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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pflegeverlaufsbericht\n um 22:45 für den 09.07.2024 22:45\nBetr.: IMC Nachtdienst-Bericht\nBem.: Pat. bei Übernahme desorientiert, agitiert, eigen- und fremd aggressiv ---- Bed. med. erhöht \nAbdomen sehr gebläht und druckschmerzhaft --- Arzt Info ----USA : Blase gefüllt ---- DK Neuanlage + abführende Massnahmen ( Klistier / Einlauf ) \nSp02 unter Raumluft grenzwertig --- 2l O2 per Maske\n\nClaudia Ehlting\nangelegt von: Ronnel Constantino am: 09.07.2024 um: 22:50\nfür: Ronnel Constantino</div>",
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">interdisziplinäre OA-Visite\nPatientin ist erneut durcheinander und aggressiv. Sie versucht sich die Kabel zu ziehen. Somit erneute Fixierung am Bett geplant. Aktuell hyperton systolisch 180 mmHg. DK wurde gewechselt danach zeigte sich Urinbeutel 700 ml Urin. GFR besser werdend ( Von 35 auf 47) CRP weiter rückläufig (auf 6,79 )</div>",
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					"identifier": {
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				}
			},
			"search": {
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		},
		{
			"fullUrl": "https://tipludb.bethanien.moers:50060/FhirR4/MedicationAdministration/26ef91b24828ce68be3955b874a2cc7e17575072",
			"resource": {
				"id": "26ef91b24828ce68be3955b874a2cc7e17575072",
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					"lastUpdated": "2024-07-20T11:47:09.4584282+00:00"
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		{
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				"id": "26f11e30a0ac880dc29fa2afd3ada61b3e2ed64b",
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							"system": "http://loinc.org",
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					]
				},
				"meta": {
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					"versionId": "1",
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								"code": "vital-signs",
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					"value": 69,
					"system": "http://unitsofmeasure.org"
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				"effectiveDateTime": "2024-07-13T23:40:00+02:00"
			},
			"search": {
				"mode": "match"
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		},
		{
			"fullUrl": "https://tipludb.bethanien.moers:50060/FhirR4/Composition/26f2c8d6ff436acdadfa98fcd8e64151de8e7136",
			"resource": {
				"id": "26f2c8d6ff436acdadfa98fcd8e64151de8e7136",
				"date": "2024-07-14T07:30:00+02:00",
				"meta": {
					"profile": [
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					"versionId": "1",
					"lastUpdated": "2024-07-18T07:43:36.7823603+00:00"
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							"system": "https://dvmd.de/fhir/CodeSystem/kdl"
						},
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							"system": "https://ihe-d.de/CodeSystems/IHEXDStypeCode"
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				},
				"_date": {
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							"valueDateTime": "2024-07-14T07:30:00+02:00"
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				"title": "Pflegeinformation",
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					{
						"reference": "Organization/47a642e218246fa53d116abda1083457a5b51d3e",
						"identifier": {
							"value": "14890",
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						"text": {
							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pflegeverlaufsbericht\n um 07:30 für den 14.07.2024 07:30\nBem.: Pat. schlafend vom ND übernommen. Unter 2 L O2 über NS ist Pat respiratorisch stabil. Kreislauf ebenfalls stabil. Jetzt wird Pat wacher, ist jedoch unkooperativ und weder zeitlich, örtlich oder situativ. Pat verweigert jede pflegerische T%ätigkeit. Arzt vom Dienst wurde telefonisch informiert. Pat. soll zur Zeit in Ruhe gelassen werden.\n\nBei BGA Kontrolle PO2 bei 49. Pat verweigert O2 Gabe. --> Pat wird zum Eigenschutz an Händen fixiert un O2 über NS verabreicht. \nangelegt von: Paola Abramides am: 14.07.2024 um: 08:13\nfür: Paola Abramides</div>",
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								"code": "DUR",
								"system": "https://ihe-d.de/CodeSystems/IHEXDSclassCode"
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						"valueCode": "unknown"
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					"value": "786521346_20240714073000+2002001",
					"system": "https://fhir.bethanienmoers.de/identifier/documents"
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				"id": "270c3c905a4de53a5f5fc4919354d9a42bba702a",
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							"system": "http://loinc.org",
							"display": "Atemfrequenz"
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				"meta": {
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				"title": "Pflegeinformation",
