Relate research from Canadian Nursing. 11pm to 7am hand of report He has been agitated and anxious during the night .He was restless and kept trying to get out of bed. He seemed confused and disoriented . He was moved closer to the nursing station to assist with frequent monitoring . The 0600 vital signs are Temp 38c, P 78, R22, BP 148/88 denies pain. His pulse oximeter reading was 96%(room air) and he has an IV of lactated Ringers infusing at 100ml/hr. Ceftriaxone 1g IV qam is ordered. Subjective Data: Has had a history of painful, frequent urination with passage of small volumes of urine for 3 days Has had an intermittent fever , chills and back pain during these 3 days. Was so frightened when he saw blood in his urine. Is anxious because his father died because of kidney cancer and his mother died of renal failure. Complaints of bilateral flank pain. Objective data: Abdominal tenderness to palpation Temp 38 degrees celsius. Diagnosis studies Urinalysis : Pyuria, hematuria Nursing Care Kardex Mr. M Age: 79 Diagnosis: Urinary Tract Infection and Urosepsis VS q4h Ambulate with assistance prn I&O q8h IV Lactated Ringers 100 ml/hr Bathroom privileges with assistance Diet: soft as tolerated Routine meds: Acetaminophen 500 mg tabs i po q4h for temperature greater than 38 degrees celsius; Ceftriaxone 1 g IVPB qAM as ordered It is now 0730. As you enter his room you notice he is restless and seems disoriented. As you provide morning care to Mr. M you note the following signs and symptoms: VS: T 38.5 C, P 98, R 22, BP 120/76, pulse oximetry 94% Fine crackles audible on auscultation in the bilateral lower lung fields Crackles audible throughout the bilateral lung fields He is sleepy, lethargic He is incontinent of a scant (small) amount of urine Follow up Action plan: Lethargic skin very warm and flushed , vs T 39.1, P130, R 28, BP 90/54, P oximetry 88% based on this new information what are your next steps ? what do you think is going on with Mr M.? What else would you do in this situation with Mr. M? 1.What other options or alternatives would you explore and why for Mr. M? 2. What referrals might you make for Mr. M at this time? 3. Who else on the interprofessional team would you involve in Mr. M’s care? Feedback – Week 8 Points to consider for Mr M: • At 0600 Temp was 38 o There is no documentation that Tylenol was given • Restlessness o Agitated and restless all night – why? o What are your thoughts about why this is happening? Sepsis Urinary retention Fever Dehydration o What should you be considering? Geriatric patient o What should you be assessing? Initiate neuro checks • At 0730 o Temp was 38.5 Did you give Tylenol? o P has gone from 78 to 98 o BP has dropped from 146/88 to 120/76 o Fine crackles audible o Sleepy and lethargic All night was agitated and restless Scant amount of urine o Complete a physical assessment as baseline has been deviated from o What should you be considering as this is an elderly patient? o You should be concerned for this patient Notify physician of change in status • At 1200 Temp was 39.1 o P – 130 o R – 28 o BP – 90/54 o Lethargic, skin warm and flushed o Oximetry 88% o What is happening? o If Tylenol had been given would this situation have developed? • Prepare for transfer to ICU I just added the feedback of the questiaqwon just as a guide.
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