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.
INFORMATION NEEDED:
An 84-year-old female is brought in by family with complaints of increased confusion and lethargy.
Patient usually lives alone and is fully functional.
Son reports that she has been increasingly confused and sleeping a lot at home.
Son denies any fever.
Patient complains of pain “all over” and responds to repeated questions with “I think I’m sick”
She has a DNR status but wants full treatment at this time.
EXAM
BP 105/64, HR 115, RR 24, T 96॰ F, SpO2 92% on room air
Patient is alert and oriented to person, however, thinks the year is 1990
PMH: HTN and Diabetes
Home Med: Metoprolol, Insulin, Lantus 10mg at bedtime, Calcium
NKDA
Initial 12-Lead EKG to assess myocardial function
CBC to assess for leukocytosis (increased WBC) and potential anemia
CMP to assess electrolyte disturbances, liver and renal function. And potential for DKA
Urinalysis to assess for potential UTI
Chest X-ray to assess for infiltrates (pneumonia)
RESULTS OF INDICATED TESTS
Complete Blood Count (CBC)
WBC 3.4 k/UL
Hgb 9.3 g/dL
Hct 28%
Platelets 250 k/UL
Differential
Neutrolphil 90%
Bands 10%
Eosinophil 0%
Basophil 0%
Lymphocyte 2%
Monocyte 3%
Complete Metabolic Panel (CMP)
NA+ 132 mEq/L
K+ 3.7 mEq/L
HCO# 27 mEq/L
Cl- 101 mEq/L
Glucose 1766
BUN 55 mg/dL
Creatinine 2.0 mg/dL
Albumin 3.2g/dL
Alkaline Phosphatase 99 IU/L
ALT 38 IU/L
AST 30 IU/L
Total Bilirubin 2.1 mg/DL
Urinalysis (U/A)
Color: Yellow
Clarity: Dark/Cloudy
Sp gravity 1.042
pH 6.2
Total Protein: Negative
Glucose: Positive
Ketones: Negative
Bilirubin: Negative
RBCS: 10
WBC: 12
Leukocyte Esterase: 3+
Nitrite: Positive
Because the patient has circulatory compromise (hypotension, altered mental status) she is in septic shock.
Septic Shock is a subset of sepsis with circulatory and/or cellular or metabolic dysfunction. Patients will have hypotension, decreased urine output, altered mental status-signs of organ damage
Associated with a higher risk of mortality
Aggressive resuscitation and early initiation of septic protocols are a must
Unformatted Attachment Preview
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 newonset 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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