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pflegeverlaufsbericht\n um 23:22 für den 15.07.2024 23:22\nBetr.: W0 Nachtdienst-Bericht\nBem.: Pat liegt ruhig im Bett, ist wach und ansprechbar.\nPat äußert auf Nachfrage derzeit keine Schmerzen, keine Dyspnoe unter laufendem O2.\nBZ bei 268 laut Insulinplan wird nichts zur Nacht verabreicht, zudem sind die Insuline anders angeordnet als auf dem Insulinplan selbst.\nNach Rücksprache mit der DHÄ wird Pat mit Humalog nach Hausschema Korrektur gespritzt, Kontrolle um 3Uhr erfolgt.\nInfusionen werden nach Plan verabreicht, ZVK durchlässig.\nDK fördert.\nBisher ruhiger Nachtverlauf, Pat meldet sich bei Bedarf.\nangelegt von: Kimberly Fitzke am: 15.07.2024 um: 23:25\nfür: Kimberly Fitzke\n\nPflegeverlaufsbericht\n um 23:22 für den 15.07.2024 23:22\nBetr.: W0 Nachtdienst-Bericht\nBem.: Pat liegt ruhig im Bett, ist wach und ansprechbar.\nPat äußert auf Nachfrage derzeit keine Schmerzen, keine Dyspnoe unter laufendem O2.\nBZ bei 268 laut Insulinplan wird nichts zur Nacht verabreicht, zudem sind die Insuline anders angeordnet als auf dem Insulinplan selbst.\nNach Rücksprache mit der DHÄ wird Pat mit Humalog nach Hausschema Korrektur gespritzt, Kontrolle um 3Uhr erfolgt.\nInfusionen werden nach Plan verabreicht, ZVK durchlässig.\nDK fördert.\nBisher ruhiger Nachtverlauf, Pat meldet sich bei Bedarf.\n3:30 Pat istkomplett verschwitzt, ganze Bett sowie Patientenhemd ist nass.\nPat hat keine Temp.\nPat wird von 2PK`s umgezogen, Bett wird komplett frisch bezogen.\nPat umziehen fällt auf, dass Pat eine kl. Wunde am Rücken hat. Pat wird auf die Seite gelagert.\ngeändert von: Kimberly Fitzke am: 16.07.2024 um: 03:55</div>",
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						"valueCode": "unknown"
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				"identifier": {
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					"system": "https://fhir.bethanienmoers.de/identifier/documents"
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				"resourceType": "Composition"
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			"search": {
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				"code": {
					"coding": [
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							"system": "http://loinc.org",
							"display": "Blood pressure panel with all children optional"
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				"meta": {
					"profile": [
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					"versionId": "1",
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					"system": "http://unitsofmeasure.org"
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			"resource": {
				"id": "273afda0b05b10d6beae1b7803a072f1110448d9",
				"code": {
					"text": "Pulsoximetrische Sauerstoffsättigung",
					"coding": [
						{
							"code": "2708-6",
							"system": "http://loinc.org",
							"display": "Oxygen saturation in Arterial blood"
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					]
				},
				"meta": {
					"profile": [
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Vorstellung in der ZNA\nDie Vorstellung der zentralen Notaufnahme erfolgte in Begleitung des Rettungsdienstes bei Vigilanzminderung unklarer Genese. Fremdanamnestisch wurde berichtet dass die Patientin heute Morgen 10 Einheiten kurzwirksames Insulin erhielt vor dem Essen. Es erfolgte daraufhin eine akute Vigilanzminderung. Das gemessene Blutzucker lag bei ca. 320 mg/dl. Die Patientin sei beim Eintreffen des Rettungsdienstes auf Schmerzreiz erweckbar, bot jedoch rezidivierend Emesis. Die Vitalwerte konnten nicht erhoben werden (RR nicht messbar)\nBeim Eintreffen der Zentralen war die Patientin soporös, auf Schmerzreiz erweckbar. Die Pupillen waren isocor, lichtreagibel bds. Bei einer ausgeprägten Hypotonie von 57 mmHg erhielt die Patienten 1000 ml Jono und 1 Ampulle Akrinor. Bei der unklaren Vigilanzminderung erfolgte ebenfalls die Antagonisierung mit 1 Ampulle Flumazenil und 1 Ampulle Naloxon. Abdomensonografisch zeigten sich kein wegweisender Befund. Es erfolgte ebenfalls eine CCT Aufnahme wobei keine ICB oder Apoplex nachweisbar war\n\nDiagnose:\nVigilanzminderung unklarer Genese\nakut auf chronisches Nierenversagen \nExsikkose\n\nKörperliche Untersuchung:\n Pupillen isocor lichtreagibel bds. miosis\nPulmo vesikuläres Atemgeräusch bds.\nCor rein arrhythmisch\nAbdomen weich kein Druckschmerz keine Abwehrspannung Peristaltik regelrecht\ngeringe Unterschenkelödeme\n\nSerologie: Kreatinin 2 CK2 160 Glukose 305\n\nEKG Vorhofflimmern, Herzfrequenz 67/min Linkslagetyp T-Negativierung III, V1, keine akuten Erregungsrückbildungsstörung\n\nAbdomensonographie: Eingeschränkt beurteilbar, Meteorismus, kein Aszites, Vena cava inferior nicht adäquat darstellbar, kein Nierenaufstau\n\nCCT altersentsprechend\n\nVerlauf in der zentralen Notaufnahme:\n1 Ampulle Akrinor, 1 Ampulle Naloxon, 1 Ampulle Flumazenil\n1000 ml Jono\nAnlage Magensonde\nC1 Aufnahme</div>",
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				"title": "Pflegeinformation",
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pflegeverlaufsbericht\n um 08:39 für den 14.07.2024 08:39\nBetr.: Pflegedurchführung\n:\n angelegt am: 14.07.2024, um: 08:39\nInformation aus Formular: \nPflegedurchführung um 07:00 für den 14.07.2024 07:00\nBett zurechtmachen, Durchführung nach Plan\n\nangelegt von: Paola Abramides am: 14.07.2024 um: 08:39\nfür: Paola Abramides</div>",
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									"code": "Diagnosen",
									"system": "https://tiplu.de/fhir/CodeSystem/DocumentSection"
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						"text": {
