RN working the 7a-7p shift on a Renal/GI Pediatric Unit in a communityhospital. The Renal/GI Pediatric Unit has 22 beds. The day staff consists of a Nurse Manager, 6 RNs, 4 PCTs (Patient Care Technicians), a Child Life Specialist, and a Unit Clerk. Patient rounds with the pediatricians, nurse practitioners, physician specialists, and charge nurse occur daily at 0800. After rounds, the charge nurse and nurse practitioner meet with the Nutritionist, PT and OT, Child Life, Certified Teacher, Nurse Case Manager and Social Work to discuss each patient’s daily plan of care. A satellite Pharmacist is assigned to the pediatric unit. RN arrive and receive report from the RN on night shift: 100 David York Age: 5 months Weight: 12 lbs Admitting Dx: Diarrhea/Dehydration PMH: Asthma, Failure to thrive Third admission for dehydration and failure to thrive EGD and colonoscopy scheduled today at 1100 02 Sats 97% on 2L humidified FiO2 via NC, lungs clear AM lab results: Hgb 10, Hct 32.0, NA 134, K 5 NPO since 12MN except breast milk, full NPO at 0600 No wet diapers since 2200, No BM D5 ½ NS @ 15cc/hr stopped due to IV infiltrate @ 0200 (attempts to replace IV unsuccessful) Consent signed Pre-procedure checklist on chart Pre-procedure medications ordered Mother at the bedside. Father at home with 2 yr old Part B.2 – establish appropriate patient outcomes and develop a discharge plan. -Expected Outcomes -Identify probable discharge day (hospital day #) or indicate length of stay and place. -Include at least two references a. Discharge in 5 days to home. Give statement about why hospitalized for that time frame.. (http://www.survivingsepsis.org/Improvement/Pages/default.aspx; http://www.qualitymeasures.ahrq.gov/content.aspx?id=26529) 2. List 2 priority measurable outcomes with timeframe. a. Patient will be afebrile for the next 2 consecutive days prior to discharge. b. Patient’s blood sugar levels are within acceptable limits within the next 48 hours.. V. Barriers to meeting Expected Outcomes 1. Identify at least 3 criteria related to primary diagnosis and interventions that could delay discharge. Include evidence-based strategies utilized to prevent these complications (with references) a. Patient has poor peripheral access, must have central line for antibiotics. 1. Obtain order for central line (reference) 2. Ensure central line placed (reference) 3. Assess patency of central line Q shift (reference) 4. Flush central line q shift and before and after medications(reference) b. Remains Febrile. 1. Monitor temps(reference) 2. Ensure infection prevention (wash hands, scrub hub, monitor CBC) (reference) 3. Ensure patient remains hydration, assess hydration status (reference) c. Blood cultures positive. 1. Administer antibiotics as ordered and monitor side effects (reference) 2. Ensure infection prevention (wash hands, scrub hub, monitor CBC) (reference) d. Patient developed allergy to prescribed medications. 1. Review allergies prior to medication administration (reference) 2. Identify at least 3 factors (co-morbid conditions, support systems, environmental factors, etc.) that could delay discharge. Include evidence-based strategies utilized to prevent these complications (with references) a. Uncontrolled blood sugars, patient non-compliant with diet -Begin diabetic teaching – diet, exercise, blood glucose monitoring. (reference) -Ensure that low sodium, diabetic diet is served. (reference) -Monitor BS AC&HS (reference)b. Wife sneaks in junk foods from home. 1. Monitor food brought in from home. (reference)c. BP has been consistently elevated, being worked-up for secondary HTN.1. Vitals Q shift and PRN (reference)2. Monitor renal function (BUN & creatinine q shift) (reference)3. Administer cardiac meds as ordered (reference)d. Financially unable to buy glucometer for his glucose monitoring.1. Consult case manager to assess needs (reference) VI. Multidisciplinary Plan of Care (post discharge) List in priority order referrals for this patient including rationale for anticipated discharge needs, i.e., Home PT, VNA. a. Home health services for central line care & continued ABX therapy.b. Infectious Disease to follow-up with infectious processc. Endocrinologist for new diagnosis of DM.d. Internal Medicine/APN for BP management. e. Nutritionist to help with meal planning, etc. Health Science Science NursingNUR 4307
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