Question

Scenario in SBAR format. Separate the text into four sections and be ready to explain the reasoning behind your selection.
Location: Bristol Unit 0900

Report from previous shift:

Mr. Robert Josh is a 55-year-old native american male who was admitted to our unit at 0700 this morning after being admitted to the ED at 0200 with a diagnosis of dehydration and hypokalemia. Nurse are monitoring his fluid and electrolyte status closely. Nurse have just received admission orders. Two days ago, he developed abdominal cramping, nausea, vomiting, and severe diarrhea 10 hours after eating lunch at a local restaurant. The symptoms have continued for the past 2 days, and food and fluid intake has been minimal to none since the symptoms began. Last night he nearly passed out while going to the bathroom around 0400. Mr. Josh was brought to the ED by his son, and reported dizziness, weakness, and continued nausea. He received 4 mg zofran IV for nausea in the ED. Lab work was drawn and is available in the patient chart, and urine and stool samples have been sent to the lab. Mr. Josh is drowsy but oriented x 3, appears ill, and is irritable. He reports having a headache, which he rates a 3 on a scale of 0–10, but he hasn't wanted anything for it. Admission weight was 72 kg (161 lb), which the patient reports to be about 4.5 kg (10 lb) less than usual. Vital signs were obtained on admission, including orthostatic blood pressure readings. Heart rate is tachycardic and irregular. He has only taken a few ice chips since admission due to his nausea. The patient had one small liquid stool in the ER. He has not voided or experienced emesis since admission. An IV bolus has been completed and now normal saline is running at 155 mL/hr. Mr. Josh has new IV orders that need to be initiated. Nurse will need to start him on oral antibiotics and potassium when nausea resolves. Provide patient education on safety, his prescribed medications, and intake and output measurement

Answer 1

S-->

Mr. Robert Josh is a 55-year-old native american male is admitted with a diagnosis of dehydration & hypokalemia.

B-->

Patient has been suffering from probable gastroenteritis and/or food poisoning since the past 2 days post having lunch at a

local restaurant.Patient had a episode of presyncope and reported dizziness, weakness, and continued nausea.

A-->

Patient is volume depleted due to continued fluid loss supported by recent unintended weight loss.

Patient is presumably suffering from hyponatremia supported by his headache,nausea and tachycardia.

His arrhythmia can be explained by hypokalemia due to poor food and fluid intake since the past 2 days.

Constipation also supports this assumption as hypokalemia is often accompanied with disturbed function of smooth muscle.

R-->

Patient has low volume hyponatremia.Moderate and/or symptomatic hyponatremia is treated by raising the serum sodium level by 0.5 to 1 mmol per liter per hour for a total of 8 mmol per liter during the first day with the use of furosemide and replacing sodium and potassium losses with 0.9% saline.

Ondansetron should be given for nausea upto 24mg/day but with careful monitoring of ecg as rapid and IV ondansetron

can predispose to arrhythmia.Stool cultures can detect the offending pathogen & assist in choice of antibiotic.

More often than not gastroenteritis is self limiting disease and requires rehydration with ORS salts or IV line for electrolytes

if severe.

Severe hypokalemia (<3.0 mEq/l) may require intravenous supplementation. Typically, a saline solution is used,
with 20–40 meq/l KCl per liter over 3–4 hours. Giving IV potassium at faster rates (20–25 meq/hr) may inadvertently
expose the heart to a sudden increase in potassium, potentially causing dangerous abnormal heart rhythms such as heart block or asystole.
Faster infusion rates are therefore generally only performed in locations in which the heart rhythm can be continuously monitored such as
a critical care unit. When replacing potassium intravenously, particularly when higher concentrations of potassium are used, infusion by a
central line is encouraged to avoid the occurrence of a burning sensation at the site of infusion, or the rare occurrence of damage to the vein.
When peripheral infusions are necessary, the burning can be reduced by diluting the potassium in larger amounts of fluid, or adding a small dose
of lidocaine to the intravenous fluid,although adding lidocaine may increase the likelihood of medical errors.Even in severe hypokalemia,
oral supplementation is preferred given its safety profile. Sustained-release formulations should be avoided in acute settings.

Hypokalemia which is recurrent or resistant to treatment may be amenable to a potassium-sparing diuretic,
such as amiloride, triamterene, spironolactone, or eplerenone. Concomitant hypomagnesemia will inhibit
potassium replacement, as magnesium is a cofactor for potassium uptake.