							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Hypovolämischer Schock bei Gastroenteritis\n\nAkute Vigilanzminderung am ehesten im Rahmen des Schocks\n\nExsikose bei Gastroenteritis\n\nAkut auf chronische NI a.e.prerenal\n\nHyperglykämie bei bek. DM Typ I\n\nDelir\n\nVordiangosen 7/2024:\nentgleister Diabetes mellitus Typ 1, ED 1969, HbA1c 9,1 %\n\n-\tSteatosis hepatis\n-\tDyslipidämie\n-\tDiabetische Polyneuropathie, Angiopathie, KHK\n-\tDiabetische Retinopathie, Arthropathie, Nephropathie, Gastroparese\n- DFS linke Ferse abgeheilt, re. Fuß lat. Fußrand 6 x 3 mm Wagner-Armstrong 1A\nAkut auf chronisches Nierenversagen Stadium 1 \nchronische Niereninsuffizienz G3bA1\n- sekundärer Hyperparathyreoidismus\n- Vitamin D Supplementation\nbekannte multifaktorielle Gangstörung bei ausgeprägter diabetischer Polyneuropathie und chronischer vaskulärer Leukenzephalopathie\nAllergie: Kontrastmittel- und Nickelsulfat-Allergie\n\nWeitere frühere Diagnosen:\n\nDiabetisches Fußsyndrom Wagner-Armstrong 2 B Ferse links\n\nCharcot-Fuß beidseits, jetzt inaktiv\n\t\t- Zustand nach Arthrodese im D II und III Tarsometatarsalgelenk\n - Maßschuhversorgung\n\nKoronare Zweigefäßerkrankung mit Z. n. NSTEMI 08/2023\n\nparoxysmales VHF\n- OAK Therapie\n\nLeichtgradiges Schlafapnoesyndrom (RDI 16,6/h) mit hohem Anteil an Hypopnoen \n- 09/2008 Einleitung einer nAPAP-Therapie\n\nZustand nach Splenektomie 07/2015\n\nEinzelne Nierenzyste rechtsseitig\nBeginnenden Schrumpfgallenblase\nFibromyalgie\nHyperurikämie\nSubst. Hypothyreose\n\nKleine kalzifizierte arteriosklerotische Plaques in beiden Bulbi, ACI und ACE</div>",
							"status": "additional"
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						"title": "Diagnosen"
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									"code": "Anamnese",
									"system": "https://tiplu.de/fhir/CodeSystem/DocumentSection"
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						"text": {
							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Die Vorstellung der zentralen Notaufnahme erfolgte in Begleitung des Rettungsdienstes bei Vigilanzminderung unklarer Genese. Fremdanamnestisch wurde berichtet dass die Patientin heute Morgen 10 Einheiten kurzwirksames Insulin erhielt vor dem Essen. Es erfolgte daraufhin eine akute Vigilanzminderung. Das gemessene Blutzucker lag bei ca. 320 mg/dl. Die Patientin sei beim Eintreffen des Rettungsdienstes auf Schmerzreiz erweckbar, bot jedoch rezidivierend Emesis. Die Vitalwerte konnten nicht erhoben werden (RR nicht messbar)\nBeim Eintreffen der Zentralen war die Patientin soporös, auf Schmerzreiz erweckbar. Die Pupillen waren isocor, lichtreagibel bds. Bei einer ausgeprägten Hypotonie von 57 mmHg erhielt die Patienten 1000 ml Jono und 1 Ampulle Akrinor. Bei der unklaren Vigilanzminderung erfolgte ebenfalls die Antagonisierung mit 1 Ampulle Flumazenil und 1 Ampulle Naloxon. Abdomensonografisch zeigten sich kein wegweisender Befund. Es erfolgte ebenfalls eine CCT Aufnahme wobei keine ICB oder Apoplex nachweisbar war</div>",
							"status": "additional"
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						"title": "Anamnese"
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					{
						"code": {
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									"code": "VerlaufEpikrise",
									"system": "https://tiplu.de/fhir/CodeSystem/DocumentSection"
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						"text": {
							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Betrifft: Vorstellung in der ZNA\nDie Vorstellung der zentralen Notaufnahme erfolgte in Begleitung des Rettungsdienstes bei Vigilanzminderung unklarer Genese. Fremdanamnestisch wurde berichtet dass die Patientin heute Morgen 10 Einheiten kurzwirksames Insulin erhielt vor dem Essen. Es erfolgte daraufhin eine akute Vigilanzminderung. Das gemessene Blutzucker lag bei ca. 320 mg/dl. Die Patientin sei beim Eintreffen des Rettungsdienstes auf Schmerzreiz erweckbar, bot jedoch rezidivierend Emesis. Die Vitalwerte konnten nicht erhoben werden (RR nicht messbar)\nBeim Eintreffen der Zentralen war die Patientin soporös, auf Schmerzreiz erweckbar. Die Pupillen waren isocor, lichtreagibel bds. Bei einer ausgeprägten Hypotonie von 57 mmHg erhielt die Patienten 1000 ml Jono und 1 Ampulle Akrinor. Bei der unklaren Vigilanzminderung erfolgte ebenfalls die Antagonisierung mit 1 Ampulle Flumazenil und 1 Ampulle Naloxon. Abdomensonografisch zeigten sich kein wegweisender Befund. Es erfolgte ebenfalls eine CCT Aufnahme wobei keine ICB oder Apoplex nachweisbar war\n\nDiagnose:\nVigilanzminderung unklarer Genese\nakut auf chronisches Nierenversagen \nExsikkose\n\nKörperliche Untersuchung:\n Pupillen isocor lichtreagibel bds. miosis\nPulmo vesikuläres Atemgeräusch bds.\nCor rein arrhythmisch\nAbdomen weich kein Druckschmerz keine Abwehrspannung Peristaltik regelrecht\ngeringe Unterschenkelödeme\n\nSerologie: Kreatinin 2 CK2 160 Glukose 305\n\nEKG Vorhofflimmern, Herzfrequenz 67/min Linkslagetyp T-Negativierung III, ...\nangelegt für: Mo, 08.07.2024\num: 11:48, von: Dr. med. Catalina Marioara\nÜbernahme aus der ZNA bei Vigilanzminderung unklare Genese. Kommt aus Pflegeheim mit Verdachtsdiagnose Hyperlipidämie. Hier schläfrig und initial nicht erweckbar. Nach Flüssigkeitssubstitution und Gabe von Naloxon leichte Besserung der Vigilanz. CT-morphologisch Ausschluss einer akuten Ischämie und Blutung. Nach Übernahme auf Intensivstation hämodynamisch instabil, hypoton, kaltschweißig gibt Übelkeit.