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Mrs. Smith is an 80-year-old female admitted from the provider's office today for an evaluation of a decubitus ulcer. The patient has an ulcer on her right heel. The skin is open and non-blanchable, and reddened tissue is exposed. The ulcer is 4 cm long, 5cm wide, and 2 cm deep.
There is pink, clear, watery drainage coming from the ulcer. The tissue around the edges is soft and light pink compared to the surrounding skin. The patient is weak when attempting to move her lower extremities. She is unable to lift the right foot completely off the bed. Redness to the buttocks was noted but was blanchable; otherwise, the skin is dry and intact.
She has an IV in the right hand, 20 gauge, no redness present, but the Tegaderm tape is peeling off on the lower right side of the dressing. This area is also damp.
The patient is in good spirits, with family present at the bedside. Labs have been completed; her last blood glucose level is 190 mg/dL. She is urinating clear, yellow urine and had 300 mL out in the previous 8 hours. Her current vital signs are temperature 98.6 F/37.0 C, pulse 84, respirations 20, BP 134/85, oxygen sat 98% on room air, and she rates her back pain 2/10 and describes as an ache but does not want anything for pain. The patient is currently resting quietly in bed.
Sally Carson is a 66-year-old female who has transferred from the ICU. She was initially admitted to the ICU from the ED two days ago, complaining of sudden onset of a severe headache and dizziness but no loss of consciousness. She underwent an emergent head CT that demonstrated bleeding in the left frontal temporal area. She has a past history of atrial fibrillation treated with rivaroxaban.
She is alert and oriented to person, place, and time. PERRLA. VS: Temp: 97.9 F/36.6°C, HR: 76, RR: 14; BP: 158/90. Moving all extremities; right side weaker than left. Slight drooping of the right side of the mouth. Headache is less intense than on admission and responds with acetaminophen. She is receiving oxygen at 2L per nasal cannula. Respiratory rate 14 to 16 with coarse crackles noted in the bases. Atrial fibrillation on cardiac monitor; peripheral pulses weak but palpable. Skin intact with no signs of pressure injury. She is voiding clear urine using bedside commode. Patient allowed up with assistance.
18 gauge IV in left forearm infusing 0.9% sodium chloride at 70mL/hr. The second 18 gauge catheter is saline locked.
