Care of the Critically-Ill Patient: Interdisciplinary Care
Chamberlain College of Nursing
NR 341: Complex Adult Health
Care of the Critically-Ill
... [Show More] Patient: Interdisciplinary Care
73-year-old, Caucasian, widowed, retired male was admitted to the hospital on May 11, 2017 from his home. He does not have a resuscitation status, and no known allergies. Admitting diagnosis is mitral valve disease secondary to bacterial endocarditis, and acute kidney injury. Past medical history includes obstructive sleep apnea, hypertension, hemothorax, gout, GERD, diabetes mellitus, atrophy of the left kidney, and alcohol abuse. Recent surgery on May 12, 2017 includes mitral valve replacement with a cardiopulmonary bypass. Significant assessment findings are as follows: temperature 37o C, pulse 84, respiratory rate 17, blood pressure 140/61, O2 saturation 94 on room air, and 0 pain reported on a scale from 0 to 10. Foley catheter is in place, and output measurement is 100 mL at 0900. A peripherally inserted central catheter is located on his left arm. Student was unable to obtain amount from pleur-evac. Patient was semi-lucid; therefore, unable to obtain a review of systems. Focused assessment includes as follows:
Integumentary: Skin is warm, dry, and no skin turgor noted.
Head and neck: Normocephalic, and jugular vein distension is absent.
Respiratory: Chest expansion is symmetric, and lung sounds are clear on the right side yet
Diminished on the left side.
Cardiovascular: S1 and S2 are noted on auscultation, and S3 and S4 are absent.
Gastrointestinal: Abdomen is rounded and symmetric, skin is smooth, bowel sounds are present
in all four quadrants, and last bowel movement was the morning of May 14, 2017.
Neurological: Patient is oriented to person, place, and time.
Eyes: Pupils are 3 mm, and equal, round, reactive to light and accommodation.
Laboratory and Diagnostic Tests
Lab Test Result Normal range Comment
Sodium 141 135 – 145
Potassium 4.2 3.5 – 5.3
Chloride 103 98 – 106
CO2 24 23 – 30
BUN 22 10 – 20 High; this is related to his acute kidney injury, and may be related to previous administration of gentamicin, which is an aminoglycoside
Creatinine 1.94 0.6 – 1.2 High; this is related to his acute kidney injury, and may be related to use of lisinopril
Glucose 182 70 – 130 High; this is related to his diabetes mellitus, and may be related to use of atorvastatin
Calcium 8.3 8.8 – 10.2 Low; this is related to his acute kidney injury, as well as alcohol abuse
eGFR 34 >90 mL Low; this is related to his acute kidney injury, and is inversely related to creatinine
WBC 9.70 5,000 – 10,000
RBC 3.14 4.7 – 6.1 Low; this may be related to his acute kidney injury, blood loss secondary to recent surgery, or anemia
Hemoglobin 9.0 14 – 18 Low; this is directly related to his red blood cell count
Hematocrit 27 42% – 52% Low; this is directly related to his red blood cell count
Platelets 125 150,000 – 400,000 Low; this may be related to administration of heparin, or bacterial endocarditis (i.e., infections may lower platelet counts)
Medications
Ampicillin Medication class: Antiinfective – broad spectrum; aminopenicillin
Therapeutic use: Treatment for bacterial endocarditis
Major adverse effects: Acute liver failure, nephrocalcinosis, thrombocytopenia, Stevens-Johnson syndrome, and anaphylaxis
Dosage: 2 g in NaCl 0.9 100 mL
Route and frequency: IV every 4 hours
Nursing implications: Monitor vital signs every 15 – 30 minutes during first infusion, watch for decreasing urinary output, increasing BUN, monitor liver function tests, and dermatitis/rash
Aspirin (Bayer Aspirin) Medication class: Nonopioid analgesic, nonsteroidal antiinflammatory, antipyretic, and antiplatelet
Therapeutic use: Stroke prophylaxis
Major adverse effects: Seizures, GI bleeding, hepatitis, thrombocytopenia, and bronchospasm
Dosage: 81 mg
Route and frequency: Oral; one every day
Nursing implications: Assess for pain, fever, and if patient is receiving long-term therapy, monitor liver function tests, creatinine and BUN
Lipitor (Atorvastatin) Medication class: Antilipemic; HMG-CoA reductase inhibitor
Therapeutic use: Hypercholesterolemia
Major adverse effects: Liver dysfunction, pancreatitis, rash, myalgia, and rhabdomyolysis [Show Less]