\nNach intensivierter Volumensubstitution besserte sich der Zustand der Patientin rasch. Zudem gab sie an zu Hause bei fehlendem Stuhlgang ( seit 5 Tagen ) eigenständig Abführmittel eingenommen zu haben. Seit dem heutigen Morgen erbricht sie und hat breiigen Stuhl. Die vorrübergehende Kreislaufunterstützung konnte nach intensivierter Volumengabe schnell beendet werden. Stuhlproben wurden bei Durchfällen abgenommen, sind zum jetzigen Zeitpunkt in der mikrobiologischen Untersuchung jedoch ausstehend. Ein diabetisches Konsil zur Optimierung des Insulinplans wurde gestellt.\n\nDie Übernahme der Patientin erfolgte am 9.7.2024 auf unsere intermediate Care.\nAufgrund von weiterhin bestehender Unterbauchschmerzen führten wir eine Abdomensonografie durch. Dort zeigte sich deutlich verdickte Darmschlingen sowie verstärkte Peristaltik mit fraglichem partiellen Ileus. In der am selbigen Tag durchgeführten Computertomografie des Abdomens zeigte sich lediglich eine Enteritis/Kolitis. In Rücksprache mit den Diabetologen eskalierten wir die i.v. antibiotische Therapie auf Piperacillin/Tazobactam. Hierunter zeigten sich die infektvariablen regredient. Des Weiteren kam es während des stationären Aufenthalts zu einem exogenen Delir mit Fremdaggressivität und visuellen Halluzinationen, welches wir initial mit Flüssigkeit sowie mit der einmaligen Gabe von Promethazin therapierten. Im weiteren Verlauf stellten wir aufgrund der Fremd- und Eigengefährdung die Indikation zur physischen Fixierung und führten eine kontinuierliche intravenöse Therapie anfangs mit Levomepromazin und später intermittierend mit Haloperidol durch. Hierunter war die Patientin gut führbar, war jedoch zeitlich, örtlich und situativ bei V. a. Delir DD demenzielles Syndrom. Diesbezüglich bitten wir um ein neurologisches Konsil, diese wurde gefaxt.\n\nWir konnten Frau Brück am 15.7.2024 in kardiopulmonal stabilen Zustand auf Normalstation verlegen.</div>",
							"status": "additional"
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						"title": "VerlaufEpikrise"
					},
					{
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									"code": "Therapieempfehlung",
									"system": "https://tiplu.de/fhir/CodeSystem/DocumentSection"
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						"text": {
							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">-Insulinplan im Verlauf beachten\n-Infektparameter beachten ggf. Antibiose anpassen\n-MiBi beachten\n-KG\n-Kostaufbau\n-ÖGD+Kolo im Verlauf zu erwägen\n-Neurologisches Konsil (gefaxt)\n-EKG-Kontrollen</div>",
							"status": "additional"
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									"code": "Medikation",
									"system": "https://tiplu.de/fhir/CodeSystem/DocumentSection"
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Aktiv\npausiert\nPausiert\npausieren\ni.v.\nper os - fest\nper os - fluessig\ns.c.\n6. T\n7. T\n3. T\n8. T\n5. T\n1. T\nMetronidazol 500mg\nCeftazidim 2g (Fortum)\nPantoprazol 40mg (Pantozol)\nJonosteril 1000ml (Sterofundin)\nBisoprolol 10mg (Concor)\nGabapentin 300mg (Gabapentin)\nRamipril 2,5mg (Delix)\nAmlodipin 5mg (Amlodipin)\nAtorvastatin 40mg (Sortis)\nRivaroxaban 20mg (Xarelto)\nASS 100mg (Godamed)\nLevothyroxin 100µg (L-Thyroxin)\nPantoprazol 40mg Tbl (Pantozol)\nEzetimib 10mg (Ezetrol)\nTramadol 50mg (Tramal)\nSpironolacton 25mg (Spironolacton)\nAllopurinol 100mg (Allopurinol)\nTorasemid 10mg (Torem)\nMacrogol Btl (Macrocol)\nHaloperidol Tropfen (Haldol)\nEnoxaparin (Clexane Multi)\nInsulin lispro IE (Humalog) und \nTresiba s. Insulinplan\n00:00: 1 Stk\n08:00: 1 Stk\n16:00: 1 Stk\n20:00: 2 g\n08:00: 40 mg\n20:00: 40 mg\n: 1000 ml\n08:00: 1 Tbl\n08:00: 2 Tbl\n20:00: 2 Tbl\n08:00: 2 Tbl\n20:00: 2 Tbl\n\nAbweichende Zeitpunkte:\n\n12.07.2024 09:09: 2 Tbl Zusätz. Gabe\n08:00: 1 Tbl\n20:00: 1 Tbl\n20:00: 1 Tbl\n08:00: 1 Btl\n12:00: 1 Btl\nPause , heute neurol. Konsil\n08:00: 0.6 ml\n20:00: 0.6 ml\n: 1 IE\n003\n3 x täglich\ntäglich\n2 x täglich\ntäglich, bei Bedarf\npausiert\n3 x täglich\n2 x täglich ab morgen</div>",
							"status": "additional"
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						"title": "Medikation"
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						"url": "http://hl7.org/fhir/StructureDefinition/extension-Composition.status",
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					"value": "786810910_20240715115805+8005000",
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			"search": {
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							"display": "Blood pressure panel with all children optional"
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						"https://gematik.de/fhir/isik/v2/VitalwerteUndKoerpermasse/StructureDefinition/ISiKBlutdruck"
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							"system": "https://ihe-d.de/CodeSystems/IHEXDStypeCode"
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Akute vermutlich exogene Psychose ca. 18:00 Uhr\nHatte schon heute Mittag ein mehr aggressives Verhalten beobachtet. Als wir sie untersucht hatten, war die Patientin durchaus sehr kooperativ, schwer besinnlich. Aber auch eine leichte Demenz. Sei im Altenheim aber sehr aktiv und dort auch sehr beliebt.\nJetzt völlig aggressiv, beschimpft die Schwestern, deutliche Verkennung der Situation und der Person. Wollen sie umbringen. Zieht sich den Blasenkatheter geblockt raus .Ist primär auch sehr aggressiv. Bett flüchtig. Will das optimierter Kabel zerreißen.Blutdruck ist noch stabil Puls stabil Sauerstoffsättigung stabil.Tibia akut 1 Ampulle Atosil fraktioniert. Danach etwas schläfrig und friedlicher, weiterhin aber desorientiert. BGA: Zucker 169 mg/dl, Elektrolyte gut Eingeschränkter pO2 50 mmHg Normokapnie..Lactat 0,8mg/dl\nDie Antibiose mit Ceftazidim soll jetzt gestartet werden. Habe die Anordnung mit Ciprofloxacin gelöscht. Wurde bislang noch nicht gegeben. Labor wurde abgenommen.\nHatte auch den Ehemann angerufen. Sehr aufgelöst ans Telefon rufen wollte sie umbringen sollte sofort mit der Polizei kommen. Jeweils auch nach wenigen Minuten vor Ort.Versucht seine Ehefrau zu beruhigen.</div>",
