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S.S. (41 y.o. Female - full code) - Coggle Diagram
S.S.
(41 y.o. Female - full code)
Admitted to ER 10/13/20
Positive MRSA & Infective Endocarditis
Pathophysiology: Staphylococcus bacterial infection that is resistant to many antibiotics d/t mecA gene sequence of bacterium
Can impact many organ-tissues, such as the cardiac tissue seen in this case (infective endocarditis)
Bacterial vegetation growth seen on Xray
Possible Complications: MI, stroke, heart valve damage, heart failure, seizures, sepsis
S.S. signs & symptoms
Likely Sepsis:
HR - 115
BP - 102/68
Temp - 102.5
RR - 8-16
Sp02 Sat - 80-90
Vitals trending downward
Nursing Interventions:
7 more items...
Increased WBC
Decreased platelets
Increased troponin (trending upwards)
ALT, AST, ALK-Phos elevated
Glucose critically high
Albumin decreased; Ca++ elevated, Mg++ decreased
Na+ increased
Encourage fluid intake and admin IV fluids
Can be linked to IV drug use
S.S. has h/o IVDA
Positive for heroine & alcohol
Provide holistic nursing care & resources specific to patient
Exhibiting s/s of anxiety and ineffective coping
R/t social history & secondary diagnoses
Bipolar disorder, depression, ADHD, addiction
H/O IV Drug Use
Ensure patient safety
Check pt surroundings; review UA drug screen
Pt positive for alcohol & heroin
request doctor order for Narcan prior to admin of narcotics
Elevated liver enzymes
May be indicative of liver disease; advocate for additional testing
Two attempted suicide attempts
Nursing intervention: Initiate psych evaluation & request psych consult
Homeless
Nursing Implications: Understand pt has limited resources and that this factor must be taken into account when creating the care plan; be aware of personal biases you or other staff may have
H/O Physical & mental abuse
Nursing implications: listen to patient and report any suspected findings of abuse
Smoker
Pt. had cigarette in mouth upon entering room & had pack of cigarettes in hand
Cigarette's confiscated and pt teaching on why she is not allowed cigarettes in the hospital
COPD
Diminished breath sounds
Gas exchange, impaired
Apply O2 to maintain SpO2 >88%
Allergy to sulfa drugs
Ask patient about any other known allergies
Prioritize care based on needs for life-threatening condition
Meds for infection, fever, and insulin need to be the priority
Maintain O2 sats above 88%
Recognize s/s of sepsis