Day 3 – ICU

BP: 92/78
HR: 98
Temp: 102
O2: 87%

WBC: 19.0
Bands: 14%
HgB: 13
HCT: 42%
PLT: 350
Glucose: 230 mg/dL
BUN: 22 mg/dL
Cr: 2.4 mg/dL

pH: 7.32
PaCO2: 66 mmHg
PaO2: 47 mmHg
HCO3: 23 mEq/L

ET tube 22cm at the lip
A/C ventilator setting
RR: 12
Peep: 5
VTE: 500
I/E: 1:2
FiO2: 1.0

Pt remains to be sedated. Based on RASS, the patient is deeply sedated with signs of delirium. Pt is NSR on the monitor with the HR around the 90s. Pt’s extremities are cold to the touch and are cyanotic in color. Pt remains on the ventilator. Respirations are 12 with an O₂ of 87% and crackles are present in the upper lung lobes and right lower lobe; and diminished lung sounds in the left lower lobe despite respiratory treatment. Bowel sounds present in all four quadrants. Pt’s abdomen is distended. Pt received an enema earlier in the morning for constipation. Pt’s Foley continues to drain 20-25mL of dark urine per hour. Skin is intact with a preventative myplex placed on the coccyx. Pt had an echocardiogram earlier today around noon. The pt ‘s echocardiogram revealed left and right side heart failure with an ejection fraction of 25%. MD and RT notified regarding O2 saturation.