Question

Grace Santos is a 45-year-old female patient admitted to hospital 3 days ago with a diagnosis of pneumonia. IV access was initiated 74 hours ago. The RN used a 20 g cathlon and was successful on her 2nd attempt at initiation. The IV is insitu in the right forearm.
Grace has been on IV antibiotics now for 72 hours and has shown great improvement.
Grace has been receiving cefuroxime 750 mg IV q8h x 5 days.
Grace is allergic to penicillin and has experienced an anaphylactic reaction in the past.
Grace has no significant medical hx and takes no prescribed medications.
This morning her WBC count was within normal limits and her respiratory status had improved.
However, over the last 4 hours you have noticed her respiratory status has declined, she is sitting up in orthopneic position, and you have auscultated coarse crackles to the bases of both lungs. Her O2 sats are now 90% on RA. Her BP is 145/80, HR 100 and RR 26. Her temp is 37o C.
Her IV has been infusing at 150 mL/hr now for the past 3 days. Grace had her last dose of IV antibiotics at 0600.
The secondary line is still hanging with the last empty bag of antibiotics still hanging.
The IV pump was cleared at 0600 before her dose of antibiotics.
The primary and secondary tubing are labeled.
The tubing was originally primed 74 hours ago.
The bag of NS is labeled. It is 0700 and your 12-hour shift has just begun.
Her urine output has decreased and the following physician orders have been received:
Furosemide 40 mg IV stat
Ventolin 2.5 mg by nebulizer q2h PRN
Saline lock IV between antibiotic doses
Strict intake and output
Daily weight
CBC
electrolytes
O2 to keep sats above 92%

What do you think is happening?
What other assessments will you need to make?
How will you collaborate with the RN?

Documentation required:
 24 hour fluid balance record – complete for your shift
 focus charting:
o initial assessment completed at 0730
o any follow up assessments related to medication administration
 MAR
Other Data:
Intake:
 0800 – 1 cup coffee, 4 oz milk
 1000 – 12 oz water
 1200 – 1 cup tea, 120 mL jello.
 1400 - 12 oz water
 1700 – 1 cup milk
Output:
 0630 – urine – 50 mL
 0900 – urine – 600 mL
 1000 – urine – 500 mL
 1200 – urine – 550 mL
 1330 – urine – 450 mL
 1600 – urine – 350 mL
 1800 – urine – 300 mL

Answer 1

Q1) What do you think is happening?

Ans: Looking at present scenarios,we can conclude that she might be suffering from the problem of dehydration, underlying respiratory disorders.

* As her blood pressure is also high from last few hours, and she is already diagnosed from ammonia.

* Urine output has decreased in recent time, and O2 saturation was also decreased to 90% , so these problems basically are root cause for her condition.

* Another reason for her bad condition recently could be the adverse effects caused by the drugs of Pneumonia Treatment.

Q2) What other assessments would you need to make?

Ans : Assessments Required-

A) Her O2 saturation needs to be checked on consistent basis.

B) Her intake and output of fluids,needs to be checked atleast thrice in a day.

C) As she is again feeling discomfort, electrolyte balance needs to be checked.

D) Complete blood count is also an very important parameter to be checked.

E) As she is diagnosed for Pneumonia full antibiotics course should be given to her.

F) Her daily weight needs to be assessed so that a proper treatment can be given to her.

Q3) How Will you collaborate with the RN?

Ans: Collaboration with the Registered Nurse is very important so that :

A) Her underlying disease could be treated properly.

B) We need to conduct her all medical tests daily and the results shall immediately be reported to the registered nurse

C) After evaluating her intake/ output of fluids, all her conditions must be compiled in front of the registered nurse.

D) Her prescribed medications must be accordingly given under the surveillance of the registered nurse.

E) Her BP and oxygen saturation must be watched carefully and same must be performed under the strict observation of the registered nurse.