Events leading to hospitalization: Mr. Paul was admitted yesterday for a surgical debridement of a non-healing venous stasis ulcer on his left lower extremity.
History of: Hypertension, Venous Insufficiency, Hypothyroidism; Multiple Sclerosis, Dysuria, DMII, paraplegic due to an automobile accident in 2001. Right lower extremity (BKA) amputated in 2004.
A peripherally inserted central catheter (PICC) line was inserted 13 days ago for home administration of intravenous antibiotics.
Assessment (pertinent to situation):
Patient is awake, alert and oriented to person, place but not to time.
Mr. Paul did experience mild nausea which was relieved by medication of Zofran. He can have another dose at 1700 if needed. He has been drinking water and eating solid foods with no reports of nausea at present. He was constipated x2 days but had a liquid bowel movement today in early AM.
Patient gets out of bed to chair with assistance x1 with no c/o weakness but does have slight balance issues.
Patient was unable to void and required intermittent urinary catheterization. Fifteen minutes ago, patient voided 200 mL of clear yellow urine with an estimated post-void residual of 50ml.
Patient has a wound dressing to left lower extremity. The nurse practitioner changed the dressing at 1200 today. The wound bed looks red with granulation, no odor noted. Dressing is dry and intact. Patient does report pain at the surgical site between 2 and 8 on the Numeric Rating Scale.
Patient has a PICC line in right upper extremity. Last dressing change was done approximately 4 days ago. Dressing is dry and intact, with no redness or swelling at the insertion site.
next section will be the recommendation -
- Change PICC line, Change dressing or Perform intermittent catheterization?
- Diet: 140 grams Carbohydrate Diet, no concentrated sweets.
- Activity: OOB to chair with assistance.
- Vital signs: every 4 hours.
- CBC and serum electrolytes, BUN, glucose Daily.
- Obtain capillary blood glucose before meals and at bedtime. See medication orders for insulin coverage.
- Bladder scan after each void and if patient is unable to void within 6 hours.
- Intermittent catheterization using sterile technique if post-void bladder scan estimated volume greater than 200mL or if patient is unable to void within 6 hours.
- Sterile dressing change to wound on the left lower leg every 12 hours. Cleanse wound with sterile normal saline. Pack wound with sterile saline-soaked 4X4 gauze. Cover with dry sterile 4X4 gauze and sterile ABD pad.
- Sterile PICC line dressing change every 3 days.