cloudy sediment urine. Pt. c/o difficulty voiding and feeling the urge to go. Urine output low. HO aware and 500cc NS bolus given with minimal response. Attempted to irrigate foley with much difficulty. Foley changed and pt. immediately put out 300cc of clear, yellow urine. Urine output has been fair since new foley inserted. Pt. also stopped c/o difficulty urinating. SKIN: anasarca, coxycx appears pink, pt. oozing from old puncture sites. ACCESS: L brachial picc line, and r radial aline. See careview for further data. Neice called. ||||END_OF_RECORD START_OF_RECORD=20||||18|||| Resp Care Note: Pt cont on NIPPV as per Carevue. Lung sounds scat rhonchi w/ wheeze improving w/ ALB/ATR nebs. Pt comes off NIPPV to receive Tx. O2 sats > 95% on NIPPV. Pt did not require NT suct overnoc. Pt currently on BIPAP 10/5/12BPM + 8LPM O2 flow bled in. Would rest pt off BIPAP if ABGs remain stable. ||||END_OF_RECORD START_OF_RECORD=20||||19|||| REVIEW OF SYSTEMS- NEURO- ORIENTED TO PERSON ONLY. THINKS IT IS 1932. HAS NO IDEA WHERE HE COULD BE. RESP- WAS ON BIPAP THIS AM. REMOVED TO GIVE PATIENT A BREAK. PATIENT PLACED ON 60% COOL NEB. SATS ON THIS 95-100%. WHEN PATIENT ASLEEP ABG CHECKED. 7.34/41/104/23. PATIENT WEANED DOWN TO 50% FM. SATS REMAIN HIGH 90'S. CONTINUES TO RECEIVE ALBUTEROL/ATROVENT NEBS Q4 ATC AND Q2PRN. HAD ONE EPISODE TODAY WHEN HE WAS AUDIBLY WHEEZY. BS COARSE DIMINISHED WITH EXP WHEEZES. REP RATE TEENS TO LOW 20'S. CARDIAC- IN AND OUT OF AFIB THIS AM. WAS ABLE TO TAKE DOSES OF VERAPRAMIL TODAY. HR THIS AFTERNOON 90-80'S NSR. SBP 120-140'S. IS BEGINNING TO SELF DIURESE. NEG FEW HUNDRED CC'S SO FAR TODAY. GI- NPO EXCEPT MEDS. WAS TO START TPN TODAY. SPOKE TO IV NURSE. IV UNABLE TO CHANGE SINGLE PICC TO DOUBLE. IR CALLED AND PATIENT WOULD NEED TO LEAVE UNIT AND TRAVEL TO RADIOLOGY FOR PICC INSERTION. HE WOULD ALSO HAVE TO LAY 30DEGREES OR LESS FLAT. PATIENT UNABLE TO DO THIS W/O SEDATION. SPOKE WITH DR [**Last Name (STitle) **]. HE DOES NOT WISH TO HAVE PATIENT TRAVEL OFF THE UNIT. HE ALSO DOES NOT WISH TO SEDATE PATIENT TO THE POINT HE MIGHT RESP DECOMPENSATE. HE WISHED IV TO PLACE DOUBLE LUMEN IN RIGHT ARM. IV UP. THEY WERE UNABLE TO PLACE PERIPHERAL TODAY . IT WAS TOO LATE TO ATTEMPT DOUBLE PICC. THEY WILL BE UP IN AM TO ATTEMPT DOUBLE LUMEN PICC IN RIGHT ARM. GU- PATIENT AUTODIURESISN. SKIN- ARMS AND FEET REMAIN EDEMATOUS. ARMS UP ON PILLOWS TO HELP DECREASE THE EDEMA. COCCYX APPEARS UNCHANGED. SOCIAL- WIFE AND NEICE IN. THEY FELT DR [**Last Name (STitle) 197**] WOULD BE IN TODAY TO SPEAK WITH THEM. THEY FEEL THE PATIENT WOULD NOT WANT TO BE INTUBATED. DR [**Last Name (STitle) 198**] IN SPOKE WITH THE