VS abnormality
Patient presented for severe hip pain after a mechanical ground level fall. Found to have hip fracture with Orthopedic surgery consulted. RN pages about 0700 VS with grossly elevated BP of 185/100. Patient without PMH of HTN or any cardiac disease. What additional information should you ask the nurse?
What is patient's pain level
Patient without history of HTN, elevated BP likely due to pain response. Treat patient's pain and re-assess.
Patient with DM2 on pre-meal and long acting insulin with AM POC glucose of 66mg/dL. Please advise.
Hypoglycemia protocol- administer carbohydrates/ glucose.
RN protocol to notify MD/DO for glucose <70mg/DL and > 380mg/dL.
Hypoglycemia protocol includes admin 15g carbohydrate and POC glucose q15min until glucose > 80mg/dL. Notify attending of next dose of DM RX to be administered.
80 year old relatively healthy female admitted with left hip fracture s/p ORIF. Awaiting insurance auth for SNF.
Overnight RN pages about patient not having BM for 4 days. No bowel regimen ordered. No nausea/ vomiting or abdominal pain. What are some RX you can order?
Stool softeners (E.g. Docusate sodium), Laxatives (Osmotics like Miralax; Stimulants like Dulcolax; Bulk forming like Metamucil); Suppositories, Enema
67 year old male with HTN, GERD who presented with fever and cough. Dx with LLL PNA, started on ceftriaxone, azithromycin and Duoneb q4h.
RN pages due to patient now with new tachycardia (HR 130s). What are your next steps and concerns?
Full set of VS, what is BP
Ask about current clinical status
Assess patient
EKG and telemetry --> New AF RVR
Recent RX administration
TX points: If hemodynamically stable --> IV Lopressor, optimize electrolytes , CHADS2-VASC
(Avoid CCB in known HFrEF). If unstable consider cardioversion, call cardiology.
Patient serum potassium resulted at 2.9 mmol/L. No electrolyte protocol ordered, please advise.
Order potassium replacement. PO preferred over IV in non-severe situations.
At least 50-60 mEq of potassium supplementation.
Expect K to increase by 0.05-0.1 mol/L per 10-20 mEq of potassium.
Don't forget the Mg level and telemetry.
60 year old male with HTN admitted for right hand cellulitis after injury from palm frond, failed outpatient antibiotic therapy. Responding well to IV antibiotic therapy.
RN paging as patient complaining of insomnia, already received Melatonin. Can we try something else?
Ensure no other complaints and otherwise stable status
**Trazodone generally safe in elderly patients**
Avoid benzodiazepines and diphenhydramine due to side effects like delirium
Avoid Zolpidem (Ambien) in in elderly and hx of liver disease
Sleep disturbance very common in hospitalized patients
Patient with alcoholic cirrhosis and COPD presented with abdominal pain. Bedside paracentesis was negative for SBP. She was admitted with constipation as suspected source of pain. She is being treated supportively and anticipated DC is tomorrow.
You are paged that her BP is 87/60 and she has had 2 episodes of melena. Name at least 2 diagnostic lab tests you would order.
CBC
Type and Cross
Coag studies
Patient with NG tube and strict NPO with serum potassium 2.9mmol/L. No replacement protocol ordered, please advise.
IV potassium/ KCL via peripheral IV access must be < 10mEq/hour.
Central venous line needed for 20-40mEq/hour. Intense vesicant.
75 year old female with hypothyroidism, DM was admitted today for abdominal pain and fever. Dx with acute cholecystitis. Currently on ABX, IVF and NPO.
RN pages for 8/10 abdominal pain, already received acetaminophen, no other pain RX ordered. Can she get something else for pain?RN reports patient has been clinically stable, pain similar to prior. T 99.1 F, BP 147/89, HR 99, RR 20, O2 sat 95% RA.
Try to re-examine patient prior to pain RX. Once established patient clinically stable can try lower dose opioids. If concern for acute abdomen obtain repeat imaging, lactic acid and call surgery.
When ordering pain medication keep age, hx of seizures, kidney and liver function in mind.
Elderly female patient with dementia, DM, CKD and morbid obesity presented from nursing home with confusion and found to be febrile with leukocytosis. Most likely source UTI. Received 1 L IVF in ED and started on ceftriaxone.
RN pages that BP is now 85/48. Repeat BP is 82/50. HR 118. How do you proceed?
Ask about change in clinical status (change in mentation, etc)
Obtain repeat CBC, Lactic acid, renal function
**IVF --> 30cc/kg (preferably in first 3 hours)**
Consider broadening antibiotic coverage
Let nurse know you are concerned patient is septic and will come to bedside. Document.
Patient with NSTEMI on heparin drip with morning labs showing hemoglobin of 6.2 g/dL. Nursing staff paged overnight intern and pRBC transfusion ordered. How many units of pRBC should be ordered?
2 unit pRBC based on restrictive transfusion strategy (Goal Hemoglobin >8g/dL). Use Adult Transfusion Order Set.
Some newer studies considering goal of 8-10g/dL.
67 year old female with AF on Eliquis, HLD, GERD present for back pain after a fall. Dx with thoracic compression fracture 3 days ago. Neurosurgery planning for kyphoplasty tomorrow.
RN pages patient with new dysphagia and unilateral weakness with 2/5 strength. What are your next steps?
Call MET Call/ Stroke Alert and proceed to bedside.
60 year old female with COPD on 2L NC, CAD s/p DES in 2009, HTN, HLD presented with SOB and cough. Dx with RLL PNA and COPD exacerbation. Currently on 3L NC, ceftriaxone, azithromycin and prednisone.
Paged by RN stating patient now more SOB and on 5L NC. What else do you want to ask the RN?
Full set of VS (change of increased O2 to 5L and increased RR now 28 from 18).
Ask about and go assess work of breathing (increased with increased wheezing, uncomfortable)
Ask if DuoNeb been administered
Obtain CXR, ABG
Bipap on stand by, confirm code status
99 year old patient admitted overnight for sepsis due to PNA with concurrent AKI. Patient is on room air. Admission orders have been placed. ED had ordered a d-dimer that has only just now resulted at 0.65 FEU (Reference normal range <0.50 FEU). RN paging about critical result and asking how to proceed.
Continue current management. Ddimer WNL when adjusted for patient age.
Only use this rule in unlikely or low to moderate pre test probability.
82 year old male with COPD, HTN, HLD and dementia admitted for COPD exacerbation 2 days ago. Patient improving on Prednisone, DuoNeb and Doxycycline.
Overnight RN pages that patient is more confused, AAO to self only (baseline AAO to self/location/situation), agitated and not able to be redirected, continually getting out of bed. She is requesting restraints.
VS are WNL, patient stable on 2L saturating 93%. ABG and glucose WNL.
How do you proceed?
Go to bedside to evaluate patient
Likely delirium precipitated by hospitalization and steroids in the setting of dementia
Try to redirect and reorient patient. Non pharmacologic interventions.
Bedside sitter, virtual sitter.
Avoid restraints, use as a last resort for agitation/symptom control.
Short course of antipsychotics to treat severe agitation in the patient with delirium due to risk of self harm. No FDA approved RX. Consider low dose haloperidol. New antipsychotics like olanzapine, ziprasidone, quetiapine.
Delirium precautions. Mobilize patient. Frequent orientation, open blinds during the day, maintain sleep wake cycle, minimize high ambient noise.