Branching Exercise: Cardiac Case 2 Assignment

Branching Exercise: Cardiac Case 2 Assignment

Admission Orders Template

Primary Diagnosis: Septic Shock. The patient is being transferred from the emergency room and admitted to the medical intensive care unit for close monitoring of her BP and worsening septic shock symptoms. The patient requires vasopressin. However, in the ER, the patient was administered 1 L NSS bolus over 1 hour, then started on maintenance rehydration with NSS at 100 ml/hr. (Froom & Shimoni, 2018).

Status/Condition: Serious Code Status: Full Code Allergies: No reported allergies. Admitted to the Medical Intensive Care Unit with Pulmonary Critical Care Attending as the assigned physician in the unit.

Activity Level:Consider bedrest to attain stability.

Diet:Consider a clear liquid diet first, then the nurse can gradually advance to a light Heart Healthy diet as per the patient’s tolerance levels (Shimoni et al., 2020).

IV Fluids:

• Give the second bolus of 1 L NSS over 1 hr since the patient initial BP was 82/42. Start norepinephrine incase the patient’s SPB remains lower than 100(Perry et al., 2018).
• Administer normal saline 100 ml per hour for rehydration, while maintaining the IV access which should be started after the second NSS bolus has been completed.
• Critical Drips:Not necessary at the moment, as the patient’s response to the second NSS bolus is monitored. In case the patient’s SPB is still lower than 100 and MAP is lower than 65, then start 8mcg Norepinephrine per minute and titrate by 2 mcg per min after every 5 minutes to attain an SPB of over 100 and MAP of over 65(Froom & Shimoni, 2018). Administration of Norepinephrine can utilize the peripheral IV route given that the dose does not go beyond 10 mcg per min for over hours. If the patient requires this medication in high doses and for a prolonged period, consider line placement.
• IV Antibiotics: Administer Ceftriaxone 2g IV twice daily for 7 days to manage the urinary tract infection (UTI). The patient can continue with an equally effective oral antibiotic once discharged (Shimoni et al., 2020).

Respiratory:Consider nasal cannula 2L for cardiac support and comfort maintaining the patient’s SPO2 at 93% or higher. Reduce oxygen as per the patient’s tolerance. Consult medical providers incase more oxygen is needed as a result of respiratory distress (Shimoni et al., 2020).

Medications:

1. Aspirin 81 mg orally once daily for cardia maintenance and anticoagulant effect (Shimoni et al., 2020).
2. Metoprolol 12.5 mg orally twice daily for blood pressure control.
3. Insulin to control the patient’s blood sugar levels. Closely monitor the patient’s blood glucose levels (Froom & Shimoni, 2018).
4. Heparin 5000 units Sub-q twice daily as prophylaxis for DVT(Perry et al., 2018).
5. Tylenol 650 mg orally after every 6 hours as needed for management of pain and fever.

Nursing Orders:

1. Continue monitoring the patient’s oxygen saturation, heart rate/rhythm, and respiration rate.
2. BP should be monitored after every 15 minutes within the first hour of admission to the MICU. During the second hour, monitor the patient’s BP at intervals of 30 minutes, then hourly for the following 24 hours (Froom & Shimoni, 2018).
3. Monitor the patient’s body temperature every 2 hours.
4. Encourage the patient to change positions frequently to avoid bed sores.
5. Closely monitor the patient’s urine output, for shifts lower than 30 ml per hour, to notify the physician (Shimoni et al., 2020).
6. In case of inadequate urine output, consider a bladder scan to determine urinary retention. Consider Foley catheter placement if urinary retention persists.
   

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Follow-Up Lab Tests:

1. Collected lab tests from the ED include CBC, Urinalysis, CMP, Lactic acid, chest x-ray, and EKG.
2. Additional lab tests in the ED include urine culture to identify the causative bacterial microorganism for appropriate antibiotic choice (Shimoni et al., 2020).
3. Routine lab tests to be collected every day in the morning include CBC, MAG, BMP, and PHOS.

Consults:

• Physical therapist or occupational therapist consultations to promote the patient’s mobility and ensure her safe with ambulation before being discharged.
• Nutrition consultation for appropriate heart-healthy diet and weight maintenance education (Froom & Shimoni, 2018).
• Consult discharge planning to prepare the patient for discharge and consider support required to promote home-based care.
• Endocrinology consultations promote appropriate dosing and administration of insulin (Shimoni et al., 2020).

Patient Education and Health Promotion:

• Educate the patient on the importance of sticking to the treatment regimen and completing the antibiotic dose to prevent multidrug resistance (Perry et al., 2018).
• The patient must be advised to adopt a healthy eating habit in addition to physical exercise such as walking around the neighborhood (Froom & Shimoni, 2018).

Discharge Planning and Required Follow-Up Care:

Discharge Plan:

• When the mental status of the patient has returned to baseline, and vital signs stabilized, the patient can then be transferred to the medical-surgical unit for further evaluation (Perry et al., 2018).
• The patient will be evaluated in the Med-Surg unit for 24 hours, upon which she will qualify for discharge if her health status is stable (Shimoni et al., 2020).
• The patient family members must be informed of the patient’s discharge state and the medications to take at home, in addition to red flags, incase of symptoms persist.
• The patient will then be discharged with a prescription which will be taken to the pharmacist to acquire the drugs and more education on how to take them (Froom & Shimoni, 2018).

Follow up appointments:

1. The patient will be required to report back to the hospital after 1 week for evaluation of the treatment outcome.

References

Froom, P., & Shimoni, Z. (2018). The uncertainties of the diagnosis and treatment of a suspected urinary tract infection in elderly hospitalized patients. Expert Review of Anti-infective Therapy, 16(10), 763-770.https://doi.org/10.1080/14787210.2018.1523006

Perry, A., Tejada, J. M., & Melady, D. (2018). An approach to the older patient in the emergency department. Clinics in geriatric medicine, 34(3), 299-311.https://doi.org/10.1016/j.cger.2018.03.001

Shimoni, Z., Cohen, R., & Froom, P. (2020). Prevalence, impact, and management strategies for asymptomatic bacteriuria in the acute care elderly patient: a review of the current literature. Expert Review of Anti-infective Therapy, 18(5), 453-460.https://doi.org/10.1080/14787210.2020.1746642

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Assignment: Branching Exercise: Cardiac Case 2
For this Assignment, you will review the interactive media piece/branching exercise provided in the Learning Resources. As you examine the patient case, consider how you might assess and treat patients with the symptoms and conditions presented.
To prepare:
• Review the interactive media piece/branching exercise provided in the Learning Resources.
• https://cdn-media.waldenu.edu/2dett4d/Walden/NRNP/6566/SC03/index.html
• Will post this in files
• Reflect on the patient’s symptoms and aspects of disorders that may be present in the interactive media piece/branching exercise.
• Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the interactive media piece/branching exercise.
• You will be asked to develop a set of admission orders based on the patient in the branching exercise.
The Assignment
Using the Required Admission Orders Template, write a full set of admission orders for the patient in the branching exercise.
• Be sure to address each aspect of the order template
• Write the orders as you would in the patient’s chart
• Make sure the order is complete and applicable to the patient
• Any rationale you feel the need to supply should be done at the end of the order set – not included with the order
• Please do not write per protocol. We do not know what your protocol is and you need to demonstrate what is appropriate standard of care for this patient.
• A minimum of three current, evidenced based references are required.