NRNP 6566F Week 4 Scenario: 84 Year Old Female
NRNP 6566F Week 4 Scenario: 84 Year Old Female
Week 4
Posted on: Monday, March 22, 2021 11:28:26 AM EDT
Greetings Students,
Welcome to week 4.
Great job on your 1st knowledge check. If anyone would like to review, please send me an email and I will be happy to go over your answers.
This week you all will be learning more about arrhythmias, shock and hypertension. Please utilize the information provided under the learning resources.
For your assignments there will be another branching exercise and your second knowledge check. Both of these assignments are due
Please remember to review the rubric and the comments I have made on your previous branching exercise to improve and receive maximum points.
Here is the information for your branching exercise:
84 y/o Female
Code Status: DNR
PMH: HTN, DM
Home meds: Metoprolol/Insulin/ASA/ Calcium
Wt: 62kg, Ht 5’5
NKDA
Critically think about where you would send this patient from the ER and write admissions orders for that unit. Remember to be specific with your orders. Especially with your nursing orders.
Remember Oxygen is a drug. We shouldn’t be placing oxygen on patients just to place it or if they have a normal O2 sat, ie: 94%. If they have an O2 sat of 92% and above O2 is not indicated. Remember if you just put oxygen on a patient routinely, if something really is going on, it could mask a problem that may warrant an investigation.
Please email me with any you have any questions, comments, concerns. If you would like to have a zoom meeting or phone conference, please email me and we can schedule a time.
Best,
Scenario #3 84 year old female
BACKGROUND
- 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”
VITAL SIGNS
- BP 105/64, HR 115, RR 24, T 96°F, SpO2 92% Room Air
- Patient is alert, and oriented to person but thinks is it 1990
- PMH: HTN: Metoprolol
- DM: Insulin
- Other meds: ASA, Calcium
Decision Point One
12 lead EKG, CBC, CMP, urinalysis, Chest x-ray
RESULTS OF DECISION POINT ONE
- Correct!
- Initial 12 lead EKG to assess myocardial function
- CBC to assess WBC and potential anemia
- BMP to assess electrolyte disturbance and potential for DKA
- Urinalysis to assess for potential infection
- Chest x-ray to asses for potential infection
RESULTS OF INDICATED TESTS
Complete Blood Count (CBC)
Hgb 9.3 g/dL
Hct 28%
Platelets 250 k/UL
Differential
Neutrolphil 90%
Bands 10%
Eosinophil 0%
Basophil 0%
Lymphocyte 2%
Monocyte 3%
Basic Metabolic Profile (BMP)
K+ 3.7mEq/L
HCO3 27mEq/L
Cl- 101mEq/L
Glucose 1766 mg/dL
BUN 55 mg/dL
Creatinine 2.0 mg/dL
Urinalysis (U/A)
Clarity Dark/Cloudy
Sp gravity 1.042
pH 6.2
Total Protein negative
Glucose positive
Ketone negative
Bilirubin negative
Hematuria positive
Leuk. Est. +++
Nitrite +++
Decision Point Two
RESULTS OF DECISION POINT TWO
- Urinalysis shows hematuria, positive nitrate, positive leukocyte esterase which all are indicative of a UTI.
- Elderly frequently have a low WBC and low body temperature in the presence infection.
- Chest x-ray is clear and EKG shows tachycardia but no arrhymia or myocardial hyposia.
- The patient remains confused and is becoming more lethargic. Follow up BP is 82/42. Serum lactate level is 4.5. What is your diagnosis now?
Decision Point Three
Guidance to Student
Correct!
SIRS (systemic inflammatory response syndrome) requires the presence of two of the four factors:
• Temperature less than 36.0 C or greater than 38.0 C
• Heart rate greater than 90 BPM
• Respiratory rate > 24 breaths per minute or PaCO2 < 32
• WBC less than 4,000 or greater than 12,000; or Bandemia>10%
Week 4: Hypertension and Shock
Issues with the heating and cooling system of your home can be relatively benign matters that are addressed easily enough with the help of a visiting technician. But in cases of extreme weather conditions or delayed attention, these matters can seriously threaten the health of the home or its occupants.
Similarly, extreme cardiovascular conditions can pose very serious health risks. Hypertension can lead to severe health complications and increase the risk of heart disease, stroke, and sometimes death. Shock can damage the body’s organs and can also be life-threatening. Effective diagnosis and treatment of hypertension and shock can, therefore, be a critically important and even life-saving endeavor.
This week, you will assess and develop management plans for patients with hypertension, including urgent and emergent conditions. You will review how to differentiate shock states and examine hemodynamic values for those shock states when evaluating treatment goals.
Learning Objectives
Students will:
- Distinguish between hypertensive urgencies and emergencies
- Develop a management plan for hypertensive emergencies
- Apply current clinical practice guidelines to address acute and chronic management of hypertension
- Distinguish shock states
- Develop patient treatment plans for shock
- Analyze pharmacologic treatments of shock
- Evaluate normal and abnormal hemodynamic monitoring values
- Develop appropriate treatment plans, including diagnostics and laboratory orders for patients with hypertension and shock
- Identify concepts related to hypertension and shock
Learning Resources
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.
Photo Credit: yodiyim – stock.adobe.com
To prepare:
- Review the interactive media piece/branching exercise provided in the Learning Resources.
- 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.
