History of present illness: The wife of

History of present illness: The wife of C.W. a 70-year old man, brought him to the emergency department at 0430. She told the ED triage nurse that he had diarrhea for the past 3 days and that last night he had a lot of “dark red” diarrhea. When he became very dizzy, disoriented and weak this morning she decided to bring him to the hospital. C.W.’s vitals in the ED were 70/- , pulse rate 110, 22 BPM, oral temp 37.6C. A 16 Gauge IV was placed and LR bolus of 1000ms was given. The triage nurse obtained the following history from the patient and his wife: idiopathic dilated cardiomyopathy for several years. The onset was insidious but the cardiomyopathy is now severe, as evidenced by an EF of 13% found during a recent cardiac catheterization. Two years ago he had a cardiac arrest that was attributed to CAD with occlusion to the MID RCA and complicated by hypokalemia. He has a new diagnosis of COPD, and a long standing history of hypertension and arthritis. He had atrial fib in the past but it has been under control recently. He also has a history of GERD and untreated sleep apnea. After the initial assessment, C.W. began to experience nausea, became diaphoretic, and was short of breath at this time the admitting provider had him transferred to a cardiac cath lab for Swan-Ganz placement and medical management of acute heart failure. Nursing Assessment 0700: Neuro: Drowsy & disoriented to time otherwise intact and able to flow commands. Complaints of generalized pain 7/10, morphine given per PRN order of 2mg/q1hr IV. Temperature 38 degrees. Cardiac: S3 and S4 present and grade II systolic murmur, peripheral pulses are +1, +2 pitting edema in all extremities. HR 135 irregular. Telemetry reads Afib w/RVR and he has had two runs of V-tach 5 beats and 11 beats in the last two hours. Cardiac pressure monitoring indicates CVP 12, RAP 15, PAP 38/26, PAWP 25, CO 2.8 L/min, CI 1.4 L/min, SCVO2 65, Art BP 88/42. Respiratory: Coarse, tachypnea RR 33, sitting upright on Non-rebreather at 10L O2 88. The last blood gas revealed pH 7.25, CO2 50, Hco3 18, PaO2 55, and Lactate 4.4. Albuterol was given 2 hours ago. GI: pt has active bowel tones in all quadrants, abdomen tender with liver margin 4cm below the costal margin. pt complained of nausea and was given zofran 4mg x one dose IV 1 hour ago. Pt last BM as reported. GU: Pt has foley present, approximately 80mls of urine in the last 4 hours, dark amber, clear. Skin: diaphoretic, fragile, lower extremities are dusky with flaking skin, left foot has 5cm venous stasis ulcer on the lateral aspect. Pt has Left Femoral Swan-Ganz, left radial ART line, 16 G left forearm IV, Left quad lumen IJ running Amiodarone (Cordarone) infusing at 1 mg/min. Levophed at 0.06mcg/kg/min, and dopamine at 10mg/kg/min. LABS and diagnostics: Chest X-ray: impression cardiomegaly, bilateral congestion with small left pleural effusion. ECCO: EF 15%, mitral prolapse, and Aortic regurgitation. Blood gas as stated above. BMP: K 2.4, Mg 1.3, Ca 8.2, Phos 1.7, Glucose 145, BUN 44, Cr 2.5, Na 138, Chloride 106, Albumin 1.4, ALT 105, AST 245. CBC: WBC 14,000, H&H 7.2 & 24.4, Platelets 300. Cholesterol 350, Triglygerides 200, HDH 40. INR 2.0. On arrival to the unit, C.W.s wife hands you a brown paper bag of medications: Enalapril 5mg PO BID, Coumadin 10mg daily, digoxin 0.125 daily, potassium 20 mEq daily, Lasix 10mg bid. Fish oil and Vit D were also in the bag but the wife isn’t sure how much he has been taking them. 1. List four nursing diagnoses, an expected outcome, and a goal

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