Description
Review the interactive media under Required Media: Branching exercise. This is provided in the Learning Resources.
Review the information provided in the case (patient presentation, vital signs, pmh, home meds, results of labs and diagnostics. With this information, critically think about what is happening with the patient.
Use your critical thinking skills and current guidelines to develop orders. Include additional labs/diagnostics, what needs repeated and followed up on. Medications that need to be ordered or changed.
The Assignment:
Using the required admission orders template found under the Learning Resources: Required Reading.
Develop a set of orders as the admitting provider.
Be sure to address each aspect of the order template
Write the orders as you would in the patient’s chart. Be specific. Do not leave room for the nurse to interpret your orders.
Do not assume anything has already been done/order. Use the information given. Example: If the case does not mention fluids were given, the patient did not receive fluids. You may have to start from scratch as if you are working in the ER. And you must provide orders if the patient needs to be admitted.
Make sure the order is complete and applicable to the patient.
Make sure you provide rationales for your labs and diagnostics and anything else you feel the need to explain. This 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 the appropriate standard of care for this patient.
A minimum of three current (within the last 5 years), evidenced based references are required.
Required Media: Branching exercise:
BACKGROUND
A 68-year-old female is brought to the hospital from the acute rehabilitation facility with complaints of shortness of breath and productive cough for 1 week. She was started on ciprofloxin 3 days ago, but her symptoms have continued to worsen. Her past medical history includes hypertension, hypothyroidism. She underwent a right knee replacement 2 weeks ago. Current medications include lisinopril 10mg, levothyroxine 75mcg, rivaroxaban 10mg daily and ciprofloxacin 500mg Q12. Her current symptoms include fever, chills, productive cough with purulent green sputum, and worsening shortness of breath. She is allergic to morphine. The patient is a full code. EXAM
Current vital signs T 102.6 HR 92. RR 22 BP 128/82. O2 saturation is 96% on 4L of O2
Chest x-ray shows consolidation in the right lower lobe.
CBC and CMP are all within normal limits.
This patient meets the criteria for hospital acquired pneumonia (HAP) due to her surgery 2 weeks ago and inpatient stay at the rehabilitation facility. She is at risk of drug resistant bacteria and MRSA. . A three-drug combination for broad spectrum coverage is indicated until culture and sensitivity report on her sputum is available and antibiotic de-escalation can occur. The patient’s culture and sensitivity report for sputum and blood culture is now available. Staph aureus grew from the sputum culture. Utilizing this information, what adjustments to the patients’ antibiotics would you make for admission?
The sensitivity report indicates that the bacteria in the sputum and blood is sensitive to piperacillin/tazobactam. Continuing it and discontinuing the other antibiotics will still provide good coverage for this infection.
The patient requires oxygen to maintain her O2 saturation at the low normal range. The safest option for the patient is to admit her to make sure her oxygen requirements do not need increasing with further intervention. A PICC can be placed for antibiotic therapy.
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Admission Orders Template
Primary Diagnosis:
Status/Condition (Critical, Guarded, Stable, etc.):
Code Status:
Allergies:
Admit to Unit:
Activity Level:
Diet:
IV Fluids:
•
Critical Drips (If ordered, include type and rate. Do not defer to ICU protocol.):
Respiratory: Oxygen (If ordered, include type and rate.), pulmonary toilet needs, ventilator settings:
Medications (include ALL, tx of primary condition, underlying conditions, pain, comfort needs, etc., dose and route):
Nursing Orders (vital signs, skin care, toileting, ambulation, etc.):
Follow-Up Lab Tests:
•
Diagnostic testing (CXR, US, 2D Echo, etc.):
Consults:
NOTE: (Do not defer management to a specialist. As an ACNP, you must manage the patient’s acute needs for at least a
24-hour period]. Include indication for consult. For example: “Cardiology consult for evaluation of new-onset atrial
fibrillation,” or “Nutrition consult for TPN recommendations.”
Patient Education and Health Promotion (address age-appropriate patient education. if applicable):
Discharge Planning and Required Follow-Up Care:
References (minimum of three timely references that prove this plan follows current standards of care):
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