Question

There is no additional information the questions are based on this nurse note

Nurse note at 10:00 am

Client was brought into the ED by her daughter due to increased shortness of breath this morning.  The daughter reports that the client. has been running a fever for the past few days and the and has started to cough up greenish colored sputum and to complain of “soreness throughout the body”.    The client was recently hospitalized for issues related to atrial fibrillation 6 days ago.  The client has a history of hypertension.  Vital Signs T 101.1F(38.4C), P 92, RR 22B/P 152/88, pulse oximetry 94% on2L nasal cannula.  Assessment, Clients breathing appears slightly labored with course crackles noted bilateral lung bases.  Skin slightly cool to touch and pale, pink skin tone, pulses 3+, radial and irregular, cap refill 3 seconds.  Client is alert and oriented to person, place and time.  The clients daughter states, “Sometimes it seems like my mother is confused.”

12:00 pm

Called to the bedside by the  daughter who states that her mother “isn’t’ acting right.”  Assessment reveals, client difficult to arouse, pale, diaphoretic in appearance.  Vital signs: T 101.5 F (38.6 C) P 112 , RR- 32, B/P 90/62, pulse oximetry 91% on 2L/min via nasal cannula

After reviewing the nurse’s note  at 10:00 and 12:00,  

8.  List all the changes in the 12:00 assessment.  For each change, indicate what the nurse is worried about, feel free to list disease or condition

Change                                                                        What is your concern for client?

9..  Below are listed some interventions.  For each intervention list if it is indicated or not.  For those that are indicated, list what it will do for the patient.

Indication                                Indicated(I) or Not(NI)                                    How will this help the client?

                                                                                                            If this is not indicated, leave blank

1.  Prepare to defibrillate

2.  Place client in semi-Fowlers

Postion

3.Request an order to increase

Oxygen

4.  Request an order to administer

IVF, intravenous fluid

5. Request an order to insert

a PICC line?

                                    

10.  The healthcare provider has ordered the following orders.  Please circle the three most important orders at this time?

1.  Insert a foley catheter

2.  Vancomycin 1 g IV every 12 hours

3.  computed tomorography scan of client

4.  0.9 normal saline bolus 500 ml once

5.  lab tests, blood culture times three, complete blood count, arterial blood gas, lactate level

List each order and state why this is important to perform at this time.

Order                                                                          Rationale for order

1.

2.

3.

4.

5.List each lab test and rationale

Answer 1

I feel that the patient is suffering from healthcare-associated pneumonia with associated sepsis shock and respiratory failure. The rationale behind this diagnosis is

1. History of a visit to a health care facility 6 days prior
2. History of fever with greenish sputum ( most likely Pseudomonas aeruginosa)
3. The patient is breathless and requires oxygen.
4. Her extremities are cold and her capillary refill time is prolonged

The changes in the 12:00 notes are

1. The patient's sensorium has deteriorated - This indicates that sepsis
2. The blood pressure has fallen - The patient has gone into the stage of septic shock
3. Fever has increase

My concern for the client is that she has gone into septic shock. The patient may require intubation and PICC line insertion for fluids and inotropes

From the list of intervention

1. Prepare to defibrillate - not indicated (however I would like continuous ECG monitoring for this patient)
2. Place the patient in a semi-fowler's position - Indicated - As the patient's sensorium has deteriorated, this position will help prevent aspiration into the lungs and promote breathing
3. Request increase oxygen - not indication - the patient's saturation is 91% which is adequate. Increasing the supplemental oxygen levels without the guidance of arterial blood gas can be detrimental.
4. Request for IV fluids - Indicated - The patient has low blood pressure. A fluid challenge is mandatory
5. Request order PICC line insertion - Indicated - Patient has low BP. A PICC line will help to fluid assessment. If the patient doesn't respond to fluid challenge, the PICC line can be used to administer inotropes.

The Three important orders are

1. Order number 5
2. Order number 2
3. Order number 4

The order and their rational is as follows

1. Blood test
   1. Blood culture - blood culture samples should be collected ideal prior to starting antibiotics and during fever spike.
   2. Complete blood count - it will help to diagnose sepsis ( increased WBC count, neutrophila). It will also help to assess the severity of the disease ( low platelet, low WBC)
   3. High WBC count is seen in bacterial infections.
   4. Arterial blood gas level- this test is important to know the degree of hypoxia and presence of acid-base balance ( metabolic acidosis is more likely in this case)
   5. Lactate levels. lactate levels > 2mmol/l is suggestive of lactic acidosis
2. Vancomycin 1g/12hrly
   1. In a suspected case of pneumonia, the antibiotics should be started within 1 hour of admission.
   2. It should be started after obtaining blood samples for testing
   3. Vancomycin has good gram-positive coverage. Methicillin-resistant staphylococcus aureus is an important cause of hospital-acquired infections. Vancomycin acts agains MRSA
3. 0.9 N saline 500 ml bolus
   1. This patient has developed hypotension
   2. A fluid challenge is required
   3. If the blood pressure doesn't build up even after the fluid change, inotropic drugs to increase the BP may be required.
4. Insert foleys
   1. This will help to monitor urinary output
   2. This, in turn, will guide in fluid challenge
   3. There is a high chance the patient might develop acute kidney injury. In that case, the urinary output monitor is mandatory.
5. Ct scan - I would keep this option for the last. Rather I would prefer to do CT after the patient stabilizes. The indication of CT in this patient is
   1. non- resolution of X-ray opacities,
   2. non- resolution of fever
   3. suspected thrombo-embolism
   4. to study new-onset effusion /empyema