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Augusta University *

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7930

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Nursing

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May 24, 2024

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Augusta Technical College SBAR/Care Plan Student Name Clinical Date S ituation Patient’s Age Range Code Status Admission Date Allergies NKA Primary Medical Diagnosis Peritonitis, infrarenal abdominal aneurysm without rupture, acute hyperkalemia, end stage renal disease on dialysis, sepsis Pathophysiology of Medical Diagnosis: Peritonitis happens when the abdomen becomes inflamed this can be due to infection (Mayo Foundation for Medical Education and Research, 2022). Infrarenal abdominal aneurysm without rupture is thought to be the cause of smoking and high blood pressure. This aneurysm results in an abnormal widening or bulging and is located below the kidneys (Russel, 2022). Hyperkalemia occurs when potassium excretion is limited by reduction of glomerular filtration rate (Hunter & Bailey, 2019). This causes increased potassium release from the cells. End stage renal disease on dialysis is a condition when the kidneys stop functioning on a permanent basis leading to long term dialysis (Ignatavicius, et al., 2021). Sepsis compromises blood flow to organs and tissues triggering a inflammation reaction by an infection. Three most common complications based on patient’s Diagnosis, Surgery or Procedure: 1) High potassium level 2) Infection 3) Pain Background Pre-hospital/ ER Care Patient presents to the ED with abdominal pain in his left lower quadrant, constipation, and no bowel movement in 5 days. Patient also has right lower back pain. While sitting in the ED, patient noted left calf swelling and redness. Procedures done in the ED were body fluid culture with gram stain and no noted results were documented, during my shift. Summary Course of Stay Patient came to the ED for abdominal pain in LLQ, constipation and RLB pain. Patient is presented with edema and redness in the left calf. Patient was scheduled for vascular surgery for the aneurysm, but due to the edema in the calf surgery was postponed. Patient’s blood pressure has dropped and was refusing medication because he stated it made him nauseous. The doctor prescribed ondansetron PRN for nausea and patient complains this did not help last night. Patient was educated on the importance of taking blood pressure medication and agreed to try it again. Patients’ blood pressure became stable. Vital signs were monitored and blood pressure dropped again during my shift. Patient’s nurse was notified. Carvedilol was held and midodrine given. Past Medical History Chronic kidney disease stage 4, congestive heart failure (CHF), coronary artery disease, end stage renal disease on hemodialysis, history of atrial flutter, history of cardio test, history of echocardiogram, hyperlipidemia, ischemic cardiomyopathy, myocardial infarction, sepsis, nonrheumatic mitral valve regurgitation, pulmonary hypertension (HTN), status post amputation of right great toe, tobacco use

Surgical History 2/1/2023: hemodialysis central line tunneled cath right chest removed 6/9/2022: insertion central line tunnel cath 5/20/2022: ablation-atrial flutter (right) 12/15/2006: cardiac cath-completed. Anterior wall infarction, residual ischemic cardiomyopathy, severe EF 25% 5/3/2022: dialysis fistula creation 8/10/2020: laparoscopic insertion peritoneal dialysis cath 12/14/2022: laparoscopic insertion peritoneal dialysis cath 6/9/2022: removal peritoneal dialysis cath 12/14/2022: repair incisional hernia 8/10/2020: repair umbilical hernia A ssessment Vital Signs MORNING 0815 AFTERNOON 1600 Temp 96.5°F (35.8°C) Temp 95°F (35°C) Pulse 63 Pulse 79 RR 24 Visual RR 20 visual BP 89/61 (72) BP 91/62 (72) O 2 Sat 93% 2L O 2 Sat 96% 2L Pain Pain Head-to-toe Assessment Findings Neuro Patient is in the bed, awake most of the day. Alert and oriented x4. Speaks clear and complete sentences without difficulty and follows commands. Face symmetrical. Oral mucosa moist and pink, intact. Missing teeth, but no dentures. Lips symmetrical; intact. Ears, intact and show no drainage. Patient wears glasses. Pupils are equal, round, and reactive to light, 4mm. Musculo- skeletal Patient moves in bed, turning self and sitting up without assistance. Mobility slightly limited. When out of bed patient uses a front wheel walker and presents with sufficient muscle strength. Moves all extremities equally. Respiratory Patient’s respirations nonlabored, symmetrical expansion. Visual respirations at 0815, 24 and 20 at 1600. Cardiac Patient’s receiving supplemental oxygen 2L nasal cannula. No dryness noted behind ears or around nasal. Chest expansion, symmetrical. No JVD noted. Bilateral pulses +1, weak. Bilateral radial pulses +2, moderate. Regular cardiac S1, S2 normal. Telemetry monitors in place. Blood pressure 89/61 at 0815 and increased to 116/71 at 115. Assessed patients BP again at 1600 91/62 GI Bowel sounds decreased. Abdomen soft. Generalized abdominal tenderness. No distention. PD cath noted in place, no erythema or tenderness surrounding site. GU Patient voided 350 mL during shift. Yellow, no odor present. Skin Patient presents with edema in left lower leg. Warm to touch in comparison to right. Scab laceration over left knee with surrounding erythema. IV site clean, dry, and patent. Skin turgor, fair and appropriate for ethnicity. Psychosocial Patient is calm and cooperative. Patient’s son visits often and during my shift his wife and mother were present. Patient is a tobacco user for 30 years. 2

