BRANCHING EXERCISE: COMMON DISEASES AND DISORDERS

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• Review the interactive media under Required Media: Branching exercise. This is provided in the Learning Resources.
• Review the information provided in the case (patient presentation, vital signs, pmh, home meds, results of labs and diagnostics. With this information, critically think about what is happening with the patient.
• Use your critical thinking skills and current guidelines to develop orders. Include additional labs/diagnostics, what needs repeated and followed up on. Medications that need to be ordered or changed.

The Assignment:

• Using the required admission orders template found under the Learning Resources: Required Reading.
• Develop a set of orders as the admitting provider.
• Be sure to address each aspect of the order template
• Write the orders as you would in the patient’s chart. Be specific. Do not leave room for the nurse to interpret your orders.
• Do not assume anything has already been done/order. Use the information given. Example: If the case does not mention fluids were given, the patient did not receive fluids. You may have to start from scratch as if you are working in the ER. And you must provide orders if the patient needs to be admitted.
• Make sure the order is complete and applicable to the patient.
• Make sure you provide rationales for your labs and diagnostics and anything else you feel the need to explain. This 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 the appropriate standard of care for this patient.
• A minimum of three current (within the last 5 years), evidenced based references are required.
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• Required Media: Branching exercise:
  
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• 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
  hypertension, hypothyroidism. She underwent a right knee replacement 2 weeks
  ago. Current medications include lisinopril 10mg, levothyroxine 75mcg,
  rivaroxaban 10mg daily and ciprofloxacin 500mg Q12. Her current symptoms
  include fever, chills, productive cough with purulent green sputum, and
  worsening shortness of breath. She is allergic to morphine. The patient is a
  full code.
  EXAM
  • 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.

  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 de-escalation
  can occur.
  The patient’s culture and sensitivity report for sputum and
  blood culture is now available. Staph aureus grew from the sputum culture.
  Utilizing this information, what adjustments to the patients’ antibiotics would
  you make for admission?

  • 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.

  The patient requires oxygen to maintain her O2 saturation at
  the low normal range. The safest option for the patient is to admit her to make
  sure her oxygen requirements do not need increasing with further intervention.
  A PICC can be placed for antibiotic therapy.