By Day 7 of Week 4
Submit your completed Assignment by Day 7 of Week 4 in Module 2.
Submission and Grading Information
To submit your completed Assignment for review and grading, do the following:
- Please save your Assignment using the naming convention “MD2Assgn2+last name+first initial.(extension)” as the name.
- Click the Module 2 Assignment 2 Rubric to review the Grading Criteria for the Assignment.
- Click the Module 2 Assignment 2link. You will also be able to “View Rubric” for grading criteria from this area.
- Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “MD2Assgn2+last name+first initial.(extension)” and click Open.
- If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database.
- Click on the Submit button to complete your submission.
Admission orders: Cardiac Case 2 Example
Primary Diagnosis:
Hypertension is the primary diagnosis. Patient is also known to be diabetic.
Status/Condition (Critical, Guarded, Stable, etc.):
The patient walks in the hospital in a stable condition.
Code Status:
The patient is of Do-Not-Resuscitate (DNR) status.
Allergies:
The patient has no known food or drug allergy (NKFDA)
Admit to Unit:
To be admitted to the medical-surgical unit.
Activity Level:
The patient has no restrictions to activity.
Diet:
The patient is on carbohydrate-controlled diet and input output control.
IV Fluids:
- Critical Drips (If ordered, include type and rate. Do not defer to ICU protocol.):
Maintain patent IV access.
0.9% sodium chloride 3-10mls flush in every 12 hours.
0.9% sodium chloride 3-10mls flush before and after every IV drug infusion.
Respiratory: Oxygen (If ordered, include type and rate.), pulmonary toilet needs, ventilator settings:
Oxygen via nasal canula for SPO2 below 92%.
Discontinue for saturation above 93% on RA.
Medications (include ALL, tx of primary condition, underlying conditions, pain, comfort needs, etc., dose and route):
Metoprolol:( 50mg – 400mg/day). 50mg administered twice a day Taken orally after meals. Increase the dose on weekly or longer intervals on need basis.
Insulin: (0.2-0.4 units/kg/day). Administer subcutaneously after measuring the glucose level. Maintain patent IV line for emergency cases. Adjust doses according to blood glucose control.
Aspirin: 162.5mg oral dose once/day. Assess for bleeding disorders and contraindications such as surgery.
Nursing Orders (vital signs, skin care, toileting, ambulation, etc.):
Maintain an input and output record every four hours, blood pressure recording every 4 hours, AC glucose monitoring before every meal and perform daily weight checking (Jian-Hong et al, 2020), prevent falls while in hospital.
Follow-Up Lab Tests:
Perform lipid profile, electrolytes level, kidney function test, BUN, KUB and Creatinine clearance.
Urine protein, urinalysis and urine drug level.
- Diagnostic testing (CXR, US, 2D Echo, etc.):
Cardiac: echocardiogram and EKG.
Consults:
Cardiology consult: hypertensive management
Nutritionist consult: review of diet plan and weight gain
Social worker consult: conducive home-based care before discharge
Pharmacist consult: antihypertensive management
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):
Diet: the patient needs to reduce on sodium related products such as salt that are likely to increase water retention. She is encouraged to take fruits and vegetables, and lower portions of carbohydrates to manage her glucose levels (Whelton et al, 2017).
Medication: She is discouraged on the use of over-the-counter drugs without review of her regimen by the pharmacist. This will intend to reduce cases of toxicity that could stress the kidney. She is also educated on importance of drug compliance, in presence of the primary caregiver.
Lifestyle: Although she is expected to ambulate while at home, precaution by the patient and the caregiver is needed to avoid any skin injury. This could expose the patient to risks of heavy bleeding due to the use of ASA, and poor wound healing due to diabetes. Prevention of falls is also a priority since her old age relates with weak bones due to bone structure breakdown.
Discharge Planning and Required Follow-Up Care:
The patient must be educated on blood pressure measurement with the help of the caregiver and mode of recording. High blood pressure values should be shared for easy identification by the caregiver. The caregiver and the patient are educated on need for compliance since at her age, she is likely to forget medication regimen frequently. The caregiver should also check with the doctor before using any additional drug to avoid possible detrimental interactions.
The patient should avoid caffeine intake, salt intake, and increase potassium rich diets. The caregiver should be educated on compliance on follow-up clinics as directed by the doctor (Franklin & McCoy, 2017). The caregiver should also be aware of signs that warrant immediate medical checkup such as unresponsiveness, sudden confusion, sweating, skin cut or fall, severe headaches and sudden changes in vision.
References
Franklin, M. & McCoy, M. (2017). A transition of care from hospital to home for patients with hypertension: Wolters Kluwer Health. DOI-10.1097/01.NPR.0000511701.94615.4f
Jian-Hong, M., Hai-Shan W., Na, L. (2020). The evaluation of a nurse-led hypertension management model in an urban community healthcare, Medicine: Volume 99 – Issue 27 – p e20967 doi: 10.1097/MD.0000000000020967
Rubric Detail
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Name: NRNP_6566_Module2_Assignment2_Rubric
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List View
Excellent
Point range: 90–100 Good
Point range: 80–89 Fair
Point range: 70–79 Poor
Point range: 0–69
Using the Admission Orders Template, write a full set of admission orders for the patient in the branching exercise. Be sure to address the following:
· Identify the Correct Diagnosis.
5 (5%) – 5 (5%)
The order set includes an accurate and correct diagnosis.
