Scenario 5 68 Year Old Female with Shortness of Breath

Scenario 5 68 Year Old Female with Shortness of Breath

Scenario 5 68 Year Old Female with Shortness of Breath

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Scenario #5 68 year old female

BACKGROUND

A 68 year old female is brought to the hospital from the acute rehabilitation facility with complaints of shortness of breath and productive cough for 1 week. She was started on ciprofloxin 3 days ago but her symptoms have continued to worsen. Her past medical history includes hypertenstion, hypothyroidism. She underwent a right knee replacement 2 weeks ago. Current medications include lisinopril, ciprofloxin, and rivaroxaban. Her current symptoms include fever, chills, productive cough with purulent green sputum, and worsening shortness of breath. Scenario 5 68 Year Old Female with Shortness of Breath

Current vital signs T 102.6 HR 92. RR 22 BP 128/82
O2 saturation is 96% on 4L of O2
Chest x-ray shows consolidation in the right lower lobe
CBC and CMP are all within normal limits
How would you treat this patient?

Decision Point One

Discontinue the ciprofloxin
Start levofloxin 750 mg IV every 24 hours
or
Discontinue the ciprofloxin
Initiate piperacillin/tazobactam 4,5 g IV every 6 hours,
tobramycin 5 mg/kg IV every 24 hours,
and vancomycin. 15 mg/kg every 12 hours
or
Continue the Ciprofloxin
and add Meropenem 1 gram IV every 8 hours

Decision Point One

Discontinue the ciprofloxin

Initiate piperacillin/tazobactam 4,5 g IV every 6 hours,

tobramycin 5 mg/kg IV every 24 hours,

and vancomycin. 15 mg/kg every 12 hours

RESULTS OF DECISION POINT ONE

Correct!

This patient meets the criteria for hospital acquired pneumonia (HAP) due to her surgery 2 weeks ago and inpatient stay at the rehabilitation facility. She is at risk of drug resistant bacteria and MRSA. . A three drug combination for broad spectrum coverage is indicated until culture and sensitivity report on her sputum is available and antibiotic deescalation can occur.

The patients culture and sensitivity report for sputum and blood culture is now available. Utilizing this information, what adjustments to the patients antibiotics would you make?

Antimicrobial chart of sputum and blood

Decision Point Two

Discontinue the Tobramycin and Vancomycin

Continue the piperacillin/tazobactam

RESULTS OF DECISION POINT TWO

Correct!

The sensitivity report indicates that the bacteria in the sputum and blood is sensitive to piperacillin/tazobactam. Continuing it and discontinuing the other antibiotics will still provide good coverage for this infection. A full 10 day course would be indicated.

The patient condition is improving and she requests to have her IV removed and go home.

Decision Point Three

Place a PICC and complete an assessment to see if discharge home or to the rehabilitation facility is a safe option for her to continue the 10 day treatment course.

Guidance to Student

Correct!

The patient needs to receive a 10 day course of IV antibiotics.

Inpatient hospitalization is not required as long as there is available resources at home or in another facility.

Assignment: Branching Exercise: Common Diseases and Disorders

For this Assignment, you will review the interactive media piece/branching exercise provided in the Learning Resources. As you examine the patient case, consider how you might assess and treat patients with the symptoms and conditions presented. Scenario 5 68 Year Old Female with Shortness of Breath

Photo Credit: Getty Images/Maskot

To prepare:

Review the interactive media piece/branching exercise provided in the Learning Resources.
Reflect on the patient’s symptoms and aspects of disorders that may be present in the interactive media piece/branching exercise.
Consider how you might assess, perform diagnostic tests, and recommend medications to treat patients presenting with the symptoms in the interactive media piece/branching exercise.
You will be asked to develop a set of admission orders based on the patient in the branching exercise.
The Assignment

Using the Required Admission Orders Template, write a full set of admission orders for the patient in the branching exercise.

Be sure to address each aspect of the order template
Write the orders as you would in the patient’s chart
Make sure the order is complete and applicable to the patient
Any rationale you feel the need to supply should be done at the end of the order set – not included with the order
Please do not write per protocol. We do not know what your protocol is and you need to demonstrate what is appropriate standard of care for this patient.
A minimum of three current, evidenced based references are required.
By Day 7 of Week 9
Submit your completed Assignment by Day 7 of Week 9 in Module 5.

