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Patient Care Report #3

Patient Care Report #3 . NIKITA PRABHU SPRING 2014 UMCB. Patient History. 31 y/o Caucasian female No significant PMH Married, stay-at-home mother with a young son. Anthropometrics. Weight : 60.5 kg (133#) Height : 162.56 cm (5’4”) Standard Wt : 54.54 kg (120#)

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Patient Care Report #3

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  1. Patient Care Report #3 NIKITA PRABHU SPRING 2014 UMCB

  2. Patient History • 31 y/o Caucasian female • No significant PMH • Married, stay-at-home mother with a young son

  3. Anthropometrics • Weight: 60.5 kg (133#) • Height: 162.56 cm (5’4”) • Standard Wt: 54.54 kg (120#) • % Standard Wt: 110%

  4. Current Hospitalization • February 14th– March 3rd • Admitted after falling in home and hitting head on tile • Was unresponsive and intubated at scene • Brought from San Marcos home via EMS • Admitting diagnoses: • Intracranial hemorrhage • Cerebal edema • Bilateral subdural hematoma • Occipital skull fracture • Acute respiratory failure • Admitting Diet Order: NPO with plan for EN by Day 3 of admission

  5. Average Estimated Kcal Needs

  6. Minimum Estimated Protein Needs

  7. Labs

  8. Labs s/p craniectomy w/ ↑ fluid drainage

  9. Labs Inadequate nutrition from TF ↑ stress response in body

  10. Medications • albuterol inhalation : bronchodilator • amantadine : anti-viral • bacitracin topical : abrasions • cefepime : anti-bacterial • erythromycin : anti-microbial • famotidine : ↓gastric acid secretion • Reglan : anti-emetic • fentanyl drip : pain • propofol (day 1-7) : sedation

  11. Intracranial Hemorrhage Bilateral subdural hemotoma Skull fracture

  12. Intracranial Hemorrhage Bilateral subdural hemotoma Skull fracture Intracranial Pressure Respiratory Failure

  13. Intracranial Hemorrhage Bilateral subdural hemotoma Skull fracture Intracranial Pressure Respiratory Failure Craniectomy

  14. Propofol Intracranial Hemorrhage Bilateral subdural hemotoma Skull fracture Intubation Intracranial Pressure Respiratory Failure Craniectomy

  15. Propofol Intracranial Hemorrhage Bilateral subdural hemotoma Skull fracture Intubation Osmolite @ 15-30 mL/hr Intracranial Pressure Respiratory Failure Trickle Feeds Craniectomy

  16. Propofol Intracranial Hemorrhage Bilateral subdural hemotoma Skull fracture Intubation Osmolite @ 15-30 mL/hr Intracranial Pressure Respiratory Failure Trickle Feeds Craniectomy PEG placement ↑ Needs Trach collar

  17. Propofol Intracranial Hemorrhage Bilateral subdural hemotoma Skull fracture Intubation Osmolite @ 15-30 mL/hr Intracranial Pressure Respiratory Failure Trickle Feeds Craniectomy PEG placement ↑ Needs Trach collar Transfer to Texas Neuro Jevity @ 50 mL/hr 100% of Needs

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