Question

SBAR HAND OFF REPORT .

What is the next step in the management of the patient

Millie has been hospitalized for several days now and has developed a fever of 102 F with some productive coughing and difficulty breathing. She is also complaining of some pleuritic chest pain when she tries to take a deep breath. Her respiratory rate has increased to 26 breaths per minute, and her heart rate is 60, blood pressure is 98/66 mm Hg, O2 saturation is 90% on 6 L/min oxygen via nasal cannula. When the nurse assessed Millie’s lung sounds, she heard rhonchi and scattered crackles. A chest Xray was obtained, and Millie is diagnosed with hospital-acquired pneumonia. A complete blood count was drawn, and the results show that Millie’s white blood cell count is 22,000. New orders have been obtained from the provider, and Millie is to be transferred to a Special Care Unit (SCU) to monitor her condition more closely. New orders include: Obtain sputum specimen and blood cultures. Oxygen at 6 Liters high flow nasal cannula to keep O2 sat at or above 92% Normal saline intravenous solution at 100 mL/hr Ciprofloxacin (Cipro) 400 mg intravenous mini bag every 12 hours Acetaminophen 650 mg oral every 6 hours prn for fever greater than 101F Ketorolac (Toradol) 30 mg IV prn q 6 hours for pain Albuterol respiratory nebulizer treatments q 4 hours and prn Respiratory monitoring per acute protocol Blood and sputum cultures have been obtained, normal saline is infusing, and the first dose of ciprofloxacin (Cipro) was given. She was given a respiratory treatment by the RT and has not received any pain medication at this time. Millie still has a Foley catheter in place, and her urinary tract infection has resolved, but the provider still wants to strictly monitor her intake and output. Millie is lethargic and appears very ill and still is not eating well or taking in oral fluids as the provider would like. Her intake has only been 300 mL IV fluids, 50 mL oral intake plus sips, and output of 200 mL clear yellow urine. You are the RN to transfer Millie to the Special Care Unit (SCU) and will be giving a handoff report to the receiving RN.

Answer 1

Maintenance of cardiac output and tissue perfusion

• Hemodynamic monitoring (e.g: CVP, CO) via central venous or pulmonary artery pressure , Cardiac output monitoring. An arterial catheter also provides continous montoring of BP and sampling of blood for ABGs
• If the cardiac output falls, it may be necessary to administer crystalloid fluids or colloid solutions or to lower PEEP
• Use of inotropic drugs such as dobutamine or dopamine may be necessary
• Packed red blood cells are used to increase hemoglobin and thus the oxygen carrying capacity of the blood. The hemoglobin level is usually kept around 9-10g/dL with an SpO2 of 90% or more

Maintenance of nutrition and fluid balance is critical for the patients who are in respiratory distress

• Consult with a dietician to determine optimal caloric needs
• Enteral or parentral feedings should be started to meet the high enegy requirements for this patients
• Entric formulas enriched with omega-3 fatty acids may improve the clinical outcomes of this patients
• Monitor hemodynamic parameters(e.g: CVP, stroke, volume variation). Controversy exists as to the benefits of the fluid replacement with crystalloids versus colloids. Critics of colloid replacement believe that proteins in colloids may leak into the pulmonary interstitium increasing the movement of the fluid into the alveoli. Advocates of colloid replacement colloids help keep fluid from leaking into the alveoli
• The patient is often placed on fluid restriction and diuretics as necessary