Country : Australia
Assignment Task

 

Introduction
You are a New Graduate Registered Nurse working on the Renal Medical Unit of a large tertiary hospital. You are asked to take over care of a Julia Tran, a 42-year-old woman, and are currently receiving handover at the bedside.

Situation
Julia was admitted via the Emergency Department (ED) today, after experiencing an acute episode of left flank and groin pain, discomfort with voiding, episodes of vertigo and describes “passing out this morning before coming to the hospital”. Julia’s partner called an ambulance after they found Julia unconscious, but rousable to voice.
On arrival to ED Julia was diaphoretic, tachycardic (HR 128) and hypotensive (BP 87/46). Her lips were cyanotic, and skin was pale. Her initial pain score was 8/10 and she showed signs of confusion.
The ED team have administered a STAT 1L bag of crystalloid. Urine and blood cultures were sent to the laboratory for microbiology, the results are pending.
Pathology: FBC, UEC and BhCG. Results showed elevated white blood cells, with all other results within normal ranges. BhCG – negative.
The ward urine analysis showed high specific gravity, blood moderate; leukocytes ++, Glucose nil, Protein +.

Background
Nil

Assessment
Airway
• Patent

Breathing
• Spontaneous effort
• Sp02 95% on room air
• Bilateral breath sounds

Circulation
• Dual Heart sounds
• Peripheral pulses thready, regular
• Cap refill >3 secs.
• NIBP 101/47 (65) mmHg
(usual SBP 120mmHg)
• HR 98/min.

Disability
• GCS 15 (E:4, V:5, M:6)
• PEARL 3mm, brisk.
• Restless/Unsettled
• Blood Glucose Level 5.4 mmol/L

Exposure
• Tympanic Temperature 38.7°C
• Pale appearance
• IV Cannula to right cubital fossa.

Recommendation
Medical impression - likely UTI, either renal or bladder (await microbiology).
Medical Plan: Admit patient to Renal Medical Unit for further observations and treatment, Commence Intravenous (IV) fluid therapy - Plasma-Lyte 148 NS 120ml/hr,
Commence IV gentamicin and IV amoxicillin as charted on the NIMC, Endone 5mg PO for pain PRN – charted on the NIMC, Await blood and urine cultures for sensitivities,
Renal and Bladder ultrasound and monitor urine output.

 

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  • Posted on : October 29th, 2019
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