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Visite internistische Intensivmedizin\nAktuelles, klinisches Problembild der Patientin/des Patienten:\n\nAkute Vigilanzminderung am ehesten im Rahmen eines Hypovolämischen Schocks \nExsikkose \nAkut auf chronische NI \nHyperglykämie bei bek. DM Typ I\n\n08.07.2024:\nÜbernahme aus der ZNA bei Vigilanzminderung unklare Genese. Kommt aus Pflegeheim mit Verdachtsdiagnose Hyperlipidämie. Hier schläfrig und initial nicht erweckbar. Nach Flüssigkeitssubstitution und Gabe von Naloxon leichte Besserung der Vigilanz. CT-morphologisch Ausschluss eine akute Ischämie und Blutung. Nach Übernahme auf Intensivstation hämodynamisch instabil, hypoton, kaltschweißig gibt Übelkeit.\n\nLabor:\n\t\t\t\tLK 6,8, Hb 12,8, Thr.: 374; PTT : 28,9; Na: 137; K 4,7;CK 262; Krea 2,1; CRP 0,4\n\nTemperatur:\n\t\t\t36 °C\n\nletzte Bilanz:\n\t\t\tXXXX ml/24h\n\nKatecholamine:\n\t\t\tVasopressoren oder Inotropika? XXXX mg/h, Substanz? Tendenz innerhalb der letzten 24h?\n\nNierenfunktion:\n\t\t\t\tNierenersatztherapie, Diuresemenge? Hyperkaliämie oder metabolische Azidose?\n\nSedierung:\n\t\t\t\tRASS-Score, Sedierungspause und Aufwachversuch?\n\nAnalgesie:\n\t\t\tNRS-Score? Alternativ BPS? Schmerzkatheter?\n\nDelir:\n\t\t\t\tCAM-ICU: Delir ja/nein?\n\nBeatmung:\n\t\t\tModus: VT in ml/kg (Ziel 6 ml/kg): \t PEEP (angepasst an FiO²?): \t ASB: FiO²/PaO²/PaCO²: Plateaudruck < 30 cm H²O?\n\nWeaning möglich:\n\t\tSpontanatemversuch möglich? Extubation möglich?\n\nOK-Hochlagerung:\n\t\t\tmindestens 30° ja/nein\n\nAntibiotikatherapie:\n\t\tja/nein, Substanz, Tag, Indikation spezifizieren, weitere Diagnostik notwendig? Neue Ergebnisse?\n\nDrainagen:\n\t\t\t\tThoraxdrainagen (Lokalisation, Fisltefluss, Fördermenge, Sekretbeschaffenheit), abdominale Drainagen (Lokalisation, Fördermenge, Sekretbeschaffenheit)\n\nAntikoagulation:\n\t\tSubstanz/Indikation/Dosis\n\nPlättchenhemmung:\nSubstanz/Indikation/Dosis\n\nUlcusprophylaxe:\n\t\t\tSubstanz/Indikation/Dosis\n\nintravasale Katheter:\n\t\tLokalisation? ZVK/ART weiterhin erforderlich? Liegedauer? Einsstichstellen reizlos?\n\nErnährung:\n\t\t\t\tenteral/parenteral, Begründung, Kalorienziel (BMI bis 30: 24 kcal/kg/d, BMI 30-50: 11-14 kcal/kg/d, jeweils Beginn mit 75% des Sollwertes), Soll/Ist-Vergleich\n\nAngehörigenkommunikation\n:\tWann? Welche Themen?\n\nBetreuung:\n\t\t\tja/nein, Vorsorgevollmacht? Patientenverfügungn? Betreuung eingerichtet\n\nMobilisation:\n\t\t\tja/nein, aktiv/passiv? Mobilisationsform?\n\nTherapielimitierung:\n\t\tnein/ja, welche?\n\nOrganisatorisches:\n\t\tKonsile/Sozialdienst/Verlegung/Reha\n\nBildgebung (CT/Rö-Thorax etc.)\n\tneue Befunde?\n\nPhysiotherapie:\n\t\t\tbei Patienten mit absehbarer, längerer Intensivtherapie bitte auch am Wochenende anmelden\n\nPflegerische Aspekte:\n \t\tDekubitalulcera? Versorgungsprobleme?\n\nSOFA-Score:\n\nAPACHE II:\n\n----------------------------------------------------------------------------------\nVisitenteilnehmer: \t Kurtylimaz,Thoukydidis(FA Intensiv)\n\nMedikation:\nIst alle notwendige Medikation angesetzt? \tJa(Thoukydidis) \t\n\t\t\t\t\t\tIst alle unnötige Medikation abgesetzt? \t\tJa(Thoukydidis)\n\nFragen zur Medikation:\n\nProcedere/Tagesziele:\n \t\tZVK, Flüßigkeitssubstitution, Stuhlprobe, Sono, TTE</div>",
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pflegeverlaufsbericht\n um 23:53 für den 16.07.2024 23:53\nBetr.: W0 Nachtdienst-Bericht\nBem.: Pat ist wach und ansprechbar, gibt unter laufender Therapie derzeit keine Schmerzen an.\nO2 pausiert, SpO2 in Ruhe stabil.\nPat ist hyperglykämisch, Insuline weiterhin verwirrend laut Plan und Anordnung im System.\nZudem soll Pat laut Plan nichts zur Nacht erhalten. Nach Rücksprache mit der DHÄ erhält Pat Humalog nach Hausschema zur nacht, Kontrolle um 3 Uhr erfolgt.\nDK fördert klaren Urin, Wasser wurde gereicht.\nInfusion nach Plan verabreicht, ZVK (1 Schenkel) durchlässig.\nangelegt von: Kimberly Fitzke am: 16.07.2024 um: 23:57\nfür: Kimberly Fitzke\n\nPflegeverlaufsbericht\n um 23:53 für den 16.07.2024 23:53\nBetr.: W0 Nachtdienst-Bericht\nBem.: Pat ist wach und ansprechbar, gibt unter laufender Therapie derzeit keine Schmerzen an.\nO2 pausiert, SpO2 in Ruhe stabil.\nPat ist hyperglykämisch, Insuline weiterhin verwirrend laut Plan und Anordnung im System.\nZudem soll Pat laut Plan nichts zur Nacht erhalten. Nach Rücksprache mit der DHÄ erhält Pat Humalog nach Hausschema zur nacht, Kontrolle um 3 Uhr erfolgt.\nDK fördert klaren Urin, Wasser wurde gereicht.\nInfusion nach Plan verabreicht, ZVK (1 Schenkel) durchlässig.\n3:18 BZ bei 258.\nPat ist wieder komplett geschwitzt. Pat wird auf den Toilettenstuhl mobilisiert.\nBett wird von 2PK`s frisch bezogen. Pat erhält Hilfestellung beim Umziehen.\nWasser wurde nochmals gereicht.\ngeändert von: Kimberly Fitzke am: 17.07.2024 um: 03:19</div>",