4 (4%) – 4 (4%)
The order set includes a diagnosis that is an appropriate differential diagnosis.
3 (3%) – 3 (3%)
The order set includes a diagnosis that is incorrect and not supported by patient data.
0 (0%) – 2 (2%)
The order set includes and inaccurate / dangerous diagnosis.
· Identify the ‘Status/Condition’, ‘Code Status’, ‘Admit to Unit’
for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set includes an accurate description / plan for condition, code status, and admission location.
4 (4%) – 4 (4%)
The order set includes an accurate description for 2 of the 3 variables.
3 (3%) – 3 (3%)
The order set includes an accurate description for 1 of the 3 variables.
0 (0%) – 2 (2%)
The order set includes inaccurate, missing, or dangerous descriptions for these variables.
· Describe the “Allergies’, ‘Activity Level’ and “Diet” for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set includes an accurate description / plan for allergies, activity level, and diet.
4 (4%) – 4 (4%)
The order set includes an accurate description for 2 of the 3 variables.
3 (3%) – 3 (3%)
The order set includes an accurate description for 1 of the 3 variables.
0 (0%) – 2 (2%)
The order set includes inaccurate, missing, or dangerous descriptions for these variables.
· Identify any ‘IV Fluids’ needed for the patient in the presenting case.
9 (9%) – 10 (10%)
The order set clearly and accurately identifies a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
7 (7%) – 8 (8%)
The order set is missing 1 element of a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
5 (5%) – 6 (6%)
The order set is missing 2 elements of a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
0 (0%) – 4 (4%)
The order set is incomplete, includes wrong / dangerous fluids or flow rate, incorrect parameters for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
· Identify any ‘Respiratory’ needs for the patient in the presenting case. Be specific about oxygen (if ordered, include type and rate), pulmonary toilet needs, and ventilator settings.
5 (5%) – 5 (5%)
The order set clearly and accurately identifies a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
4 (4%) – 4 (4%)
The order set is missing 1 element of a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
3 (3%) – 3 (3%)
The order set is missing 2 elements of a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
0 (0%) – 2 (2%)
The order set is incomplete, includes wrong / dangerous orders, or incomplete parameters for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
· Describe the ‘Medications’ including any IV drips for the patient in the presenting case.
Be specific about medications related to the reason for admission and any chronic medications the patient may be taking (ALL, tx of primary condition, underlying conditions, pain, comfort needs, etc.). Be sure to include name, dose, route of administration, and frequency of each medication.
13 (13%) – 15 (15%)
The order set clearly and accurately identifies a complete set of medication orders for the patient in the presenting case. Orders are complete, account for all conditions, and are appropriate to treat the patient.
10 (10%) – 12 (12%)
The order set clearly and accurately identifies a complete set of medication orders for the patient in the presenting case. There are incomplete orders, missing medications, or missing elements in the orders.
5 (5%) – 9 (9%)
The order set is missing essential elements of a medication order, missing medications, or are inappropriate to treat the patient in the presenting case.
0 (0%) – 4 (4%)
The order set is incomplete, includes wrong / dangerous orders, or inappropriate medications to treat the patient in the presenting case.
· Explain any ‘Nursing Orders’ for the patient in the presenting case. Be specific about vital signs, skin care, toileting, and ambulation.
9 (9%) – 10 (10%)
The order set includes a full set of nursing orders that provide essential direction to provide care, monitor, assess, ensure safety, prevent complications and promote healing.
7 (7%) – 8 (8%)
The order set include inaccurate or is missing 1 or 2 nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
5 (5%) – 6 (6%)
The order set include inaccurate or is missing 3 or 4 nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
0 (0%) – 4 (4%)
The order set include inaccurate, missing, or provides dangerous nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
· Explain the ‘Follow-Up Lab’ tests for the patient in the presenting case. Be specific about diagnostic testing (e.g., CXR, US, 2D Echo, etc.).
9 (9%) – 10 (10%)
The order set includes complete laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
7 (7%) – 8 (8%)
The order set includes most (missing 1 or 2) laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
5 (5%) – 6 (6%)
The order set includes some (missing 3 or 4) complete laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
0 (0%) – 4 (4%)
The order set is missing essential laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
· Explain the ‘Consults’ for the patient in the presenting case. Be specific about how you, as an ACNP, would manage the patient’s acute needs for at least a 24-hour period. Include indication for consult (e.g., “Cardiology consult for evaluation of new-onset atrial fibrillation,” “Nutrition consult for TPN recommendations”).
5 (5%) – 5 (5%)
The order set includes clear, accurate, and essential consults for the patient in the presenting case including complete rationale for the consult.
4 (4%) – 4 (4%)
The order set is missing one of the following: necessary consult, inaccurate information, or inaccurate rationale for consults needed to manage the presenting patient.
3 (3%) – 3 (3%)
The order set is missing 2 or more of the following: necessary consult, inaccurate information, or inaccurate rationale for consults needed to manage the presenting patient.
0 (0%) – 2 (2%)
The order set is missing multiple consults, rations, or accurate descriptions for consults needed to manage the presenting patient.
·.
9 (9%) – 10 (10%)
The order set provides clear, accurate, and complete patient education and health promotion recommendations for the patient in the presenting case.
7 (7%) – 8 (8%)
The order set is missing 1 or 2 essential elements of patient education and health promotion for the patient in the presenting case.
