1. Patient History
Patient Name:
Age: 58 years-old
DNR: Unknown
Admitted:
Allergies: ACE Inhibitors
Chief Complaint: Sedation
HPI: Patient has history of poorly controlled diabetes, hypertension, chronic renal
insufficiency and congestive heart failure exacerbation and probably community acquired
pneumonia. The patient was incubated in Emergency center on admission, causing
atraumatic loosening of one of her teeth. During the course of her stay, the patient
experienced an allergic reaction with marked angioedema secondary to ACE inhibitor,
which was resolved with IV Benadryl.
The patient is continuing supportive care with CPAP, dieresis and antidotic pneumonia
coverage. The patient was discontinued off her sedation (versed) but there is concern for
persistent sub-sedated state.
The patient is being fed through PEG Tube.
Medical History: HTN, Diabetes, Chronic Renal Insufficiency, Congestive Heart Failure.
Radiology: MRI brain with and without contrast, MRA brain and MRA neck and
perfusion Imaging, dated 6/29/14 t assess for ischemic changes and perfusion.
Surgical History: Non-Contributory.
Family History: Myocardial Infraction- father at age 67; CHF – Brother at age 66; and
mother with cancer at age 55.
Social History: Lives in a remote town with husband. They deny illicit drug use,
alcohol and smoking.

2. Lab Values:
Lab Values
10/04/08 Normal Limits Suspected
Reason
Potassium
4.1
3.5-5.1mEq/L Within normal
limits
BUN 23 10-20 mg/dL Congestive
Heart Failure
Glucose 222 65-110 mg/dL Diabetes
WBC 14 4.8-10.8
K/CMM
Infections
RBC
3.25 4.20-5.40
Infection, Diet

3. Hemoglobin 9.4 12-16g/dL Anemia, Diet
Hematocrit 27.5 36-48% Chronic disease,
Anemia
Vital Signs:
10/7/14 10/6/14 10/5/14
P: 80 78 91
BP: 166/86 158/86 151/79
R: 18 20 22
T: 97.0 98.8 99.0
MAR
MEDICATION
GENERIC/TRADE
NAME & DOSAGE
INDICATIONS
(Underlined
indications
relate to the
patient)
SIDE
EFFECTS
THERAPEUTIC
CLASS PHARMACOLOGIC
CLASS
Albuterol/proventil 2.5
mg neb unit
RTID
Relieves
bronchospasm,
reduces airway
resistance
Headache,
nauseas
restlessness.
Relieves
bronchospasm
Bronchodilator
Albuterol 2.5 mg neb
unit.
PRN

4. Hlorhexidine/Pendex
0.12% Oral Rinse
SPIT Q4h
Acetamonophen-
hdrocodone/Vicodin
500 mg/tab
PO Q4h, PRN
Levetiracetuam/Keppia
100 mg/ml Soltn
PEG Q12h
Pravastin/Pravachol
20 mg Tab
PEG Q P.M
Care Plan

5. Patient:
Nursing Diagnosis 1: Risk for Aspiration.
Nursing Diagnosis 2: Risk for Disuse Syndrome related to altered level of Consciousness
Nursing Diagnosis 3: Impaired Physical Mobility related to musculoskeletal impairment
secondary to Sub sedated state as evidenced patient non-responsive.
Subjective Data: Check patient record.
Objective Data:
Check gastric residual prior to feeding and giving medications.
Monitor for signs of aspiration during feedings: coughing, choking, and drooling.
Verify placement of enteral tube prior to feeding and giving medications.
Nursing Diagnosis:
Risk for Aspiration related to presence of endotracheal tube and gastrointestinal tubes.
Planning:
Goal: patient will experience no aspiration.
Goal: Patient will tolerate enteral feedings without aspiration.
Goal: Patient will have clear lung sounds and patent airway.
Expected outcome: patient will respirate noiselessly, will have clear breath sounds and a
clear odorless secretion.
Interventions:
Note level of consciousness/awareness of surroundings.
Assess amount of and consistency of respiratory secretions.
Observe for neck and facial edema.
Note administration of enteral feedings.

6. Patient:
Nursing Diagnosis 1: Risk for Aspiration.
Nursing Diagnosis 2: Risk for Disuse Syndrome related to altered level of Consciousness
Nursing Diagnosis 3: Impaired Physical Mobility related to musculoskeletal impairment
secondary to Sub sedated state as evidenced patient non-responsive.
Subjective Data: Check patient record.
Objective Data:
Check gastric residual prior to feeding and giving medications.
Monitor for signs of aspiration during feedings: coughing, choking, and drooling.
Verify placement of enteral tube prior to feeding and giving medications.
Nursing Diagnosis:
Risk for Aspiration related to presence of endotracheal tube and gastrointestinal tubes.
Planning:
Goal: patient will experience no aspiration.
Goal: Patient will tolerate enteral feedings without aspiration.
Goal: Patient will have clear lung sounds and patent airway.
Expected outcome: patient will respirate noiselessly, will have clear breath sounds and a
clear odorless secretion.
Interventions:
Note level of consciousness/awareness of surroundings.
Assess amount of and consistency of respiratory secretions.
Observe for neck and facial edema.
Note administration of enteral feedings.