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pflegeverlaufsbericht\n um 07:13 für den 16.07.2024 07:13\nBetr.: W0 Frühdienst-Bericht\nBem.: Pat wird im Bett liegend angetroffen, ist wach und orientiert, gibt an, gut geschlafen zu haben. Pat gibt auf Nachfrage keine Schmerzen an. SPO2 unter 4LO2 stabil. Pat schwitzt weiterhin. Pat möchte auf Wunsch Augentropfen zum Befeuchten von der PK erhalten. Pat benötigt Hilfe bei der Körperfpflege, wird später unterstützt. ZVK Verband löst sich und wird später erneuert. ZVK Einstichstelle ist reizlos, zwei Schenkel sind undurchlässig. Antbiose und Jono werden über einen Schenkel verabreicht. Katheterbeutel wurde geleert (1000ml klarer Urin). Pat erhält 14 IE Tresiba und Bolus nach Plan. Getränke wurden erneuert und angereicht. \nangelegt von: Chiara Josephine Neumann am: 16.07.2024 um: 07:17\nfür: Chiara Josephine Neumann\n\nPflegeverlaufsbericht\n um 07:13 für den 16.07.2024 07:13\nBetr.: W0 Frühdienst-Bericht\nBem.: Pat wird im Bett liegend angetroffen, ist wach und orientiert, gibt an, gut geschlafen zu haben. Pat gibt auf Nachfrage keine Schmerzen an. SPO2 unter 4LO2 stabil. Pat schwitzt weiterhin. Pat möchte auf Wunsch Augentropfen zum Befeuchten von der PK erhalten. Pat benötigt Hilfe bei der Körperfpflege, wird später unterstützt. ZVK Verband löst sich und wird später erneuert. ZVK Einstichstelle ist reizlos, zwei Schenkel sind undurchlässig. Antbiose und Jono werden über einen Schenkel verabreicht. Katheterbeutel wurde geleert (1000ml klarer Urin). Pat erhält 14 IE Tresiba und Bolus nach Plan. Getränke wurden erneuert und angereicht.\n\nPat. wurde auf den Toilettenstuhl mobilisiert und ins Badezimmer gefahren, Oberkörper wäschte Pat. Selbstständig, Unterkörper und Rücken wurde von PK übernommen, Haare wurden mit einer Waschhaube gewaschen, ZVK Pflaster gewechselt, Umgebung Unaufällig, Hautbild trocken, wurde eingecremt, Hautdefekt ca. 5cm Oberflächlich am Rücken, trocken, Pat. ist in der Lage kurz zu stehen, Sättigung unter Raumluft unaufällig so wie die Atmung, Fr. Dr. Abel wurde darüber Informiert, dass 2 Schenkel des ZVK´s nicht mehr Durchlässig ist, Getränke wurden eingeschenkt \ngeändert von: Michaela Akyüz am: 16.07.2024 um: 11:04\nfür: Chiara Josephine Neumann</div>",
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pflegeverlaufsbericht\n um 16:44 für den 09.07.2024 16:44\nBetr.: IMC Spätdienst-Bericht\nBem.: Pat. Az mäßig- insgesamt schlapp und erschöpft, wirkt zeitweise zeitlich und situativ desorientiert. Pat wird weiterhin am Monitor überwacht, resp. und hämodynamisch stabil. Pat führt weiterhin dünnflüssig ab mit Frischblutbeimengungen, soll vorerst nüchtern bleiben, CT Abdomen gelaufen\nangelegt von: Sabrina Ickelsheimer am: 09.07.2024 um: 16:46\nfür: Sabrina Ickelsheimer\n\nPflegeverlaufsbericht\n um 16:44 für den 09.07.2024 16:44\nBetr.: IMC Spätdienst-Bericht\nBem.: Pat. Az mäßig- insgesamt schlapp und erschöpft, wirkt zeitweise zeitlich und situativ desorientiert. Pat wird weiterhin am Monitor überwacht, resp. und hämodynamisch stabil. Pat führt weiterhin dünnflüssig ab mit Frischblutbeimengungen, soll vorerst nüchtern bleiben, CT Abdomen gelaufen\n16:30 Pat ist hyperton- Arzt info Dr. Leipold erfolgt\ngeändert von: Sabrina Ickelsheimer am: 09.07.2024 um: 17:03\n\nPflegeverlaufsbericht\n um 16:44 für den 09.07.2024 16:44\nBetr.: IMC Spätdienst-Bericht\nBem.: Pat. Az mäßig- insgesamt schlapp und erschöpft, wirkt zeitweise zeitlich und situativ desorientiert. Pat wird weiterhin am Monitor überwacht, resp. und hämodynamisch stabil. Pat führt weiterhin dünnflüssig ab mit Frischblutbeimengungen, soll vorerst nüchtern bleiben, CT Abdomen gelaufen\n16:30 Pat ist hyperton- Arzt info Dr. Leipold erfolgt\n17:00 Pat darf jetzt wieder TEE und Zwieback\ngeändert von: Sabrina Ickelsheimer am: 09.07.2024 um: 18:13\n\nPflegeverlaufsbericht\n um 16:44 für den 09.07.2024 16:44\nBetr.: IMC Spätdienst-Bericht\nBem.: Pat. Az mäßig- insgesamt schlapp und erschöpft, wirkt zeitweise zeitlich und situativ desorientiert. Pat wird weiterhin am Monitor überwacht, resp. und hämodynamisch stabil. Pat führt weiterhin dünnflüssig ab mit Frischblutbeimengungen, soll vorerst nüchtern bleiben, CT Abdomen gelaufen\n16:30 Pat ist hyperton- Arzt info Dr. Leipold erfolgt\n17:00 Pat darf jetzt wieder TEE und Zwieback\n18:30 Pat wirkte bis jetzt schlafend, ist wach geworden\ngeändert von: Sabrina Ickelsheimer am: 09.07.2024 um: 18:42\n\nPflegeverlaufsbericht\n um 16:44 für den 09.07.2024 16:44\nBetr.: IMC Spätdienst-Bericht\nBem.: Pat. Az mäßig- insgesamt schlapp und erschöpft, wirkt zeitweise zeitlich und situativ desorientiert. Pat wird weiterhin am Monitor überwacht, resp. und hämodynamisch stabil. Pat führt weiterhin dünnflüssig ab mit Frischblutbeimengungen, soll vorerst nüchtern bleiben, CT Abdomen gelaufen\n16:30 Pat ist hyperton- Arzt info Dr. Leipold erfolgt\n17:00 Pat darf jetzt wieder TEE und Zwieback\n18:30 Pat wirkte bis jetzt schlafend, ist wach geworden fängt an sich zu entkabeln und PP massivst zu beschimpfen und zu drohen, zieht sich im Beisein von OA Dr. Stark den BDK, versucht nach PP zu schlagen, Ehemann wurde informiert und kommt vorbei\ngeändert von: Sabrina Ickelsheimer am: 09.07.2024 um: 18:45</div>",