Rubric Detail – Scenario 5 68 Year Old Female with Shortness of Breath

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Name: NRNP_6566_Module5_Assignment_Rubric
Grid View
List View
Excellent

Point range: 90–100 Good

Point range: 80–89 Fair

Point range: 70–79 Poor

Point range: 0–69
Using the Admission Orders Template, write a full set of admission orders for the patient in the branching exercise. Be sure to address the following:
· Identify the Correct Diagnosis.
5 (5%) – 5 (5%)
The order set includes an accurate and correct diagnosis.
4 (4%) – 4 (4%)
The order set includes a diagnosis that is an appropriate differential diagnosis.
3 (3%) – 3 (3%)
The order set includes a diagnosis that is incorrect and not supported by patient data.
0 (0%) – 2 (2%)
The order set includes and inaccurate / dangerous diagnosis.
· Identify the ‘Status/Condition’, ‘Code Status’, ‘Admit to Unit’
for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set includes an accurate description / plan for condition, code status, and admission location.
4 (4%) – 4 (4%)
The order set includes an accurate description for 2 of the 3 variables.
3 (3%) – 3 (3%)
The order set includes an accurate description for 1 of the 3 variables.
0 (0%) – 2 (2%)
The order set includes inaccurate, missing, or dangerous descriptions for these variables.
· Describe the “Allergies’, ‘Activity Level’ and “Diet” for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set includes an accurate description / plan for allergies, activity level, and diet.
4 (4%) – 4 (4%)
The order set includes an accurate description for 2 of the 3 variables.
3 (3%) – 3 (3%)
The order set includes an accurate description for 1 of the 3 variables.
0 (0%) – 2 (2%)
The order set includes inaccurate, missing, or dangerous descriptions for these variables.
· Identify any ‘IV Fluids’ needed for the patient in the presenting case.
9 (9%) – 10 (10%)
The order set clearly and accurately identifies a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
7 (7%) – 8 (8%)
The order set is missing 1 element of a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
5 (5%) – 6 (6%)
The order set is missing 2 elements of a complete order for IV fluid type, flow rate, and administration parameters for the patient in the presenting case. Scenario 5 68 Year Old Female with Shortness of Breath
0 (0%) – 4 (4%)
The order set is incomplete, includes wrong / dangerous fluids or flow rate, incorrect parameters for IV fluid type, flow rate, and administration parameters for the patient in the presenting case.
· Identify any ‘Respiratory’ needs for the patient in the presenting case. Be specific about oxygen (if ordered, include type and rate), pulmonary toilet needs, and ventilator settings.
5 (5%) – 5 (5%)
The order set clearly and accurately identifies a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
4 (4%) – 4 (4%)
The order set is missing 1 element of a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
3 (3%) – 3 (3%)
The order set is missing 2 elements of a complete order for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
0 (0%) – 2 (2%)
The order set is incomplete, includes wrong / dangerous orders, or incomplete parameters for respiratory care, delivery method, treatments and parameters for the patient in the presenting case.
· Describe the ‘Medications’ including any IV drips for the patient in the presenting case.