5 (5%) – 6 (6%)
The order set is missing 3 or 4 essential elements of patient education and health promotion for the patient in the presenting case.
0 (0%) – 4 (4%)
The order set is missing multiple essential elements of patient education and health promotion for the patient in the presenting case.
· Explain the ‘Discharge Planning and Required Follow-Up Care’ for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set provides clear, accurate, and complete discharge planning and necessary follow up care for the patient in the presenting case.
4 (4%) – 4 (4%)
The order set is missing 1 or 2 essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
3 (3%) – 3 (3%)
The order set is missing 3 or 4 essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
0 (0%) – 2 (2%)
The order set is missing multiple essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
· Identify a minimum of three ‘References.’ Be sure that they are timely and support the admission order in following current standards of care.
9 (9%) – 10 (10%)
The order set includes a minimum of three professional level references that are timely and clearly support the admission orders following current standards of care. References are formatted in APA format.
7 (7%) – 8 (8%)
The order set does not include a minimum of three professional level references that are timely and clearly support the admission orders following current standards of care. APA format is incorrect.
5 (5%) – 6 (6%)
The order set does not include a minimum of three references or includes non-professional level resources to support their admission order set. APA format is incorrect.
0 (0%) – 4 (4%)
The order set is missing minimum number of references or includes poor sources that do not reflect professional writing or current standard of care information. APA format is not followed.
Written orders include all elements, address all the needs of the patient, are complete, logical, and meets the complete needs of the patient.
5 (5%) – 5 (5%)
Written order set is complete, addresses all the needs of the patient, and are based on current literature.
4 (4%) – 4 (4%)
Written orders are mostly complete only missing 2 essential elements in addressing the needs of the patient.
3 (3%) – 3 (3%)
Written orders are missing 3 to 4 essential elements are reflect an incorrect standard of care.
0 (0%) – 2 (2%)
Written orders are incomplete, do not address the needs of the patient, or reflect an outdated standard of patient care.
Total Points: 100
Name: NRNP_6566_Module2_Assignment2_Rubric
Select Grid View or List View to change the rubric’s layout.
| Excellent Point range: 90–100 | Good Point range: 80–89 | Fair Point range: 70–79 | Poor Point range: 0–69 | |
|---|---|---|---|---|
| Using the Admission Orders Template, write a full set of admission orders for the patient in the branching exercise. Be sure to address the following: · Identify the Correct Diagnosis. | 5 (5%) – 5 (5%) The order set includes an accurate and correct diagnosis. | 4 (4%) – 4 (4%) The order set includes a diagnosis that is an appropriate differential diagnosis. | 3 (3%) – 3 (3%) The order set includes a diagnosis that is incorrect and not supported by patient data. | 0 (0%) – 2 (2%) The order set includes and inaccurate / dangerous diagnosis. |
| · Identify the ‘Status/Condition’, ‘Code Status’, ‘Admit to Unit’ for the patient in the presenting case. | 5 (5%) – 5 (5%) The order set includes an accurate description / plan for condition, code status, and admission location. | 4 (4%) – 4 (4%) The order set includes an accurate description for 2 of the 3 variables. | 3 (3%) – 3 (3%) The order set includes an accurate description for 1 of the 3 variables. | 0 (0%) – 2 (2%) The order set includes inaccurate, missing, or dangerous descriptions for these variables. |
| · Describe the “Allergies’, ‘Activity Level’ and “Diet” for the patient in the presenting case. | 5 (5%) – 5 (5%) The order set includes an accurate description / plan for allergies, activity level, and diet. | 4 (4%) – 4 (4%) The order set includes an accurate description for 2 of the 3 variables. | 3 (3%) – 3 (3%) The order set includes an accurate description for 1 of the 3 variables. | 0 (0%) – 2 (2%) The order set includes inaccurate, missing, or dangerous descriptions for these variables. |
| · Identify any ‘IV Fluids’ needed for the patient in the presenting case. | 9 (9%) – 10 (10%) The order set clearly and accurately identifies a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case. | 7 (7%) – 8 (8%) The order set is missing 1 element of a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case. | 5 (5%) – 6 (6%) The order set is missing 2 elements of a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case. | 0 (0%) – 4 (4%) The order set is incomplete, includes wrong / dangerous fluids or flow rate, incorrect parameters for IV fluid type, flow rate, and administration parameters for the patient in the presenting case. |
| · Identify any ‘Respiratory’ needs for the patient in the presenting case. Be specific about oxygen (if ordered, include type and rate), pulmonary toilet needs, and ventilator settings. | 5 (5%) – 5 (5%) The order set clearly and accurately identifies a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case. | 4 (4%) – 4 (4%) The order set is missing 1 element of a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case. | 3 (3%) – 3 (3%) The order set is missing 2 elements of a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case. | 0 (0%) – 2 (2%) The order set is incomplete, includes wrong / dangerous orders, or incomplete parameters for respiratory care, delivery method, treatments and parameters for the patient in the presenting case. |
| · Describe the ‘Medications’ including any IV drips for the patient in the presenting case. Be specific about medications related to the reason for admission and any chronic medications the patient may be taking (ALL, tx of primary condition, underlying conditions, pain, comfort needs, etc.). Be sure to include name, dose, route of administration, and frequency of each medication. | 13 (13%) – 15 (15%) The order set clearly and accurately identifies a complete set of medication orders for the patient in the presenting case. Orders are complete, account for all conditions, and are appropriate to treat the patient. | 10 (10%) – 12 (12%) The order set clearly and accurately identifies a complete set of medication orders for the patient in the presenting case. There are incomplete orders, missing medications, or missing elements in the orders. | 5 (5%) – 9 (9%) The order set is missing essential elements of a medication order, missing medications, or are inappropriate to treat the patient in the presenting case. | 0 (0%) – 4 (4%) The order set is incomplete, includes wrong / dangerous orders, or inappropriate medications to treat the patient in the presenting case. |