WIFE THEN SPOKE WITH DR [**Last Name (STitle) **] AND DR [**Last Name (STitle) 197**] ON THE PHONE. PER DR [**Last Name (STitle) 198**] DR [**Last Name (STitle) 197**] HAD TALKED TO THE PATINET YESTERDAY AND HE AGREED TO BE INTUBATED TO SAVE HIS LIFE. PATIENT PER DR [**Last Name (STitle) 198**] AND HIS NOTE REMAINS A FULL CODE. SPOKE TO WIFE AND NEICE ABOUT THE FACT THAT DR [**Last Name (STitle) 197**] HAD TOLD DR [**Last Name (STitle) 198**] BY PHONE THAT HE HAD SPOKEN TO THE PATIENT YESTERDAY AND THAT HE AGREED TO BE INTUBATED. BOTH WIFE AND NEICE FEEL THE PATIENT DID NOT UNDERSTAND WHAT WAS SAID TO HIM. THEY FEEL HE THOUGHT HE WAS AGREEING TO A CENTRAL LINE. THE NEICE WILL ATTEMPT TO GET IN TOUCH WITH DR [**Last Name (STitle) 197**] SO THAT SHE AND THE PATIENT'S WIFE CAN DISCUSS THIS WITH DR [**Last Name (STitle) 197**]. FOR NOW PATIENT REMAINS A FULL CODE. ||||END_OF_RECORD START_OF_RECORD=20||||20|||| Neuro:Pt. confused and oriented only to self. Initially thought that it was 1938 and now thinks that it is 1927. Attempts made to reorient pt, however as the night progressed he became more agitated, calling out "they are killing my friend [**Name (NI) 199**]", attempts made again to reorient pt. without success. Dr. [**Last Name (STitle) **] aware, and 1mg iv ativan given without relief. Pt. continued through the night to call out, try and get out of restraints, pulling on cloths and aline. Dr. [**Last Name (STitle) 200**] aware, and haldol prn ordered. Pt. given 2mg iv and will asses. Pt. has not had a good night sleep since admission due to poor resp. status. RESP: Recieved on cool neb, titrated to 5LNC, with sat's in the upper 90's. Lungs are decreased with wheezes heard after exertion (turning), continues to received nebs per respiratory. Pt. with weak nonproductive cough. ABG will be done with am labs. CV: BP stable, NSR with occ pvc's. Pt. able to take po verapamil. GI: remains npo except meds. Plan is for picc line placement today and starting tpn. GU: voiding large amounts of yellow urine with sediment. SKIN: anasarca. Pt. noting to be oozing from previous puncture sites. Arm elevated on pillows. Family: Neice called and was reupdated on plan of care. See careview for further details ||||END_OF_RECORD START_OF_RECORD=20||||21|||| THIS AM ON 5L NC, PT DROPPED SAT'S INTO THE 80'S. ABG DONE SHOWED A PO2 OF 40. PT. PLACED BACK ON 35% COOL NEB, AND REPEAT ABG TO BE DRAWN. ||||END_OF_RECORD START_OF_RECORD=20||||22|||| Resp Care Note: Pt received ALB/ATR HHN as per Carevue. O2 sat stable until around 5AM when pt sat dropped into 80's ABG's PaO2 40's. Pt returned to aerosol mask @.35 FIO2. Repeat ABG's