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38 Year Old Female Full Code No religious preferences Dx: Cardiogenic Shock Patho: Ischemia causes myocardial dysfunction which then causes the heart's ischemia to worsen which causes the heart to not function properly. It is a vicious circle and if not addressed quickly can be deadly. Hx: Heavy drug use, Fetal demise, Sepsis. Patient came to the ER experiencing chest pain and shortness of breath. She was found to have a complete block of her RCA and when they went to stent it she went into Cardiogenic Shock and had to be put on Ecmo to keep her heart functioning. Pt. was also placed on a Vent.
Lansoprazole 30mg
Senna
Docusate 100mg
5 Musculoskeletal
1 Educate the patient on her condition and how to reverse it.
Unsuccessful. Pt. verbally and physically aggressive. Not taking in the info.
2 Range of motion exercises
Unsuccessful. Pt. very agitated and aggressive. Had to be restrained otherwise rips everything out.
3 Physical therapy
Unssucessful. Pt. non compliant and very aggressive and agitated.
2 Respiratory
Ventilated Patient
3 Passed ZEEP. Taken off of the vent
Successful. Patient able to breath and maintain her own airway.
2 Turn Patient q2hrs
Successful even after extubation
1 Deep suction patient as needed
Successful. Large, thick mucous removed.
3 Neurological
Versed Continuous
Fentanyl Continuous
Stroke
3 Occupational Therapy
2 Physical Therapy
Unsuccessful. Non cooperative and non compliant with evaluation.
Successful. Able to maintain therapeutic level
4 Integumentary
Weeping wounds and skin breakdown
1 Wound consult
Successful. Proper wound care developed.
3 Protective foam patch on sacrum
Successful, but had to be change constantly due to stool incontinence.
2 Turn q2hrs
1 Cardiac
Meds
Vancomycin IV
Lasix 40mg IV
Zosyn 3.375mg
Stroke
Complete block of RCA
2 Heparin Assay drawn q6hrs to adjust dose
3 Echo daily to check heart function
1 Continuous IV Heparin Infusion
Successful
