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ongoing IPS on patient armband of no BP

by | May 24

Thi Minh Tran:
In your shift plan did you consider:
• ongoing IPS
• vital signs on right arm with alert placed in notes and on patient armband of no BP and IV on left side do to nodal clearance (lymphoedema risk)
• vital signs hourly as patient has had acute deterioration from NH for at least 4 hours then 4/24 if no changes (though remains at risk of sepsis)
• Patient is hypotensive, and in CR zone so alert nursing team leader. Possibly will not need a CR as has IV fluid charted and IVABs, encourage oral intake of fluids to reduce dehydration. If pt BP does not improve or continues to decline then call CR. If you wish to call CR anyway that is also not wrong
• Serum lactate needs to be checked (as per sepsis guidelines)
• administration of charted medications, especially antibiotics at due time, withhold metoprolol due to low BP, withhold temazepam due to delirium (benzodiazepine contraindicated). First antibiotics should be commenced within 1 hour.
• IV fluid charted in context of low BP and low Urine output is less than the requirements of 30mls/kg as a bolus if that patients lactate level comes back elevated – this needs to be discussed with the medical team. Sepsis guidelines state that this patient needs a bolus of 1470mls if lactate is high.
• pain assessments with vitals (increase pain will increase delirium)
• Falls risk assessment and falls prevention strategies (patient is high falls risk)
• transfer to room close to nurses station for closer supervision
• physiotherapy review and application of mobility aids recommended by physiotherapy
• 2nd hourly toileting due to high falls risk and IV hydration, urine output needs to be measured after IV bolus if BP is improved
• encouraging oral fluids with toilet rounds (not on the toilet, but after toileting is finished)
• suggest walk around the ward after toileting (at toileting rounds) to promote early mobilisation and decrease delirium (with assistance and supervision, after IV bolus if BP is improved)
• Delirium assessment (likely the CAM) at least once per shift (delirium is not confusion)
• dietician referral due to malnourishment, if patient not eating then oral assessment is indicated – is this patient in pain/have dental problems impairing mastication? Does speech pathology need to review patient eating?
• assistance with mealtimes to optimise dietary intake, starting a food chart
• mouth care prior to bedtime
• skin care (high risk of pressure ulcers and tears due to age, malnutrition, dehydration) this should include repositioning the patient, ensuring not to dry, assessment and treatment of incontinence associated dermatitis
• FBC and measuring urine output due to risk of kidney injury from sepsis and dehydration
• activities to cognitive stimulate and interest the patient (reading, TV, chatting to people, doing puzzles/word games, in cases of dementia folding washing/towels, rolling bandages or other activities to interest the patient).
• Ensure CXR (already ordered) is attended and follow up results
• Many recent falls and fractures – suggest gerontology review, consider bone density scan for ? osteoporosis
• Patient should have admission ECG – also should have ECG for ? causation of previous falls and current delirium (though delirium is most likely due to UTI and urosepsis, this could also be a contributing factor)
• DVT risk – anticoagulation, early mobilisation with physiotherapy and hourly foot and ankle exercises. At least once per shift assessment of deep veins to ensure no DVT developing
• Wash or shower with assistance, particularly groin and vulva area due to urinary incontinence
• VIP score for P.IVC
• This patient has elevated Blood sugar likely due to sepsis. Informing the MO of this at some stage would be necessary
• Please see sepsis guidelines here: https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/Adult-Patients
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