pending. Did not require BiLevel overnoc. Cont neb tx & Bilevel as required. ||||END_OF_RECORD START_OF_RECORD=20||||23|||| REPEAT ABG ON 35% COOL NEB WITH PO2 62. HO AWARE. FIO2 INCREASED TO 50%. CXR ORDERED. PER DR. [**Last Name (STitle) **]. ||||END_OF_RECORD START_OF_RECORD=20||||24|||| Rehabilitation service/physical therapy 10:25 - 10:35 Chart reviewed, progress noted. Pulmonary care completed by nursing this AM. Will follow patient [**05-09**] AM for pulmonary care and mobility progression as tolerated. ||||END_OF_RECORD START_OF_RECORD=20||||25|||| REVIEW OF SYSTEMS- NEURO- PATIENT ORIENTED TO PERSON ONLY. RESP- PATIENT'S SAT THIS AM 93-94. HE DID COUGH AND RAISE A LARGE THICK OLD BLOODY TAN SPUTUM PLUG {? THE CAUSE OF HIS DESATING EARLIER} SATS TODAY HAVE RANGED 94-100% ON 50% FM. SAT DOWN TO 90% AT ONE POINT THIS AM AND REPONDED TO CPT ALTHOUGH PATIENT UNABLE TO COUGH UP ANY SPUTUM AT THE TIME. PLACED ON BIPAP FOR 2 HOURS TODAY TO ASSIST WITH HELPING PATIENT NOT TIRE AND TO AVOID NEED [**Street Address 201**] FOR INTUBATION. PATIENT PLACED ON THE BIPAP BECAME AGGITATED AND WAS TX WITH 1MG IV ATIVAN. THE ATIVAN APPEARED TO MAKE HIM MORE RESTLESS. BIPAP REMOVED AFTER THE TWO HOURS AS PATIENT APPEARED QUITE AGGITATED ON IT. PLACED ON A 50% FM AND HAS BEEN MUCH CALMER. BS DIMINIHED THROUGHOUT. MORE SO ON THE LEFT. RESP RATE AROUND 20. PLAN IS TO ATTEMPT BIPAP PERIODICALLY AS PATINT TOLERATES TO PREVENT HIM FROM REQUIRING INTUBATION. CARDIAC- HR 80-103 SR TO ST WITH OCCASIONAL PVC. SBP 150-160 TODAY. GOAL FOR FLUID BALANCE IS 500-1000CC NEG. PATINET NEG 660 SO FAR. GI- REMAINS NPO EXCEPT MEDS. IV UNABLE TO PLACE PICC LINE FOR TPN. IR NOTIFIED TO CHANGE SINGLE LUMEN PICC TO A DOUBLE. ? IF CAN BE DONE TODAY OR TOMMORROW. ABD DISTENDED WITH POS BS. NO BM TODAY. GU- UO 45 TO 230CC/HR VIA FOLEY CATH. SKIN- ARMS, FEET ,SCROTOM AND PENIS REMAIN EDEMATOUS. PATIENT PLACED ON KINAIR BED TO PREVENT SKIN BREAKDOWN. OLD HEALED DECUB ON COCCYX UNCHANGED. SOCIAL- WIFE IN TO VISIT TODAY. HER QUESTIONS WERE ANSWERED. ||||END_OF_RECORD START_OF_RECORD=20||||26|||| RESP. CARE NOTE: PT PLACED ON BIPAP 10/5 FOR 2 HRS TODAY. PT GIVEN ALBUTEROL AND ATROVENT NEBULIZERS X3. PT HAS PRODUCTIVE COUGH AT TIMES FOR THICK BLOODY PLUGS. BREATH SOUND COARSE CRACKLE AND VERY DECREASED AT TIMES ON LEFT SIDE. PTS RR 16-22. PLAN IS TO CONTINUE WITH BRONCHIAl hygiene and MONITOR PT CLOSELY. FOR FURTHER INFORMATION PLEASE REFER TO CAREVUE CHARTING. ||||END_OF_RECORD START_OF_RECORD=20||||27|||| PT. REMAINS IN MICU ON NEUTROPENIC PRECAUTIONS WITH PNEUMONIA, AND COMPRAMISED RESP. STATUS. NEURO: PT. VERY AGITATED THROUGHOUT NIGHT. DR. [**Last Name (STitle) 202**] AWARE. PT. CALLING OUT, TRYING TO TAKE OFF O2MASK DESPITE HAVING BILATERAL SOFT RESTRAINTS ON, TRYING TO PULL ON FOLEY, ONLY ORIETNED TO SELF. 2MG IV HALDOL GIVEN INITIALLY WITHOUT MUCH RELIEF. HALDOL ORDERED CHANGED AND PT. GIVEN 5MG IV HALDOL, HOWEVER CONTINUED TO CALL OUT AND ACT AGITATED. DR. [**Last Name (STitle) 202**] AWARE. 