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pflegeverlaufsbericht\n um 17:54 für den 08.07.2024 17:54\nBetr.: C1 Frühdienst-Bericht\nBem.: Pat. aufgenommen von der ZNA initial aufgrund von sinkendem RR -> Hypotonie. \nPat. kommt aus dem Heim, hat mehrere Tage keine Verdaaung gehabt, hat Abführmittel erhalten und ist Kollabiert.\nPat. ansprechbar, jedoch ziemlich eingetrübt, hat in der ZNA mehrfach erbrochen, MS-Anlage ist erfolgt. \nPat. äußert weiterhin starke Übelkeit, hat n. Mündl. Anordnung von DHA Ondensatron i.v erh.\nZVK, Arterieller Zugang und BDK-Anlage ist erfolgt.\nPat. anfangs Katecholaminpflichtig, nach Gabe von Volumenshift stabilisiert sich Pat. wieder.\nPat. deutlich besser, reagiert adäquat, kann auf fragen eingehen. Pat. scheint ZÖPS orientiert zu sein.\nEhemann war zu Besuch, Kollaps in der Vorgeschichte sind bekannt. \nPat. deutlich exsikkiert, hat massiv breiig/flüssig abgeführt, Stuhlproben abgenommen.\nTrinken wurde angereicht.\nDiurese suffizient.\n\nangelegt von: Tunahan Temel am: 08.07.2024 um: 18:19\nfür: Tunahan Temel\n\nPflegeverlaufsbericht\n um 17:54 für den 08.07.2024 17:54\nBetr.: C1 Frühdienst-Bericht\nBem.: Pat. aufgenommen von der ZNA initial aufgrund von sinkendem RR -> Hypotonie. \nPat. kommt aus dem Heim, hat mehrere Tage keine Verdaaung gehabt, hat Abführmittel erhalten und ist Kollabiert.\nPat. ansprechbar, jedoch ziemlich eingetrübt, hat in der ZNA mehrfach erbrochen, MS-Anlage ist erfolgt. \nPat. äußert weiterhin starke Übelkeit, hat n. Mündl. Anordnung von DHA Ondensatron i.v erh.\nZVK, Arterieller Zugang und BDK-Anlage ist erfolgt.\nPat. anfangs Katecholaminpflichtig, nach Gabe von Volumenshift stabilisiert sich Pat. wieder.\nPat. deutlich besser, reagiert adäquat, kann auf fragen eingehen. Pat. scheint ZÖPS orientiert zu sein.\nEhemann war zu Besuch, Kollaps in der Vorgeschichte sind bekannt. \nPat. deutlich exsikkiert, hat massiv breiig/flüssig abgeführt, Stuhlproben abgenommen.\nTrinken wurde angereicht.\nDiurese suffizient.\n\ngeändert von: Tunahan Temel am: 08.07.2024 um: 18:20\n\nPflegeverlaufsbericht\n um 17:54 für den 08.07.2024 17:54\nBetr.: C1 Spätdienst-Bericht\nBem.: Pat. aufgenommen von der ZNA initial aufgrund von sinkendem RR -> Hypotonie. \nPat. kommt aus dem Heim, hat mehrere Tage keine Verdaaung gehabt, hat Abführmittel erhalten und ist Kollabiert.\nPat. ansprechbar, jedoch ziemlich eingetrübt, hat in der ZNA mehrfach erbrochen, MS-Anlage ist erfolgt. \nPat. äußert weiterhin starke Übelkeit, hat n. Mündl. Anordnung von DHA Ondensatron i.v erh.\nZVK, Arterieller Zugang und BDK-Anlage ist erfolgt.\nPat. anfangs Katecholaminpflichtig, nach Gabe von Volumenshift stabilisiert sich Pat. wieder.\nPat. deutlich besser, reagiert adäquat, kann auf fragen eingehen. Pat. scheint ZÖPS orientiert zu sein.\nEhemann war zu Besuch, Kollaps in der Vorgeschichte sind bekannt. \nPat. deutlich exsikkiert, hat massiv breiig/flüssig abgeführt, Stuhlproben abgenommen.\nTrinken wurde angereicht.\nDiurese suffizient.\n\ngeändert von: Tunahan Temel am: 08.07.2024 um: 18:21</div>",
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Pflegeverlaufsbericht\n um 08:50 für den 10.07.2024 08:50\nBetr.: IMC Frühdienst-Bericht\nBem.: - Pat. mit Handfixierung übernommen, Pat. ist sehr aggressiv und beleidigend, möchte sich alle zugänge rausziehen - Arzt Info\n- Fixierung der Hände wurde von Dr. Stark angeordnet und reiht nach Rückfrage so aus \n- Pat. ist Hyperton - 1 Amp- Neurocil 25mg/ml als KI verabreicht \n- Respiratorisch ist Pat. mit 1 L O2 stabil\n- Diurese gut \n- Bauch gebläht, schmerzt, zur Zeit keine Diarrhoe \n- Pat. wird gelagert \nangelegt von: Tatjana Woitena am: 10.07.2024 um: 08:56\nfür: Tatjana Woitena\n\nPflegeverlaufsbericht\n um 08:50 für den 10.07.2024 08:50\nBetr.: IMC Frühdienst-Bericht\nBem.: - Pat. mit Handfixierung übernommen, Pat. ist sehr aggressiv und beleidigend, möchte sich alle zugänge rausziehen - Arzt Info\n- Fixierung der Hände wurde von Dr. Stark angeordnet und reiht nach Rückfrage so aus \n- Pat. ist Hyperton - 1 Amp- Neurocil 25mg/ml als KI verabreicht \n- Respiratorisch ist Pat. mit 1 L O2 stabil\n- Diurese gut \n- Bauch gebläht, schmerzt, zur Zeit keine Diarrhoe \n- Pat. wird gelagert \n- Orale Medikamente nimmt Pat. nicht ein \ngeändert von: Tatjana Woitena am: 10.07.2024 um: 08:57\n\nPflegeverlaufsbericht\n um 08:50 für den 10.07.2024 08:50\nBetr.: IMC Frühdienst-Bericht\nBem.: - Pat. mit Handfixierung übernommen, Pat. ist sehr aggressiv und beleidigend, möchte sich alle zugänge rausziehen - Arzt Info\n- Fixierung der Hände wurde von Dr. Stark angeordnet und reiht nach Rückfrage so aus \n- Pat. ist Hyperton - 1 Amp- Neurocil 25mg/ml als KI verabreicht \n- Respiratorisch ist Pat. mit 1 L O2 stabil\n- Diurese gut \n- Bauch gebläht, schmerzt, zur Zeit keine Diarrhoe \n- Pat. wird gelagert \n- Pat. weigert sich ihre oralen Medikamente einzunehmen \n- Logopädin war da- Pat. hat gerade keinen Schluckrefelx - Pat. muss nüchtern bleiben. - Kontrolle morgen erneut \ngeändert von: Tatjana Woitena am: 10.07.2024 um: 11:07\n\nPflegeverlaufsbericht\n um 08:50 für den 10.07.2024 08:50\nBetr.: IMC Frühdienst-Bericht\nBem.: - Pat. mit Handfixierung übernommen, Pat. ist sehr aggressiv und beleidigend, möchte sich alle zugänge rausziehen - Arzt Info\n- Fixierung der Hände wurde von Dr. Stark angeordnet und reiht nach Rückfrage so aus \n- Pat. ist Hyperton - 1 Amp- Neurocil 25mg/ml als KI verabreicht \n- Respiratorisch ist Pat. mit 1 L O2 stabil\n- Diurese gut \n- Bauch gebläht, schmerzt, zur Zeit keine Diarrhoe \n- Pat. wird gelagert \n- Pat. weigert sich ihre oralen Medikamente einzunehmen \n- Logopädin war da- Pat. hat gerade keinen Schluckrefelx - Pat. muss nüchtern bleiben. - Kontrolle morgen erneut \n- Pat weiterhin Hyperton - Arzt erneut Info\ngeändert von: Tatjana Woitena am: 10.07.2024 um: 11:08\n\nPflegeverlaufsbericht\n