| · Explain any ‘Nursing Orders’ for the patient in the presenting case. Be specific about vital signs, skin care, toileting, and ambulation. | 9 (9%) – 10 (10%) The order set includes a full set of nursing orders that provide essential direction to provide care, monitor, assess, ensure safety, prevent complications and promote healing. | 7 (7%) – 8 (8%) The order set include inaccurate or is missing 1 or 2 nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing. | 5 (5%) – 6 (6%) The order set include inaccurate or is missing 3 or 4 nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing. | 0 (0%) – 4 (4%) The order set include inaccurate, missing, or provides dangerous nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing. |
| · Explain the ‘Follow-Up Lab’ tests for the patient in the presenting case. Be specific about diagnostic testing (e.g., CXR, US, 2D Echo, etc.). | 9 (9%) – 10 (10%) The order set includes complete laboratory and diagnostic testing to adequately monitor and assess the presenting patient. | 7 (7%) – 8 (8%) The order set includes most (missing 1 or 2) laboratory and diagnostic testing to adequately monitor and assess the presenting patient. | 5 (5%) – 6 (6%) The order set includes some (missing 3 or 4) complete laboratory and diagnostic testing to adequately monitor and assess the presenting patient. | 0 (0%) – 4 (4%) The order set is missing essential laboratory and diagnostic testing to adequately monitor and assess the presenting patient. |
| · Explain the ‘Consults’ for the patient in the presenting case. Be specific about how you, as an ACNP, would manage the patient’s acute needs for at least a 24-hour period. Include indication for consult (e.g., “Cardiology consult for evaluation of new-onset atrial fibrillation,” “Nutrition consult for TPN recommendations”). | 5 (5%) – 5 (5%) The order set includes clear, accurate, and essential consults for the patient in the presenting case including complete rationale for the consult. | 4 (4%) – 4 (4%) The order set is missing one of the following: necessary consult, inaccurate information, or inaccurate rationale for consults needed to manage the presenting patient. | 3 (3%) – 3 (3%) The order set is missing 2 or more of the following: necessary consult, inaccurate information, or inaccurate rationale for consults needed to manage the presenting patient. | 0 (0%) – 2 (2%) The order set is missing multiple consults, rations, or accurate descriptions for consults needed to manage the presenting patient. |
| · Explain the ‘Patient Education and Health Promotion’ for the patient in the presenting case. Be sure to address age-appropriate patient education, if applicable. | 9 (9%) – 10 (10%) The order set provides clear, accurate, and complete patient education and health promotion recommendations for the patient in the presenting case. | 7 (7%) – 8 (8%) The order set is missing 1 or 2 essential elements of patient education and health promotion for the patient in the presenting case. | 5 (5%) – 6 (6%) The order set is missing 3 or 4 essential elements of patient education and health promotion for the patient in the presenting case. | 0 (0%) – 4 (4%) The order set is missing multiple essential elements of patient education and health promotion for the patient in the presenting case. |
| · Explain the ‘Discharge Planning and Required Follow-Up Care’ for the patient in the presenting case. | 5 (5%) – 5 (5%) The order set provides clear, accurate, and complete discharge planning and necessary follow up care for the patient in the presenting case. | 4 (4%) – 4 (4%) The order set is missing 1 or 2 essential elements of discharge planning and necessary follow up care for the patient in the presenting case. | 3 (3%) – 3 (3%) The order set is missing 3 or 4 essential elements of discharge planning and necessary follow up care for the patient in the presenting case. | 0 (0%) – 2 (2%) The order set is missing multiple essential elements of discharge planning and necessary follow up care for the patient in the presenting case. |
| · Identify a minimum of three ‘References.’ Be sure that they are timely and support the admission order in following current standards of care. | 9 (9%) – 10 (10%) The order set includes a minimum of three professional level references that are timely and clearly support the admission orders following current standards of care. References are formatted in APA format. | 7 (7%) – 8 (8%) The order set does not include a minimum of three professional level references that are timely and clearly support the admission orders following current standards of care. APA format is incorrect. | 5 (5%) – 6 (6%) The order set does not include a minimum of three references or includes non-professional level resources to support their admission order set. APA format is incorrect. | 0 (0%) – 4 (4%) The order set is missing minimum number of references or includes poor sources that do not reflect professional writing or current standard of care information. APA format is not followed. |
| Written orders include all elements, address all the needs of the patient, are complete, logical, and meets the complete needs of the patient. | 5 (5%) – 5 (5%) Written order set is complete, addresses all the needs of the patient, and are based on current literature. | 4 (4%) – 4 (4%) Written orders are mostly complete only missing 2 essential elements in addressing the needs of the patient. | 3 (3%) – 3 (3%) Written orders are missing 3 to 4 essential elements are reflect an incorrect standard of care. | 0 (0%) – 2 (2%) Written orders are incomplete, do not address the needs of the patient, or reflect an outdated standard of patient care. |
| Total Points: 100 |
|---|
Admission Orders Sample Paper
Introduction.