1MG IV ATIVAN GIVEN WITHOUT CHANGE IN BEHAVIOR, FOLLOWED BY ADDITIONAL 1MG IV ATIVAN. PT. APPEARED TO CALM DOWN HOWEVER AT 3AM BEGAN TO SCREAM AND WAS GIVEN 5MG IV HALDOL WITH GOOD EFFECT. THIS AM PT. SLIGHLY AGITATED, HOWEVER ALLOWING CARE TO BE DONE, AND TOLERATING BIPAP MASK. RESP: RECEIVED ON 50% COOL NEB. LUNGS DECREASED WITH WHEEZES. SAT MONITOR NOT READING. ABG DONE 42/7.42/84/27. HO AWARE. AS NIGHT PROGRESSED CONTINUED TO HAVE DIFFICULT WITH O2 SAT MONITOR. REPEAT ABG DONE WITH 45/7.34/88 WITH A SAT OF 97%. PT. STABLE UNTIL THIS AM, NOT MOVING MUCH AIR WITH DECREASED BREATH SOUNDS BILATERALLY. NEB TREATMENT GIVEN WITHOUT MUCH CHANGE. PT. PLACED ON BIPAP I=10 E=5 50%. ABG ON THIS 49/7.35/117 SAT 97%. DR. [**Last Name (STitle) 202**] AWARE. PT. HAD BEEN GETTING CHEST PT EARLIER, BUT NOT BRINGING UP SPUTUM, ATTEMPTED TO SUCTION BACK OF THROAT WITHOUT SUCCESS. CV: BP ELEVATED, GETTING VERAPAMIL. THOUGHT TO BE DUE TO AGITATION. WHEN RESTING COMFORTABLY BP DOWN TO 110-120/40-50, AND HR DOWN TO 80. NSR WITH OCC PVC'S. GI: REMAINS NPO EXCEPT MEDS, VERY WEAK GAG REFLEX. PLAN IS FOR PT. TO BE STARTED ON TPN, AFTER RECIEVING PICC IN IR. ACTIVE BOWEL SOUNDS, ABDOMEN FIRM AND DISTENDED. GU: VOIDING ADEQUATE AMOUNTS OF CLOUDY YELLOW URINE WITH SEDIMENT. SPECIMAN SENT. SKIN: COXYCX REMAINS PINK, BUT SKIN INTACT. PT. WITH BRUISE UNDER L EYE, DR. [**Last Name (STitle) 202**] AWARE, COULD BE DUE TO BIPAP MASK. ANASARCA, AND CONTINUES TO WEEP FLUID FROM PUNCTURE SITES. ACCESS: R RADIAL ALINE, PT. FREQUENTLY FOUND TRYING TO PICK OFF DRESSING DESPITE HAVING WRIST RESTRAINTS ON. L BRACHIAL PICC WITH NS AT KVO. NEICE IN TO VISIT LAST NIGHT. FULL CODE. SEE CAREVIEW FOR FURTHER DETAILS. ||||END_OF_RECORD START_OF_RECORD=20||||28|||| NEURO: PT VERY AGGITATED MOST OF DAY, REQUIRING ATIVAN Q2H. MOVING ALL EXTREMITIES. FOLLOWS COMMANDS, REMAINS ONLY ORIENTED TO SELF. AFEBRILE. CURRENTLY SEDATED ON PROPOPHOL @ 20MCG/KG/MIN FOLLOWING INTUBATION. CV: SR-ST ON MONITOR WITH FREQ PVC'S. S1S2 ON AUSCULTATION. ABP 170-190/80'S MOST OF DAY UNTIL PT INTUBATED. CURRENTLY ABP 100-120/60'S. PALPABLE PULSES ALL AROUND. +ANASARCA NOTED ALL OVER. MG 1.8, 2GMS IV MGSO4 GIVEN. RESP: PT INTUBATED @1600. #8 ETT PLACED AT 23 AT LIPLINE. POST CXR DONE, PLACEMENT OKAY'D. LUNGS WITH INSP/EXP WHEEZES A