In this activity, you will review the case scenario, answer related questions, and formulate a care plan for the priority nursing diagnosis for your client.

A 72 year-old man was admitted to the hospital for pneumonia two days ago. He has a history of Type II diabetes that requires insulin therapy. Diabetic neuropathy has led to several complications including cardiovascular disease. He had a cardiac stent placed 3 years ago. On admission, he had a productive cough with vesicular and bronchovesicular sounds auscultated in all lobes on inspiration and expiration with wheezes.
On admit VS were: BP: 125/80; HR: 98; RR: 22; O2 sats 90% on Room air.
Admission orders included:

9/24/2016 Admit to Medical Surgical Floor
DX: Pneumonia
0600 VS q 4 hr; I&O qshift
O2 per NC up to 3L prn to keep sats > 92%
Diet: 1800 ADA Diet
IVF: NS @ 100ml/hr continuous
Medications:
Vancomycin 1gm IVPB over 30minutes q12h
Lovenox 30mg SQ q 12 hr
Protonix 40mg IVP q12hr
Tylenol Elixir 650 mg PO q6h prn headache/fever
Solu-medrol 40mg IV daily
Continue home medications
Novolog Insulin SQ per Mild sliding scale protocol
Labs: CMP, CBC, tomorrow am and daily
Cxr tomorrow am and daily
J. Marsall, MD Date: 9/24/2016 0600

Today is 9/26/2016

Currently, he has a non-productive cough with course crackles auscultated in all lobes. Chest x-ray this morning revealed marked pulmonary infiltrates with pulmonary edema. While performing your am assessment the patient states that he feels palpitations and his heart rate is irregular. He also has 2+ edema to the lower extremities bilaterally.

1. What other assessments should be made at this time? (10 points)
2. What are the priority nursing interventions at this time and why? (10 points)
3. What medical orders do you expect? (10 points)
4. The random vancomycin level is 98 ug/mL. Explain the meaning of this result. What new orders to you expect based on this value? (8 points)
5. What are the general rationales monitoring for random, peak, and trough labs for medications? There are two main reasons. (8 points)
6. The patient’s BUN is 65 and Serum Creatinine is 4.5. The patient is diagnosed with Acute Renal Failure. Discuss the type/cause of ARF that is most likely in this situation. (10 points)
7. What other abnormal lab results on the complete metabolic (CMP) do you anticipate and why? (10 points)
8. What is the most likely cause of the patient’s complaints of palpitations? (6 points)
9. How has this patient’s history contributed to ARF? (8 points)
10. In general, (not related to this scenario), describe nursing and collaborative measures to prevent acute renal failure in hospitalized patients? (8 points)
11. What lab value should be monitored prior to administration of the Lovenox? (6 points)
12. What concerns do you as the nurse have regarding the Solu-medrol? (6 points)
13. Extra credit: What is incorrect or not Joint Commission compliant in the above orders? (6 points)

Sample Solution