A 68-year-old female is brought to the hospital from the acute rehabilitation facility. She complains of shortness of breath and a productive cough. The symptoms have been there for the past one week. The patient was started on ciprofloxacin three days, but her condition has just worsened. The patient is hypertensive and has a history of hypothyroidism. She recently underwent knee replacement surgery about two weeks ago. She is currently on lisinopril, ciprofloxacin and rivaroxaban. She is presently experiencing fever, chills, productive cough with green purulent sputum, and worsening shortness of breath. On examination, her vitals are recorded as T 102.6, HR 92, RR 22, and BP 128/82. Oxygen saturation is recorded as 96% on four liters of oxygen. A chest X-ray done indicates consolidation in the right lower lobe. The patient’s CBC and CMP are within the normal range. This essay aims to write down admission orders for this patient.
Treatment of the patient.
I would immediately discontinue the ciprofloxacin and initiate piperacillin/tazobactam, 5g IV every six hours, tobramycin, 5mg/kg IV every 24 hours, and vancomycin, 15mg/kg every 12 hours. The patient meets the criteria for hospital-acquired pneumonia (HAP). This is because of her surgery two weeks prior and her inpatient admission at the rehabilitation facility. A chest X-ray done shows a consolidated right lower lobe. This further increases the risk of a diagnosis of pneumonia. It is important to commence a three-drug combination for broad-spectrum coverage until a culture and sensitivity report of the patient’s sputum is available to begin de-escalation of antibiotics. This is because the patient is at risk of drug-resistant bacteria and MRSA.
In 2007, the Infectious Diseases Society of America and the American Thoracic Society guidelines defined treatment based on the population at risk of infection with antibiotic-resistant pathogens. The current recommendations established in 2016 propose using narrower spectrum antibiotics in instances where it is possible. The recommended drugs for use in institutions where MRSA incidence is below 20%, and there is prior IV antibiotic use within 90 days are piperacillin/tobramycin, cefepime, levofloxacin, imipenem, and meropenem (Martin-Loeches et al., 2018). In instances where the MRSA rate is more than 20%, and there is a great risk of antibiotic-resistant micro-organisms, the following drugs are recommended. A beta lactam/lactamase inhibitor such as piperacillin or tazobactam is recommended, an aminoglycoside such as amikacin, tobramycin, and finally, either linezolid or vancomycin are recommended in such instances. Although this indiscriminate use of antibiotics is a major predisposing factor for antibiotic resistance, it is recommended to commence treatment with these broad-spectrum drugs and later narrow down depending on the response to treatment and results obtained from further tests, such as culture and antibiotic susceptibility.
Adjustments to make.
Adjustments to make include the discontinuation of tobramycin and vancomycin. The patient should be continued on piperacillin/tazobactam. The sensitivity report obtained indicates that the bacteria cultured from the patient’s sputum and blood is sensitive to piperacillin/tazobactam. Continuation of piperacillin/tazobactam and discontinuation of the other antibiotics provide good coverage for the patient’s condition. A full ten-day course is indicated.
As indicated earlier, the use of broad-spectrum drugs increases the risk of antibiotic resistance. It is important to narrow down these antibiotics as soon as the results recommend it. In this case, results obtained from sputum and blood culture show that the causative agent is susceptible to piperacillin/tazobactam. It is therefore advisable to discontinue the other antibiotics. Piperacillin/tazobactam is sold under the brand name Zosyn and is administered via the intravenous route. It is very effective against gram-negative organisms, including pseudomonas aeruginosa, gram-positive organisms, and anaerobic organisms (Huang et al., 2022). It is effective in managing gastrointestinal infections, skin infections, uterine infections, and pneumonia. Discontinuing the other medications is vital in minimizing the risk of antibiotic resistance.
Care Management.
As the patient’s condition is improving, she requests that the IV be removed and that she be discharged. It is crucial to place a peripherally inserted central catheter and carry out an assessment to determine whether discharging her or transferring her back to the rehabilitation facility is a safe option. It is essential to evaluate whether she can safely continue and complete her ten-day treatment course in such a setting. Continued inpatient hospitalization is unnecessary in situations where there are resources at home or in the other facility to continue treatment.
Conclusion.
Hospital-acquired pneumonia (HAP) is one of the commonly observed conditions. It is advisable to commence antibiotic administration as soon as possible. Appropriate antibiotics are recommended for a seven-day period that is adjusted depending on the patient’s response to treatment (Roquilly et al., 2021). Broad-spectrum antibiotics should be initially used. These antibiotics are narrowed down depending on the results obtained from tests such as sputum culture and blood and antibiotic susceptibility. Dose adjustment is important as it minimizes the risk of antibiotic resistance. Before discharging patients, it is crucial to assess whether administration of the antibiotics will be possible in the setting that the patient is transferred to.
References.
