Mr. McMillan, a 92-year old male, presents to the Emergency.

Mr. McMillan, a 92-year old male, presents to the Emergency… Mr. McMillan, a 92-year old male, presents to the Emergency Department (ED) with urinary hesitancy and burning and a fever at home of 101.6°F.  His caregiver states “he just doesn’t seem like himself”.Upon further assessment, Mr. McMillan is weak, his face is flushed, his skin is warm and dry. He is oriented to person and place, but states the year is 1952. His vital signs were as follows:BP 99/60 mmHg Ht 69 inHR 92 bpm and regular Wt 60 kg RR 28 bpm SpO2 93% on Room AirTemp 102.2°FThe Dr. Jonas orders the following:• Bloodwork – CBC, BMP, ABG, Lactic Acid, Blood Cultures x 2• Urine Tests – Urinalysis, Urine Culture• Diagnostics – CXR, KUB • O2 to keep SpO2> 92% • Meds – 1L NS bolus IV x 1, now.  1,500 mg Vancomycin IVPB x 1 dose, now AFTER all blood and urine tests are completed and you initiate the fluid bolus for Mr. McMillan. You are still waiting for the Vancomycin to arrive from the  pharmacy. You notice Mr. McMillan is more drowsy. He is now only oriented to self and feels warmer. You take another set of vital signs to find the following:• BP 86/50 mmHg; HR 108 bpm Temp 102.7°F; RR 36 bpm SpO2 88% on Room AirMr. McMillan’s lab results have also resulted, the following abnormal values were reported:• WBC 22,000 / mcL Lactic Acid 3.6 mmol/L• pH 7.22 pCO2 30 mmHg• HCO3 16 mEq/L pO2 64 mmHg• Urine Cloudy with sediment• Creatinine level 1.7 56) Does Mr. McMillan have to have an order to be admitted to the hospital?  57) Given Mr. McMillan’s latest lab results, what new orders do you think Dr. Jonas will order?  58) Are you sure that is all Dr. Jonas will order? Mr. McMillan responds well to the first liter of fluids, and antibiotics are  initiated within an hour of arrival. The Dr. Jonas places an arterial line and central line to initiate vasopressors. They order a Norepinephrine infusion to be titrated to keep MAP > 65 mmHg. The Critical Care team asks you to prepare the patient for transfer to the ICU.• BP 82/48 mmHg; HR 122 bpm Temp 103.1°F; RR 32 bpm; SpO2 90% on Room Air• Creatinine level 1.7 59) Given Dr. Jonas’ original orders, what have the nurses not done for Mr. McMillan? Is this omission effecting Mr. McMillan’s possible outcome? 60) If you were the oncoming nurse, after assessing Mr. McMillan and reviewing his orders, what would you do NOW? Why? 61) Should you be concerned about Mr. McMillan’s temperature? What can you do for it?  62) If you discuss Mr. McMillan’s temperature with Dr. Jonas, do you document the conversation? Why? 63) What is Norepinephrine? What can low doses of Norepinephrine do for the kidneys? What will higher doses do for Mr. McMillan? Will this help Mr. McMillan’s creatinine level? Explain. 64) Do you think Norepinephrine is a good choice for Mr. McMillan? Explain. 64) Will Norepinephrine help Mr. McMillan’s B/P? How will it help? 68) Given Mr. McMillan’s B/P, would you expect him to remain on IVF? Which IVF would be best for him? 69) Do you think Mr. McMillan is hungry? Does he need nutrition? Why? 70) How long can Mr. McMillan go without eating? 71) What are some other options for Mr. McMillan if he is unable to eat? Are these reasonable options?  Health Science Science Nursing HNUR 2123

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