Situation and Background
E.P. is an 88-year-old Caucasian male. He was admitted on 02/18/13. His code status is full code, and he declines to bring in his advanced directive. He reports that he is 68.5” tall, and his actual weight is 165 pounds. He and his wife are the sources of information, and they are reliable. His blood pressure is 124/62, taken on his right arm in a lying position, his oral temperature is 99.8, his right radial pulse is 74 beats per minute, his respiration rate is 16 breaths per minute and his pulse oximetry reading is 92 on room air. He is allergic to latex, cephalexin and sulfa drugs, with a reaction of hives, and to IV dye, with a reaction of moderate rash. He was admitted for TURB (Trans-Urethral Resection of the Bladder), and left ureteroscopy related to a bladder tumor, and kyphoplasty secondary to compression fractures of the L1 and L3 vertebrae. His significant past medical history includes hypertension, atrial fibrillation, and chronic heart failure. He had a permanent pacemaker placed in 2003, and a history of MRSA over five years ago. E.P.’s fall-risk score is 2; however, he is on fall precautions related to anesthesia recovery, as fall risk is deemed appropriate by clinical judgment. He reports a pain level of 6 out of 10 numeric scale. Head-to-toe Assessment:
Neurological: E.P.’s Glasgow Coma Scale score is 15. He is awake, alert and oriented to person, place, and time. His speech is clear and understandable, and appropriate to the situation. EENT: E.P.’s pupils are equal, round, reactive to light and accommodative. His sclera is white without drainage, and his nares and mucosa are pink and moist. Cardiovascular: He has +2 pitting edema in lower extremities bilaterally, a right radial pulse of 74 BPM, and blood pressure of 124/62 (right arm, lying). Respiratory: E.P. has diminished lung sounds, with a pulse-ox reading of 92% on room air. Gastrointestinal: He has hypoactive bowel sounds present, and reports that his last bowel movement was on 2/17. Genitourinary: E.P. is receiving continuous bladder irrigation running at 1000 milliliters per hour, through a size 18F Foley catheter, and excreting blood-tinged urine. Musculoskeletal: Sequential compression devices are present on both lower extremities. E.P. performed full range of motion with equal strength bilaterally, but displays fear of movement. He requires assistance to stand from a seated position, and his gait is unsteady. Integumentary: E.P. has an incision on lower back from the kyphoplasty, which is open to air. There is also a deep tissue injury (pressure ulcer) on the left sacral area, covered with Mepilex dressing and Xenaderm ointment. E.P. has a hep-locked 20 gauge I.V. access in right wrist. He has generalized dry skin, which is pale and warm. Neurovascular: E.P. has brisk capillary refill, with strong radial and pedal pulses. Psycho-Social-Cultural Assessment
E.P.’s current emotional state is calm and pleasant. Although he is in pain, he is happy to have gotten both procedures done “all in one shot”. He stated that his health hasn’t been great in the past few years, and he recently stopped his consulting work with an engineering firm. His wife has been very supportive, but he fears she may not be able to continue caring for him with the small amount of home-help they have. E.P. has not experienced any growth or development problems as a result of these particular problems, although he joked about how he hoped the “back surgery will stop my shrinking”. He has a cooperative relationship with healthcare providers; however, he has trouble interpreting the different doctors’ estimations of discharge time and home-care planning. He stressed a need for more home-care staff when he goes home, because he feels he and his wife aren’t equipped to properly manage his care independently. His fear of further injury is making it difficult for him to comply with the providers’...