Huang, C. T., Chen, C. H., Chen, W. C., Wang, Y. T., Lai, C. C., Fu, P. K., Kuo, L. K., Chen, C. M., Fang, W. F., Tu, C. Y., & Ku, S. C. (2022). Clinical effectiveness of cefoperazone-sulbactam vs. piperacillin-tazobactam for the treatment of pneumonia in elderly patients. International Journal Of Antimicrobial Agents, 59(1), 106491. https://doi.org/10.1016/j.ijantimicag.2021.106491
Martin-Loeches, I., Rodriguez, A. H., & Torres, A. (2018). New guidelines for hospital-acquired pneumonia/ventilator-associated pneumonia: USA vs. Europe. Current Opinion In Critical Care, 24(5), 347–352. https://doi.org/10.1097/MCC.0000000000000535
Roquilly, A., Chanques, G., Lasocki, S., Foucrier, A., Fermier, B., De Courson, H., Carrie, C., Danguy des Deserts, M., Gakuba, C., Constantin, J. M., Lagarde, K., Holleville, M., Blidi, S., Sossou, A., Cailliez, P., Monard, C., Oudotte, A., Mathieu, C., Bourenne, J., Isetta, C., … Leone, M. (2021). Implementation of French Recommendations for the Prevention and the Treatment of Hospital-acquired Pneumonia: A Cluster-randomized Trial. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 73(7), e1601–e1610. https://doi.org/10.1093/cid/ciaa1441
NRNP 6566 WEEK 7 KNOWLEDGE CHECK
- Question 1
Needs Grading
| A patient is admitted to the ICU with severe necrotizing pancreatitis. Three hours after admission his oxygen saturations decreased and he was intubated for hypoxia. Initially his oxygen saturation improved to 94% on FiO2 of 50% but over the past two hours his FiO2 has been increased to 70% and his saturation is 89%. The patient is on 5 cm H2O of PEEP. His current ABG shows pH 7.34, pCO2 36, PO2 61, HCO3 21 on an FIO2 of 80%. The patient’s repeat chest x-ray shows diffuse bilateral opacities in a pattern consistent with pulmonary edema. An echo earlier today was read as normal. How would you explain his worsening oxygen status? | ||||
| Selected Answer: Based on the presentation, the patient may be experiencing an acute respiratory distress syndrome (ARDS) given that he had a normal echo result in the morning. Further, pulmonary edema revealed in his recent repeat xray alongside the pO2 and FiO2 rations further indicate a possible ARDS. To improve the patient’s oxygenation, the initial response should be to increase FiO2 and PEEP. The PEEP will help keep alveoli open and prevent closure of small airways. However, should the intervention fail to improve pO2 levels, consider lowering the PEEP value as higher PEEP may hinder venous return, which may affect the patient’s cardiac output and blood pressure. Correct Answer: | ||||
- Question 2
Needs Grading
| A 34 year ole email who weights 96 kg (211 lbs.) and is 165 cm (5 ft. 6 inches) tall has chest trauma due to a motorcycle accident. The patient has just been intubated, sedated and paralyzed with morphine sulfate and pancuronium bromide. What initial ventilator settings are appropriate for this patient? | ||||
| Selected Answer: Calculate the patient’s ideal body weight using the formula Men = {(Height in inches – 60)x 2.2} + 50. His ideal weight will thus be {(66 in – 60) x 2.2} + 50 = 63.2 kgs. The tidal volume based on n average of 8-10 ml per kg is 500 to 600 ml. FiO2 is initially at 100% and should be lowered based on patient response. Start PEEP at 5. You may start Rate at 12. Consider ABG post intubation and make any necessary adjustments. Correct Answer: | ||||
- Question 3
Needs Grading
| A 61 year old woman was intubated three days ago for respiratory failure secondary to pneumonia and sepsis. She is on antibiotics and is now off all vasopressors. Her WBC is declining to a normal range. She is currently on 40% FIO2 with 5 cm H20 of PEEP. Her current ABG shows pH 7.35, pCO2 45, PO2 76, HCO3 25. She has a weak cough and copious secretions that required suctioning every 30-60 minutes. How do you determine if the patient is capable of being separated from the ventilator? | ||||
| Selected Answer: Certain conditions must be met to determine if the patient is ready to be weaned off the ventilator. First, there must be signs that the patient’s underlying conditions has improved. Secondly, the patient should be able to maintain oxygenation without support, with a pO2 value of more than 80 and lower PEEP and FiO2 levels as the indicators. Further, the patient should record and maintain an acid balance rate of less than 12 liters per minute. During weaning, it is advisable to place the patient on a spontaneous breathing trial to assess their ability to breath with minimal or zero ventilator support. To pass the trial, the patient must have stable vital signs, including heart rate, saturation rate, blood pressure, and improved oxygenation rate. Other indicators include stable CO2 level based on ABG and adequate ventilatory capacity. Eventually, for the patient to qualify for extubation, they must not have any upper airway condition must be able to cough and clear secretions without sunctioning must be able to protect themselves from aspiration. Correct Answer: | ||||
- Question 4
Needs Grading
| A 59 year old man was admitted to the ICU for a COPD exacerbation. He was intubated earlier in the day. Initially after being intubated his static pressure was 23 cm H2o and peak pressure 47 cm H20. The APRN is notified that currently his peak pressure has risen to 62 cm H20 and the static pressure is 42 cm H20. His heart rate has increased from 88 to 112beats / minute and his blood pressure has decreased from 112/88 to 92/ 72. He has decreased breath sounds on the left side. What management steps should you institute at this point? | ||||
| Selected Answer: At this point, consider initiating the patient on CXR/ spiral CT with contrast, and if necessary, with labs drawn in order to determine the cause of the observed abnormal vital signs as well as the newly decreased breath sounds registered on his left side. Correct Answer: | ||||
