3-3 PATIENTS WITH DEHYDRATION, FEVER, DO-NOT-RESUSCITATE ORDER. “The patient was admitted today for dehydration. She is 88 years old and has a stage IV pressure ulcer on her

sacrum. A wet-to-dry dressing is clean and intact. A pressure ulcer with eschar is on her left heel. She weighs

90 pounds and she refused her lunch. An IV was started at 1400. You have 750 mL credit. She is a sweet

little lady, quiet, and at times forgetful. Her admission lab results just came in, her Hgb is 9.6, Hct 27,

WBC 11,000, and K+ 4.5. I have not called the physician.”

The patient’s current flowcharts contain the following information:

Integrated Learning Activity: With a partner, use the clinical situation and the flowcharts to:

Patient Care Kardex

VS q4h Diet: Pureed

HOH

Siderails ! Å~2

W-D Drsg c-

0.9 NS q12h 0800 – 2000

IV: D5/0.9 NS at 75 mL/hr

IV site: R hand #24 g cannula

Medication: Colace 100 mg po daily

Do not resuscitate (DNR)

Intake and Output Record

Day Shift — 8 hour

Intake Output

PO = 50 UA = inc Å~2

IV = 250

THREE

3-3 Patient With Dehydration, Fever, Do-Not-Resuscitate Order 193

1. Identify the pertinent

patient information

made known to you in

the report.

2. Identify the pertinent

patient information

made known to you in

the flowcharts.

3. Review the data in

columns 1 and 2 and

identify information that

needs follow-up.

Copyright © 2014, 2010, 2006, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.

It is 1630 when the handoff report is completed. Prioritize your plan of care for the next 4 hours:

At 2000 the nursing assistant reports that the patient is restless and trying to get out of bed. You document the

following assessment: Speech incoherent, skin warm, flushed. VS: T 101° F, P 92, R 24, BP 108/60, pulse ox

88%. Incontinent of dark-colored urine with strong odor. Physician called. The following telephone orders are

given:

VS q2h, I & O

Acetaminophen 325 mg po q4h prn temperature greater than 100.4° F

Enc. fluid intake

Ceftriaxone 1 g IVPB qAM

Critical reflection: To promote patient-centered care, list nursing interventions that you could independently

implement for this patient: