Using the Nursing Clinical Pathway , document the patient’s.
Using the Nursing Clinical Pathway , document the patient’s… Using the Nursing Clinical Pathway, document the patient’s condition according to the following scenario: “You are an ICU nurse caring for a case of a severe Covid-19 patient. A working diagnosis of Communin-Acquired Pneumonia and COVID-19 suspect is made. The patient started on Ceftriaxone 2g intravenously (IV) once daily (OD) and Azithromycin 500mg OD. NPS/ORS specimens were collected and sent to the RITM. On January 27, the results of a respiratory pathogen real-time PCR detection panel performed at RITM on the NPS/OPS samples were released reporting detection of Influenza B viral RNA and Streptococcus Pneumoniae DNA. The NPS/OPS samples were sent to the VIDRL for additional testing. Oseltamivir 75mg BID was commenced on the basis of the Influenza result. During illness days 9 and 10, his fever continued with occasional non-productive cough. He remained clinically stable apart from intermittent SpO2 desaturations of 93-97% on 2-3 L/min of oxygen. On illness day 11, he developed increasing dyspnea with reduced SpO2 at 88% despite 8 L/min of oxygen via a face mask and hemoptysis and was noted to have bilateral chest crepitations. A chest radiograph was reported as showing hazy infiltrates in both lung fields consistent with pneumonia. Meropenem 2g IV three times a day (TDS) was commenced. On illness day 12, he became increasingly dyspneic hypoxic and agitated and was intubated and sedated with a Midazolam drip. An endotracheal aspirate (ETA) and a further NPS/OPS were collected and sent to the RITM. Vancomycin, 30mg kg loading dose followed by 25mg/kg BD, was commenced with a working diagnosis of severe Community-Acquired Pneumonia due to Streptococcus Pneumoniae secondary to influenza B infection, plus consideration of COVID-19 pending the ETA result. A complete blood count showed values within the normal range. On illness day 13, he continued to be febrile (38.5-40.0 °C) with bibasal crackles. Vital signs were stable with adequate urine output. A chest radiograph was reported as showing worsening of pneumonia. On illness day 14, increased crepitations in both lung fields were noted. Blood cultures showed no growth after 24 h of incubation. An HIV test was non-reactive. On this day, the RITM reported detection of SARSCOV-2 viral RNA by real-time PCR from the NPS/OPS taken on illness day 12 and hence the 2nd confirmed COVID-19 infection in the Philippines. This result was later confirmed on February 4 on the initial admission sample sent to VIDRL. On the morning of illness day 15, the patient remained febrile at 40 °C, with BP 110/70, HR 95, RR 30, SpO2 99% with 80% Fi02, and adequate urine output. However, the patient’s condition deteriorated with the formation of thick sputum and blood clots in the ET tube. Despite frequent suctioning, the patient’s condition deteriorated. He was noted to have labored breathing followed by a cardiac arrest. Despite several rounds of cardiopulmonary resuscitation, it was not possible to revive the patient.” Document his illness. Make your present day at Day 13 use the Nursing Clinical Pathwayas if you are the professional nurse. Use the blank form NURSING SERVICE DEPARTMENTNursing Intervention Checklist (Nic) And Algorithm for PneumoniaName of Patient: Date:Attending Physician: Room:Staff Nurse in-charge: PRIORITY NURSING DIAGNOSIS: Impaired Spontaneous Ventilation related to ____________________PERTINENT DATASPECIFICINTERVENTIONSIMPLEMENTATIONREMARKS AND SPECIAL ENDORSEMENTS(EVALUATION)Patient-centered (Subjective)Nurse-centered (Objective)PerformedNot Performed Assisted patient in deep breathing exercises Positioned patient properly by elevating the head of the bed Suctioned secretions as necessary- Oral- Nasal-ET tube Administered medications as ordered (please specify): Administered and maintained oxygen support as ordered- Funnel- Nasal cannula- Face mask- Mechanical ventilator Referred the patient to the attending physician as necessary Other interventions relevant to the nursing diagnosis(please indicate and use another sheet if necessary);(VARIANCES) SAMPLE OF THE CHECKLIST: NURSING SERVICE DEPARTMENT NURSIN G INTERVENTION CHECKLIST (NIC) AND ALGORITHM FOR URINARY TRACT INFECTION Name of Patient: MS Date: July, 8, 2020Attending Physician: Dr. AB Room Number: 123Staff Nurse in-charge: ABC, RNPERTINENT DATASPECIFIC INTERVENTIONSIMPLEMENTATIONREMARKS AND SPECAL ENDORSEMENT(EVALUATION) Patient-centered (Subjective)Nurse-centered(Objective) Performed Not Performed Unable to take in oral fluids. Warm to touch Unable to intake T= 38.6C CR= 111BPM RR = 22BPM Advised patient to increase oral fluidintake ?Patient had dysphagia2 hours upon admission butprogressed to unableto swallow Maintained adequate intravenous hydration ?Intermittentintravenous hydrationwas done due tocollapsible veins Provided tepid sponge bath? Loosened patient’s clothing ?Patient had looseclothing already Maintained adequate ventilation inside theroom? Monitored intake and output accurately? Administered medications as ordered(please specify): Hydrocortisone 25mg IV q6 for 3 doses Hydroxychloroquine 400mg TID perNGT Paracetamol 300mg IV q4h for Temp = 38.6 ? Referred the patient to the attendingphysician as necessary? Other interventions relevant to the nursingdiagnosis (please indicate and use anothersheet if necessary): V-patient was unable to swallowA – Inserted siliconized NGT fr 16 on Right nostril Placed on semi-fowlers position Administered osteorized feeding of 3000Kcal/day to be divided in 6 equalfeedings q4 as ordered O – Medical officer reviewed patient, medication order changed, Patient wasable to tolerate osteorized feeding Health Science Science Nursing
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