- Question 5
Needs Grading
| The APRN is monitoring a newly intubated patient. He appears to be very anxious and “fighting” the ventilator. What would be the most appropriate action? | ||||
| Selected Answer: Consider removing the patient from the vent and bag then with 100% FiO2 then reassess vent function. Be sure to check the endotracheal tube as well as the dislodgement or displacement. Use the DOPE mnemonic (displacement, obstruction, pneumothorax and equipment failure) to make assessments. Also try reassuring the patient to reduce their anxiety. You may also consider sedation if deemed appropriate. Correct Answer: | ||||
- Question 6
Needs Grading
| A patient with respiratory failure has hemodynamic monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP) of 10 cm H2O. Which information indicates that a change in the ventilator settings may be required? a. The arterial line shows a blood pressure of 90/46. b. The pulmonary artery pressure (PAP) is decreased. c. The cardiac monitor shows a heart rate of 58 beats/min. d. The pulmonary artery wedge pressure (PAWP) is increased. | ||||
| Selected Answer: Since the arterial line shows a BP of 90/46, the hypotension indicates indicates an elevated intrathoracic pressure likely due to the PEEP. The appropriate intervention is to decrease the PEEP, which in turn will increase venous return, resulting in improved cardiac output. Correct Answer: | ||||
- Question 7
Needs Grading
| Four hours after mechanical ventilation is initiated for a patient with chronic obstructive pulmo-nary disease (COPD), the patient’s arterial blood gas (ABG) results include a pH of 7.50, PaO2 of 80 mm Hg, PaCO2 of 29 mm Hg, and HCO3- of 23 mEq/. What change in ventilator settings would be indicated? | ||||
| Selected Answer: Evidently, the patient is experiencing acute respiratory alkalosis that is uncompensated for. This is indicated by the low PaCO2 level that is below the normal range of 35-45 mmHg. The reduced PaCO2 value leads to increased blood alkalinity. To address this problem, compensate for it by reducing the amount of air the patient takes in per minute. To achieve this, decrease the respiratory rate reduce the breathing tidal volume. Also, if possible, facilitate excretion of body bicarbonate to compensate for the acute respiratory alkalosis. The essential respiratory setting is reduced respiratory rate and reducing the tidal volume. Correct Answer: | ||||
- Question 8
Needs Grading
| A 59 year old man was admitted to the ICU for a COPD exacerbation. He was intubated earlier in the day. Initially after being intubated his static pressure was 23 cm H2o and peak pressure 47 cm H20. The APRN is notified that currently his peak pressure has risen to 62 cm H20 and the static pressure is 42 cm H20. His heart rate has increased from 88 to 112beats / minute and his blood pressure has decreased from 112/88 to 92/ 72. He has decreased breath sounds on the left side. Where do you think the problem lies with this particular patient? | ||||
| Selected Answer: Given the patient’s increased peak pressure and statistic pressure, he is likely having a change in the compliance of his respiratory system. The cause of the altered compliance is likely to be tension pneumothorax, as evidenced by diminished breath sounds on the left, tachycardia and hypotension. Correct Answer: | ||||
- Question 9
Needs Grading
| A 59 year old man was admitted to the ICU for a COPD exacerbation. He was intubated earlier in the day. Initially after being intubated his static pressure was 23 cm H2o and peak pressure 47 cm H20. The APRN is notified that currently his peak pressure has risen to 62 cm H20 and the static pressure is 42 cm H20. His heart rate has increased from 88 to 112beats / minute and his blood pressure has decreased from 112/88 to 92/ 72. He has decreased breath sounds on the left side. What do static and peek pressures represent on the ventilator? | ||||
| Selected Answer: Static pressure indicates respiratory system compliance (that is, lungs, chest wall and the abdomen). It shows how much pressure it takes to inflate the alveoli with each breath. Any condition that results in reduced compliance, such as onset ARDS, will produce an increased static pressure. Peak pressure, on the other hand, indicates the resistance of the segmental bronchi of the ventilator tube system. Essentially, any problem that alters the resistance of these tubes, such as bronchospasm or blood clots, will increase the maximum pressure. Correct Answer: | ||||
- Question 10
Needs Grading
| A patient is admitted to the ICU with severe necrotizing pancreatitis. Three hours after admission his oxygen saturations decreased and he was intubated for hypoxia. Initially his oxygen saturation improved to 94% on FiO2 of 50% but over the past two hours his FiO2 has been increased to 70% and his saturation is 89%. The patient is on 5 cm H2O of PEEP. His current ABG shows pH 7.34, pCO2 36, PO2 61, HCO3 21 on an FIO2 of 80%. The patient’s repeat chest x-ray shows diffuse bilateral opacities in a pattern consistent with pulmonary edema. An echo earlier today was read as normal. What can you do to improve his oxygenation? | ||||
| Selected Answer: To improve oxygenation, consider increasing the PEEP pressure to help open the alveoli and prevent the closure of small airways, an intervention that is effective in ARDS, pulmonary edema or alveoli hemorrhage. However, note that high PEEP pressure may distant the capillaries and result in in impaired venous return, which may in turn decrease the cardiac output. Be sure to monitor PaO2 and SaO2 to ensure that the patient if getting enough oxygen to to prevent the mentioned complications. Correct Answer: | ||||
