1. Diagnosis
1.1. Pericardial/Pleural Effusion
1.1.1. Pathophysiology
1.1.1.1. Pericarditis
1.1.1.2. Tamponade develops from fluid accumulation within pericardial sac due to stress on heart, infection, pericarditis
1.1.1.3. Pericarditis occurs from inflammation and infection of heart and pericardial sac
1.1.1.4. Pleural effusion occurs from inflammation and back up of fluid into lungs
1.1.1.5. pneumonia and/or sepsis can occur
1.1.1.6. s/s: Beck's triad, chest pain, SOB
2. Medical/Surgical History
2.1. Patient admitted a month prior due to chest pain- evolved in cardiogenic shock
2.2. Patient had pericardial effusion/tamponade
2.3. Patient had pericardial window procedure
2.4. Patient had no complications and was discharged home after vitals returned to WNLs and labs WNL
3. Medications
3.1. Prednisone
3.1.1. Therapeutic Classification: Corticosteroids
3.1.1.1. Can have a anti-immune effect, so monitor for s/s of infection
3.1.1.2. Effect: Open bronchioles, anti-inflammation, can stimulate appetite and cause patient to "feel better"
3.1.1.3. Patient prescribed this, likely for inflammation in lungs, pleural effusion, to open bronchioles and work against nausea/stimulate appetitie
3.1.1.4. 20 mg BID PO
3.2. Reglan
3.2.1. Therapeutic Classification: Antiemetic
3.2.1.1. Patient reported side effect of dizziness
3.2.1.2. Effect: Works on dopamine receptors in CTZ of vomiting center of brain
3.2.1.3. Patient prescribed this medication due to the patient reports of severe nausea and vomiting for 3 days
3.2.1.4. 5mg IV TID 30 minutes before meals
3.3. Marinol
3.3.1. Therapeutic Classification: Cannibinoids
3.3.1.1. No reported side effects from patient, but patient ordered a pizza and ate half
3.3.1.2. Effect: Works on CNS cannabinoid receptors that inhibit nausea/vomiting and stimulates appetite
3.3.1.3. Patient prescribed this for intended effect
3.3.1.4. 2.5mg BID PO
3.4. Lovenox
3.4.1. Therapeutic Classification: antithromobolytic
3.4.1.1. No reported side effects, but patient hates needles
3.4.1.2. Effect: Inhibits thrombin III action
3.4.1.3. Patient prescribed this, likely due to remaining in bed for anti-thrombus formation, also due to dehydration and pericardial effusion/stress
3.4.1.4. 40mg once daily subq
3.5. Discharged Dextrose 5% in NS: fluids
4. Goals/Prioritization
4.1. Nursing Diagnosis: Risk for Electrolyte Imbalance (Hyponatremia)
4.1.1. Desired Outcomes:
4.1.1.1. Patient will have BMP WNL
4.1.2. Interventions:
4.1.2.1. Fluid replacement with NS
4.1.2.2. Check BMP labs for verification
4.1.2.3. Potassium Cl if hypokalemic
4.1.2.4. Report to HCP abnormal findings
4.1.2.5. Monitor EKG for changes
4.2. Nursing Diagnosis: Deficient Fluid Volume Related to N/V evidenced by hypotension
4.2.1. Desired Outcomes:
4.2.1.1. Patient will report no nausea/vomiting
4.2.1.2. Patient will be able to eat and drink
4.2.1.3. Patient's blood pressure will return to her baseline
4.2.2. Interventions:
4.2.2.1. Restore and replenish fluids
4.2.2.2. Medication intervention for nausea and vomiting: Reglan and Marinol
4.2.2.3. Reassess vitals continuously
4.2.2.4. Ensure patient has foods she enjoys eating to get her to eat more
4.2.3. Referral
4.2.3.1. To PT for Eval
4.2.3.1.1. Patient has to walk up 3 flights of stairs at home
4.3. Nursing Diagnosis: Risk for Infection Related to Malnutrition as evidenced by nausea and vomiting/Related to Pleural Effusion
4.3.1. Desired Outcomes:
4.3.1.1. CBC will be checked and be WNL
4.3.1.2. Lactate WNL
4.3.1.3. Patient will be free of pneumonia
4.3.1.4. Patient VS WNL
4.3.1.5. Patient will remain free from S/S of infection
4.3.2. Interventions
4.3.2.1. Check CBC for S/S of infection
4.3.2.2. Check lactate and ensure patient is not veering towards sepsis
4.3.2.3. Make recommendation of using incentive spirometer (she does not have one in room)
4.3.2.4. Make sure patient is in semi-fowlers to fowlers position
4.3.2.5. Manage patient n/v and ensure patient eats and gets enough fluids
4.3.2.6. Check albumin levels
4.3.2.7. Check lung sounds frequently
4.3.2.8. Chest x-ray for fluid in lungs/heart
4.3.3. Possible referral to nutritionist
4.3.3.1. Patient is very thin and cachetic
4.3.3.2. May need guidance for adding calories and diet for maximum health
4.4. Nursing Diagnosis: Risk for Malnutrition Related to Vomiting
4.4.1. Desired Outcomes:
4.4.1.1. Patient is able to eat and drink on own
4.4.1.2. Patient reports no nausea