Focused Assessment 1) GI- Assessment is important because patient presents with decreased bowel sounds. Patient has been constipated with no bowel movement. 2) Cardiac- Patient has low blood pressure. Blood pressure was monitored throughout the day. Low blood pressure can cause fainting, dizziness, or even death. 3) Skin- Patient has swelling and redness in his left lower leg that was noticed in the ED. This can cause fluid buildup. Making sure the patient gets enough fluids and evaluates extremity is crucial. Isolation Reason for Isolation Why is the patient in isolation? Tubes/Drains hemodialysis central line tunneled cath right chest removed on 2/1/2023. Diet Order Renal diet Amount consumed Breakfast Lunch Dinner Output Urinary 350 mL GI Output 0 Other Output 0 IV Assessment IV Site Right forearm Gauge/ Lumen IV Site Assessment ☒ Clean ☒ Dry ☒ Patent ☐ Redness ☐ Tenderness ☐ Hardened ☐ Painful ☐ Streaking Additional IV Site/ IV Site Notes None IV Fluids Enter type of fluids IV Fluid Rate Enter rate in mL/h Activity Orders Activity as tolerated. Nursing Activity Precautions Front wheel walker Shift Activity Patient can ambulate with assistance. Patient was in pain during shift and did not want to participate in anything. Hygiene Care Patient refused. He stated, “I do not need clean linen or a bath because my nurse gave one to me yesterday.” SAFETY 1) Sepsis: hand hygiene, be safe with medications, infection prevention and control, frequently re-assessing vitals, septic shock. 2) Infection: treatment for contamination on catheter sites and educating patient on keeping area clean and avoid tight clothing. 3) Pain: educate the patient on the concerns of pain and expressing pain concerns so this will not leave to anxiety or more discomfort in the patient. MEDICATIONS (list all medications) Medication Name Dose Route Frequency Reason Why is THIS patient taking the prescribed 3

medication? Midodrine (Proamatine) 10 mg PO 3x daily Low blood pressure Carvedilol (Coreg) 6.25 mg PO 2x with meals High blood pressure (hold) Cefazolin (Ancef) 1 g IV daily Treat bacterial infection Sodium chloride 0.9% IV daily With cefazolin Heparin 5000 units Subq 3x daily Anticoagulant (held) Levothyroxine (Synthroid) 25 mcg PO 3x daily Hypothyroidism Nystatin 5 mL PO 4x daily Infection Morphine 2 mg PO PRN Pain Sodium chloride flush 100ml (200mL/hr) IV once Used to clean IV line Sodium zirconium cyclosilicate 10 g PO once Hyperkalemia Acetaminophen 650 mg PO PRN q6h Mild pain, headache Albuterol 1 puff Inhaled PRN q6h Wheezing, SOB Magnesium hydroxide 30 ml PO Daily PRN Constipation Ondansetron 4 mg IV PRN q12h Nausea Iopamidol 100 ml IV Once Diagnostic imaging PERTINENT LABS (based on the patient’s diagnosis, history, medications, etc., which labs are pertinent and why?) HINT: Do not simply enter ALL labs, select the labs pertinent to this patient . Lab Name Normal Range Patient Results Reason Abnormal or Reason Pertinent (specific to this patient) 1/25/2023 High, Low or Normal? Date of Lab High, Low or Normal? Date of Lab High, Low or Normal? HGB (hemoglobin) 13.8-17.2 g/dL 11.3 Patient’s Result Patient’s Result Protein in red blood cells that carry oxygen around the body. Low hemoglobin can cause a patient to become anemic. This can presents with end stage renal 4

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