NUR251 Medical Surgical Nursing 2 - Assessment 2: Case scenario one

Assessment 2: Case scenario one

Shift handover:

Identify:

Mr William Blue, HRN: 123456, DOB: 26/01/1953

Situation:

William (known as Bill) is a 68-year-old Indigenous man from a
remote community in the NT. He has been admitted to the CDU medical ward with Acute Kidney Injury (AKI) secondary to dehydration. He has a 3/7 history of confusion, fatigue, decreased
urine output, and decreased skin turgor. He has now been transferred to the CDU Medical ward for continuing care.

Background:

Bill lives with his wife, his 2 adult children and 6 grandchildren in a single storey home. His wife is supportive and the family help where possible. He is usually independent with his ADL’s. He has an extensive past medical history including: T2DM (on insulin), HTN, Hyperlipidaemia, chronic kidney disease
stage 3 (Baseline eGFR 40 ml/min/1.73m2), previous toe amputations due to diabetes and has a history of falls. No known drug allergies (NKDA). He is obese (BMI 30) he drinks 3 bottles of beer every night.

Assessment: Airway: Own, patent

Breathing: RR 23, O2 Sats 93% on RA.
Circulation: HR 62bpm, BP 95/65 mmHg.
Disability: GCS 14/15, he is drowsy and ‘wants to be left alone to sleep’.
Exposure: Temp 37.8 oC, BGL 3.9mmol/L Bill looks unwell. He is restless and confused. His urine is dark in
colour and offensive smelling. He has passed approximately 30 ml of urine in 6 hours. He had 2 x IVC’s inserted to both ACF’s and is not tolerating any food due to nausea. He last opened his bowels this morning and says it was ‘like liquid’.

Recommendations/Read back:

Medical orders
• Routine ward assessments and observations
• Strict fluid monitoring
• Administer Intravenous fluids as prescribed
• MSU for MC & S
• Diabetic diet and fluids as tolerated
• TED stockings and DVT prophylaxis
IV Fluid orders
• Intravenous compound sodium lactate (CSL) 500mls over
2 hours followed by:
• Intravenous sodium chloride 1000mls/8 hourly.
Medication orders
• Furosemide 10mg BD (IV)
• Ramipril OD (PO)
• Insulin Glargine 30 Units OD (s/c)
Nursing orders
• Devise a plan of care for your patient