um 08:50 für den 10.07.2024 08:50\nBetr.: IMC Frühdienst-Bericht\nBem.: - Pat. mit Handfixierung übernommen, Pat. ist sehr aggressiv und beleidigend, möchte sich alle zugänge rausziehen - Arzt Info\n- Fixierung der Hände wurde von Dr. Stark angeordnet und reiht nach Rückfrage so aus \n- Pat. ist Hyperton - 1 Amp- Neurocil 25mg/ml als KI verabreicht \n- Respiratorisch ist Pat. mit 1 L O2 stabil\n- Diurese gut \n- Bauch gebläht, schmerzt, zur Zeit keine Diarrhoe \n- Pat. wird gelagert \n- Pat. weigert sich ihre oralen Medikamente einzunehmen \n- Logopädin war da- Pat. hat gerade keinen Schluckrefelx - Pat. muss nüchtern bleiben. - Kontrolle morgen erneut \n- Pat weiterhin Hyperton - Arzt erneut Info\ngeändert von: Tatjana Woitena am: 10.07.2024 um: 11:08\n\nPflegeverlaufsbericht\n um 08:50 für den 10.07.2024 08:50\nBetr.: IMC Frühdienst-Bericht\nBem.: - Pat. mit Handfixierung übernommen, Pat. ist sehr aggressiv und beleidigend, möchte sich alle zugänge rausziehen - Arzt Info\n- Fixierung der Hände wurde von Dr. Stark angeordnet und reiht nach Rückfrage so aus \n- Pat. ist Hyperton - 1 Amp- Neurocil 25mg/ml als KI verabreicht \n- Respiratorisch ist Pat. mit 1 L O2 stabil\n- Diurese gut \n- Bauch gebläht, schmerzt, zur Zeit keine Diarrhoe \n- Pat. wird gelagert \n- Pat. weigert sich ihre oralen Medikamente einzunehmen \n- Logopädin war da- Pat. hat gerade keinen Schluckrefelx - Pat. muss nüchtern bleiben. - Kontrolle morgen erneut \n- Pat weiterhin Hyperton - Arzt erneut Info\n- 12.00 Uhr - Logopädie erneut da, Pat, darf schluckweise trinken \ngeändert von: Tatjana Woitena am: 10.07.2024 um: 12:31</div>",
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Aktuelles, klinisches Problembild der Patientin/des Patienten:\n\nHypovolämischer Schock bei Gastroenteritis\n\nAkute Vigilanzminderung am ehesten im Rahmen des Schocks\n\nExsikose bei Gastroenteritis\n\nAkut auf chronische NI a.e.prerenal\n\nHyperglykämie bei bek. DM Typ I\n\n08.07.2024:\nÜbernahme aus der ZNA bei Vigilanzminderung unklare Genese. Kommt aus Pflegeheim mit Verdachtsdiagnose Hyperlipidämie. Hier schläfrig und initial nicht erweckbar. Nach Flüssigkeitssubstitution und Gabe von Naloxon leichte Besserung der Vigilanz. CT-morphologisch Ausschluss eine akute Ischämie und Blutung. Nach Übernahme auf Intensivstation hämodynamisch instabil, hypoton, kaltschweißig gibt Übelkeit.\n09.07: erhebliche Besserung der Vigilanz, jedoch noch verlangsamte Reaktion, wach und orientiert. kein Katecholaminbedarf. leicht erhöhte Infektparameter bei Gastroenteritis, im Verlauf weiterbeobachten ggf. Beginn mit Antibiose. respiratorisch und hämodynmiasch stabil. Keine Übelkeit. heute lediglich leichte positiv Bilanz, da seit gestern ausreichend erfolgt. Kreatinin regredient. heute Verlegung IMC. Im Röntgen-Thx keine Infiltrate.\nheute blutiger Stuhl, Stuhlproben noch nicht gänzlich vorhanden.\n\nLabor:\n\t\t\t\tLK 17 6,8, Hb 10 12,8, Thr.: 336 374; PTT : 28,9; Na: 140 137; K 5 4,7;CK 262; Krea 1,6 2,1; CRP 7,9 0,4\n\nTemperatur:\n\t\t\t36 °C\n\nletzte Bilanz:\n\t\t\t9000 ml/24h\n\nKatecholamine:\n\t\t\tNA 5/50 >>\n\nNierenfunktion:\n\t\t\t\t1400/24h Krea 1,6\n\nSedierung:\n\t\t\t\tRASS-Score 0\n\nAnalgesie:\n\t\t\tNRS-Score 2/10\n\nDelir:\n\t\t\t\tCAM-ICU: Delir nein\n\nBeatmung:\n\t\tModus: VT in ml/kg (Ziel 6 ml/kg): PEEP (angepasst an FiO²?): \t ASB: FiO²/PaO²/PaCO²: Plateaudruck < 30 cm H²O?\n\nWeaning möglich:\n\t\tSpontanatemversuch möglich? Extubation möglich?\n\nOK-Hochlagerung:\n\t\t\tmindestens 30° ja/nein\n\nAntibiotikatherapie:\n\t\tja/nein, Substanz, Tag, Indikation spezifizieren, weitere Diagnostik notwendig? Neue Ergebnisse?\n\nDrainagen:\n\t\t\t\tThoraxdrainagen (Lokalisation, Fisltefluss, Fördermenge, Sekretbeschaffenheit), abdominale Drainagen (Lokalisation, Fördermenge, Sekretbeschaffenheit)\n\nAntikoagulation:\n\tEnoxaparin therap. , OAk pausiert\n\nPlättchenhemmung:\nASS pausiert\n\nUlcusprophylaxe:\n\t\t\tPPi\n\nintravasale Katheter:\n\t ZVK d2 /ART d2\n\nErnährung:\n\t\t\t\tenteral\n\nAngehörigenkommunikation\n:\tWann? Welche Themen?\n\nBetreuung:\n\t\t\tja/nein, Vorsorgevollmacht? Patientenverfügungn? Betreuung eingerichtet\n\nMobilisation:\n\t\t\tja/nein, aktiv/passiv? Mobilisationsform?\n\nTherapielimitierung:\n\t\tnein\n\nOrganisatorisches:\n\t\tKonsile/Sozialdienst/Verlegung/Reha\n\nBildgebung (CT/Rö-Thorax etc.)\nneue Befunde?\n\nPhysiotherapie:\n\t\t\tbei Patienten mit absehbarer, längerer Intensivtherapie bitte auch am Wochenende anmelden\n\nPflegerische Aspekte:\n \t\tDekubitalulcera? Versorgungsprobleme?\n\nSOFA-Score:\n\nAPACHE II:\n\n----------------------------------------------------------------------------------\nVisitenteilnehmer: \t Thoukydidis (FA Intensiv), Hamidy , Kurtyilmaz\n\nMedikation:\nIst alle notwendige Medikation angesetzt? \tJa (Thoukydidis\n) \t\n\t\t\t\t\t\tIst alle unnötige Medikation abgesetzt? \t\tJa (Thoukydidis\n)\n\nFragen zur Medikation:\n\nProcedere/Tagesziele:\n \t\tVerlegung IMC</div>",
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							"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">OA Visite\nAZ gebessert. Blutzuckerwerte im gesamten Niveau etwas zu hoch, Insulinplan angepasst. Die Patientin beklagt beidseitige diskrete Unterschenkelödeme, Amlodipin in der Dosis reduziert. Zudem Röntgen rechter Fuß, bei nahezu abgeheiltem Ulcus an der lateralen Fußkante. Ansonsten Wohlbefinden.</div>",
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