Stage IV pressure ulcer

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 flow charts contain the following information: Patient Care Kardex VS q4h Diet: Pureed HOH Siderails ↑ ×2 W-D Dressing with 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: PO = 50, IV = 250 Output= inc x2

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. •It is 1630 when the handoff report is completed. Prioritize your plan of care for the next 4 hours: Time Plan of Nursing Care

•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 1.Identify the nursing interventions that require immediate follow-up. 2. Identify the nursing actions that you can delegate/assign to unlicensed personnel.

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

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