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It is the information for this care plan you will write and also, there is a file write on this paper
1. **Lab results and abnormalities**:
– There are several abnormal lab values, including elevated **troponin levels**, which are notable for potential cardiac issues, possibly indicating myocardial injury. Elevated troponin should be closely monitored.
– **Comprehensive chemistry panel** shows elevated glucose (125), elevated urea nitrogen (24), and other abnormal values like creatinine and sodium, which could suggest kidney involvement or dehydration.
– Elevated **white blood cell count** (12.5) indicating an inflammatory or infection process.
2. **Imaging and Physical Exam Findings**:
– The presence of a **fat-containing umbilical hernia** with fat necrosis is noted. This hernia is tender to the touch and non-reducible, which might require surgical consultation or urgent attention.
– There is also mention of **severe atherosclerotic disease** in the abdominal aorta and iliac arteries with stenosis, suggesting vascular involvement that needs ongoing cardiovascular monitoring.
3. **Risk Factors and Recommendations**:
– The patient is at risk for both **cardiac** (elevated troponin) and **vascular complications** (severe atherosclerosis).
– There is low suspicion for bowel obstruction but concern for **leukocytosis** likely tied to infection or inflammatory causes.
4. **Next steps**:
– Continuous monitoring of the elevated **troponin levels**.
– Referral to a vascular or general surgeon regarding the **umbilical hernia** with necrosis.
– Potential for further imaging to monitor the **atherosclerosis** and stenosis.
– Consideration of managing the elevated white cell count, possibly with antibiotics if an infection is suspected.
The care plan seems focused on addressing both the acute concerns related to troponin and the potential chronic issues with the hernia and atherosclerosis.
5. **Review of Systems and Physical Exam**:
– The patient has **periumbilical abdominal pain** noted in the gastrointestinal system, but denies any fever, chest pain, shortness of breath, or genitourinary symptoms.
– Vitals are stable, with temperature at 97.1°F, heart rate 73 bpm, blood pressure 128/75 mmHg, and oxygen saturation at 96%.
– The physical exam highlights a soft abdomen with tenderness, specifically around the area of the hernia. Cardiovascular and respiratory exams are unremarkable.
6. **Medical History**:
– This is a 90-year-old female patient who presented with abdominal pain, possibly related to a **ventral hernia** with potential incarceration or strangulation. She has a history of small bowel obstruction (SBO).
– The patient reports that the current episode of pain is different from previous experiences, indicating a change in her condition.
7. **Imaging and Lab Findings**:
– The results indicate **troponin I elevation** (seen in previous images), which suggests cardiac monitoring is necessary due to the potential for myocardial injury. However, her cardiac and pulmonary assessments in this visit are normal.
– **White blood cell count** (WBC) is elevated at 12.5, consistent with infection or inflammation. However, the trend of WBC over time should be monitored to assess whether an active infection or ongoing inflammation is present.
8. **Surgical Consultation and Hernia Management**:
– The patient has a **fat-containing umbilical hernia**, and there is a concern about potential strangulation or incarceration given her presentation of pain and tenderness.
– There is a note that the patient will be assessed for surgical intervention if necessary. Given her advanced age and other comorbidities, the surgical team will likely weigh risks and benefits carefully.
9. **Sepsis Risk**:
– The patient has a SOFA score of 1.9, which is low, indicating that she does not meet the criteria for sepsis but should still be monitored for signs of infection given her elevated WBC and history.
10. **Care Plan**:
– **Observation and monitoring**: Continuous monitoring of vital signs, abdominal pain, and hernia status, with possible imaging or intervention if her condition worsens.
– **Cardiac monitoring** due to elevated troponin levels, despite the lack of current chest pain.
– **Surgical evaluation** for the hernia if it becomes more concerning, or if signs of obstruction or strangulation appear.
– **Laboratory monitoring** to assess for changes in WBC count or other markers that might indicate an infection or worsening condition.
This care plan revolves around addressing the risks of the hernia, cardiac health, and ensuring that any potential infection is caught early. Given the patient’s age and complexity, the team is likely managing the balance between aggressive intervention and comfort measures.
11. **Functional and Mobility Assessments**:
– **Occupational Therapy (OT)** progress notes detail a focus on activities of daily living (ADLs) and mobility improvement. The patient requires minimal assistance (1 person assist) with transfers and bed mobility, using a walker for safety.
– **Balance and Strengthening**: The patient’s progress in standing balance and dynamic standing is being closely monitored. OT aims to increase her independence in performing grooming tasks and toileting with minimal assistance.
– The patient has shown progress, as her **balance and standing tolerance** have improved.
12. **Discharge Planning**:
– The patient’s care team is working towards placement in an **Assisted Living Facility (ALF)** due to her current functional needs.
– Discharge planning is evolving, with **case management** working on getting the required medical forms completed and submitted for placement. There’s active communication with facilities and the patient’s family about this transition.
– The patient is concerned about missing bills, indicating ongoing social and financial concerns that the team is addressing.
13. **Goals and Outcomes**:
– The patient’s **goals** include achieving independence in toileting, grooming, and mobility over the next 7 days. There is a specific goal for her to be able to stand and transfer with minimal assistance, and to use her walker with increased safety.
– Some goals have already been met, like performing standing activities for 3-8 minutes and standing balance with supervision.
14. **Continued Monitoring and Safety**:
– **Fall risk** remains a significant concern, with safety measures such as assisted walking and bed alarms in place.
– Ongoing monitoring of her hernia, pain management, and cardiac status are also part of her care.
In conclusion, the care plan is comprehensive, focusing on increasing the patient’s independence through therapy, while managing her hernia and other health concerns. Discharge to an ALF is the goal once she achieves enough functional improvement.
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