Be specific about medications related to the reason for admission and any chronic medications the patient may be taking (ALL, tx of primary condition, underlying conditions, pain, comfort needs, etc.). Be sure to include name, dose, route of administration, and frequency of each medication.
13 (13%) – 15 (15%)
The order set clearly and accurately identifies a complete set of medication orders for the patient in the presenting case. Orders are complete, account for all conditions, and are appropriate to treat the patient.
10 (10%) – 12 (12%)
The order set clearly and accurately identifies a complete set of medication orders for the patient in the presenting case. There are incomplete orders, missing medications, or missing elements in the orders.
5 (5%) – 9 (9%)
The order set is missing essential elements of a medication order, missing medications, or are inappropriate to treat the patient in the presenting case.
0 (0%) – 4 (4%)
The order set is incomplete, includes wrong / dangerous orders, or inappropriate medications to treat the patient in the presenting case.
· Explain any ‘Nursing Orders’ for the patient in the presenting case. Be specific about vital signs, skin care, toileting, and ambulation.
9 (9%) – 10 (10%)
The order set includes a full set of nursing orders that provide essential direction to provide care, monitor, assess, ensure safety, prevent complications and promote healing.
7 (7%) – 8 (8%)
The order set include inaccurate or is missing 1 or 2 nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
5 (5%) – 6 (6%)
The order set include inaccurate or is missing 3 or 4 nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
0 (0%) – 4 (4%)
The order set include inaccurate, missing, or provides dangerous nursing orders essential to direct nursing care, monitor, assess, ensure safety, prevent complications, and promote healing.
· Explain the ‘Follow-Up Lab’ tests for the patient in the presenting case. Be specific about diagnostic testing (e.g., CXR, US, 2D Echo, etc.).
9 (9%) – 10 (10%)
The order set includes complete laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
7 (7%) – 8 (8%)
The order set includes most (missing 1 or 2) laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
5 (5%) – 6 (6%)
The order set includes some (missing 3 or 4) complete laboratory and diagnostic testing to adequately monitor and assess the presenting patient. Scenario 5 68 Year Old Female with Shortness of Breath
0 (0%) – 4 (4%)
The order set is missing essential laboratory and diagnostic testing to adequately monitor and assess the presenting patient.
· Explain the ‘Consults’ for the patient in the presenting case. Be specific about how you, as an ACNP, would manage the patient’s acute needs for at least a 24-hour period. Include indication for consult (e.g., “Cardiology consult for evaluation of new-onset atrial fibrillation,” “Nutrition consult for TPN recommendations”).
5 (5%) – 5 (5%)
The order set includes clear, accurate, and essential consults for the patient in the presenting case including complete rationale for the consult.
4 (4%) – 4 (4%)
The order set is missing one of the following: necessary consult, inaccurate information, or inaccurate rationale for consults needed to manage the presenting patient.
3 (3%) – 3 (3%)
The order set is missing 2 or more of the following: necessary consult, inaccurate information, or inaccurate rationale for consults needed to manage the presenting patient.
0 (0%) – 2 (2%)
The order set is missing multiple consults, rations, or accurate descriptions for consults needed to manage the presenting patient.
· Explain the ‘Patient Education and Health Promotion’ for the patient in the presenting case. Be sure to address age-appropriate patient education, if applicable.
9 (9%) – 10 (10%)
The order set provides clear, accurate, and complete patient education and health promotion recommendations for the patient in the presenting case.
7 (7%) – 8 (8%)
The order set is missing 1 or 2 essential elements of patient education and health promotion for the patient in the presenting case.
5 (5%) – 6 (6%)
The order set is missing 3 or 4 essential elements of patient education and health promotion for the patient in the presenting case.
0 (0%) – 4 (4%)
The order set is missing multiple essential elements of patient education and health promotion for the patient in the presenting case.
· Explain the ‘Discharge Planning and Required Follow-Up Care’ for the patient in the presenting case.
5 (5%) – 5 (5%)
The order set provides clear, accurate, and complete discharge planning and necessary follow up care for the patient in the presenting case.
4 (4%) – 4 (4%)
The order set is missing 1 or 2 essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
3 (3%) – 3 (3%)
The order set is missing 3 or 4 essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
0 (0%) – 2 (2%)
The order set is missing multiple essential elements of discharge planning and necessary follow up care for the patient in the presenting case.
· Identify a minimum of three ‘References.’ Be sure that they are timely and support the admission order in following current standards of care.
9 (9%) – 10 (10%)
The order set includes a minimum of three professional level references that are timely and clearly support the admission orders following current standards of care. References are formatted in APA format.
7 (7%) – 8 (8%)
The order set does not include a minimum of three professional level references that are timely and clearly support the admission orders following current standards of care. APA format is incorrect.
5 (5%) – 6 (6%)
The order set does not include a minimum of three references or includes non-professional level resources to support their admission order set. APA format is incorrect.
0 (0%) – 4 (4%)
The order set is missing minimum number of references or includes poor sources that do not reflect professional writing or current standard of care information. APA format is not followed.
Written orders include all elements, address all the needs of the patient, are complete, logical, and meets the complete needs of the patient.
5 (5%) – 5 (5%)
Written order set is complete, addresses all the needs of the patient, and are based on current literature.
4 (4%) – 4 (4%)
Written orders are mostly complete only missing 2 essential elements in addressing the needs of the patient.
3 (3%) – 3 (3%)
Written orders are missing 3 to 4 essential elements are reflect an incorrect standard of care.
0 (0%) – 2 (2%)
Written orders are incomplete, do not address the needs of the patient, or reflect an outdated standard of patient care.
Total Points: 100
Name: NRNP_6566_Module5_Assignment_Rubric