You are assigned to Mr. M. a 79-year-old man who was admitted to your unit for a urinary tract infection and urosepsis.
He has been agitated and anxious during the night. He was restless and kept trying to get out of bed. He seems confused and disoriented. He was moved closer to the nurses’ station to assist with frequent monitoring.
6 AM vitals: T 38C, P 78, R 22, BP 146/88, denies pain.
7 AM pulse ox. 96% (room air) and he has an IV lactated Ringers infusing at 100 ml/hr. Cefriaxone 1g IV qAM is ordered.
Subjective data: History of painful frequent urination with passage of small volumes of urine for 3 days. Intermitent fever, chills and back pain during these 3 days. Got scared when saw blood in his urine. Anxious because his father died of kidney cancer and his mother died of renal failure. Complains of bilateral fank pain.
Objective data: abdominal tenderness to palpitation. Temperature is 38C.
Urinalysis: Pyuria and hematuria.
-Dg – Urinary Tract Infection and Urosepsis
-Ambulate with assistance prn
-IV lactated Ringers infusing at 100 ml/hr.
-Bathroom privilege with assistance
-Diet – soft as tolerated
-Routine meds: Acetaminophen 500mg tabs i po q4h for temperature above 38C
– Cefriaxone 1g IV qAM as ordered.
As you provide morning care to Mr. M you note the following signs and symptoms:
- VS: T 38.5 C, P 98, R 22, BP 120/76, pulse oximetry 94%
- Fine crackles audible on auscultation in the bilateral lower lung fields
- Crackles audible throughout the bilateral lung fields
- He is sleepy, lethargic
- He is incontinent of a scant (small) amount of urine
Update: patient lethargic, skin very warm and flushed, VS T 39.1C, P 130, R 28, BP 90/54, pulse ox. 88%.
You call the physician and complete an ISBAR template (only last 2 rows):
|Assessment||Give a summary of the patient’s condition or situation. Explain what you think the problem is (if you can)|
|Request / Recommendation||State your request or recommendation|