4.4.1.3. Patient is free from vomiting
4.4.1.4. Patient is able to teach back adequate diet for herself while at home
4.4.2. Interventions:
4.4.2.1. Medication Treatment for nausea and vomiting: Reglan and Marinol
4.4.2.2. Reassess for patient reports of nausea
4.4.2.3. Check albumin
4.4.2.4. Labs
4.4.2.5. Ensure patient eats and drinks on own: see above interventions
4.4.3. Referral: see above referral to nutritionist
5. Demographics
5.1. 29-year-old
5.2. Caucasian
5.3. Female
5.4. Lives at home alone
5.5. Aunt lives in DFW area and is point of contact until mother arrives by plane from Los Angeles
6. Chief Complaint
6.1. Patient reports back to ED with complaints of hypotension "in the 90's" and chest pain, plus "not being able to keep anything down" due to constant nausea and vomiting
6.2. Patient drove herself
6.3. Admit October 30
6.4. Reports pain of 7/10
6.5. Patient has noticeable anxiety
7. Assessment
7.1. Vitals
7.1.1. Blood pressure: 103/66
7.1.2. Heart Rate: 90
7.1.3. Respiratory Rate: 18
7.1.4. Temperature: 36.5 C
7.1.5. O2 Sats: 98%
7.2. Musculoskeletal
7.2.1. Shoulders
7.2.1.1. Symmetric
7.2.1.2. Range of motion:
7.2.1.2.1. Right adduction: expected range of motion, approximately 50 degrees
7.2.1.2.2. Right extension: expected range of motion, approximately 50 degrees
7.2.1.2.3. Right forward flexion: expected range of motion, approximately 180 degrees
7.2.1.2.4. Left adduction: expected range of motion
7.2.1.2.5. Left extension: expected range of motion
7.2.1.2.6. Left forward flexion: expected range of motion
7.2.2. Elbows: bilaterally symmetric and no abnormal findings
7.2.2.1. Range of motion: WNL
7.2.3. Wrists: bilaterally symmetric and no abnormal findings
7.2.3.1. Range of motion: WNL
7.2.4. Hands/fingers: bilaterally symmetric and no abnormal findings
7.2.4.1. Range of motion: WNL
7.2.5. Hips: bilaterally symmetric and no abnormal findings
7.2.5.1. Range of motion: WNL
7.2.6. Knees: bilaterally symmetric and no abnormal findings
7.2.6.1. Range of motion: WNL
7.2.7. Lower legs: bilaterally symmetric and no abnormal findings
7.2.7.1. Range of motion: WNL
7.2.8. Ankles: bilaterally symmetric and no abnormal findings
7.2.8.1. Range of motion: WNL
7.2.9. Feet/toes: bilaterally symmetric and no abnormal findings
7.2.9.1. Range of motion: WNL
7.2.10. Thighs: bilaterally symmetric and no abnormal findings
7.2.10.1. Range of motion: WNL
7.3. Cardiovascular
7.3.1. S1S2 sounds present
7.3.2. Patient runs NSR -> SR tachy
7.3.3. radial, dorsal, and pedal pulses +2 bilaterally
7.3.4. cap refills <3 seconds
7.3.5. No muffled sounds heard indicating fluid
7.3.6. No JVD detected
7.4. Integumentary
7.4.1. Wounds or Sores: none
7.4.2. Color or Appearance: No abnormal findings
7.4.3. Skin Characteristics and Hair Growth: No abnormal findings
7.4.4. Temperature
7.4.4.1. Bruising/discoloration along the lower back at lumbar region that appears to be a week old
7.4.4.2. Asked Landon about it: his answer was "I don't know" and looked away and/or down
7.4.4.3. Asked mom about it: her answer was that she asked Landon how he got it. He answered that "he fell on a toy"
7.4.4.4. warm and WNL
7.4.5. Masses or texture: No abnormal findings
7.5. Neurovascular
7.5.1. Tested Arm Sensation:
7.5.1.1. Left arm: no abnormal findings
7.5.1.2. Right arm: no abnormal findings
7.5.2. Capillary Refill: Left and Right are under 3 seconds
7.5.3. Alert and oriented x4
7.5.3.1. Landon was looking to mom for answers at times
7.5.3.2. Landon was looking down a lot and was quiet; appeared afraid or sheepish
7.5.4. hypersensitive to touch when fearing invasive procedures/anything deemed painful
7.5.5. PERRLA
7.5.6. Patient wears reading glasses
7.5.7. Patient does not wear hearing aids; hearing WNL
7.6. Pain Assessment: 0/10
7.7. Lungs
7.7.1. bilateral diminished sounds heard at bases
7.7.2. RML, LUL, and RUL clear lung sounds
7.7.3. on room air
7.7.4. Needs incentive spirometry
7.7.5. no cough
7.8. GI
7.8.1. Bowel sounds normoactive all 4 quadrants
7.8.2. Patient reports no n/v, no pain
7.9. GU
7.9.1. LBM: Nov. 2 21:00
7.9.2. patient reports voiding normally; viewed contents in toilet. Straw-colored, clear
8. Diagnostics
8.1. BMP
8.1.1. ran hyponatremic upon admission and until 11/2
8.2. Chest x-ray
8.2.1. Check for pleural effusion and s/s of pericardial effusion- came back with bilateral base slight effusion and no s/s of pericardial effusion 11/3 10:30