Arterial line and triple lumen subclavian central venous catheter was placed for hemodynamic monitoring and administering medication.
Physical Examination Vital sign. Mr. P is a 1.8 meter tall and weight 152.2kg. His other vital sign are as follow: blood pressure is 114/68 mm Hg, heart rate of 88 bpm, oxygen saturation 99%, and respiratory rate 18 breaths per minute.
General appearance. Mr. P appears obese, stated age, and critically ill. He is sedated and has no signs of discomfort. He has 9.2kg fluid weight gain since admission and after CA.
Head, Eyes, Ears, Nose, Throat (HEENT). Mr. P’s HEENT assessment is normal. Nasogastric tube (NGT) and endotracheal tubes (ETT) are in place and secured. The assessment his oral mucosa reveals …show more content…
P’s lung is clear on auscultation sound. With inspiration, equal chest wall movement was noticed. He is intubated and validated on assist-control with volume control mode. The ventilator settings are tidal volume of 500 mL, the respiratory rate of 18 per minute, the inspired oxygen concentration (FIO2) of 70%, and the level of positive end-expiratory pressure (PEEP) of 10 cm H2O. Sputum via ETT suctioning is clear think moderate amount.
Cardiovascular: his heart rhythm is normal signs with occasion atrial pace. Normal first heart sound (S1) and a second heart sound (S2) without out murmur or gallop heard on cardiac examination. He has plus one pitting edema on his lower extremity. Pulses were strong in all his extremities.
Abdomen. Mr. P last bowel movement was POD 3, bowel sound appreciated in all quadrants. His abdomen appears soft and non-distended with incisions that are healing without any signs of complication. There was 200 mL light green drainage that was drained via NGT in the canister.
Neurologic. Mr. P is sedated and not responsive to verbal or tactile stimuli. Pupils are pinpointed but reactive and equal. Other neurological assessment finding are positive gag reflex, cough reflex, and corneal reflex. On painful stimuli to lower extremities, minimal withdrawal noted. It is absent in upper extremities. Normal reflexes present at in all four extremities with negative Babinski's sign. Glasgow Coma Scale (GCS) score is