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1. What is the primary problem your patient is most likely presenting? (Management of Care/Physiologic Adaptation) 2. What are the most common signs and symptoms of acute delirium? 3. What signs and symptoms is this patient presenting with that are consistent with acute delirium? 4. What is the underlying cause/pathophysiology of this primary problem? (Management of Care/Physiologic Adaptation) 5. What is a CAM assessment and how will it help assess delirium in this patient? 6. Using the CAM assessment tool, does John meet diagnostic criteria for acute delirium? Basic Metabolic Panel (BMP:) Current: High/Low/WNL? Prior to Admission: Sodium (135-145 mEq/L) 134 136 Potassium (3.5-5.0 mEq/L) 3.6 3.7 Glucose (70-110 mg/dL) 72 114 Creatinine (0.6-1.2 mg/dL) 1.1 0.8 Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome: Discontinue Foley catheter Reinsert IV and saline lock Haloperidol 1-2 mg IV PRN every 4 hours Quetiapine 50 mg PO at bedtime Acetaminophen 500 mg PO every 4 hours PRN pain 12 lead EKG One to one sitter PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders: Order of Priority: Rationale: • Quetiapine 50 mg PO at bedtime • 12 lead EKG • One to one sitter • Reinsert IV and saline lock • Haloperidol 1-2 mg IV PRN every 4 hours • Acetaminophen 500 mg PO every 4 hours PRN pain Collaborative Care: Nursing 7. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY) (Management of Care) 8. What interventions will you initiate based on this priority? (Management of Care) Nursing Interventions: Rationale: Expected Outcome: Copyright © 2018 Keith Rischer, d/b/a KeithRN. All Rights reserved. 9. What body system(s) will you assess most thoroughly based on the primary/priority concern? (Reduction of Risk Potential/Physiologic Adaptation) 10. What is the worst possible/most likely complication to anticipate? (Reduction of Risk Potential/Physiologic Adaptation) 11. What nursing assessments will identify this complication EARLY if it develops? (Reduction of Risk Potential/Physiologic Adaptation) 12. What nursing interventions will you initiate if this complication develops? (Reduction of Risk Potential/Physiologic Adaptation) 13. What psychosocial needs will this patient and/or family likely have that will need to be addressed? (Psychosocial Integrity/Basic Care and Comfort) 14. How can the nurse address these psychosocial needs? (Psychosocial Integrity/Basic Care and Comfort) Evaluation Evaluate the response of your patient to nursing and medical interventions during your shift. All physician orders have been implemented under medical management. Two hours later… Current VS: Most Recent: Current PQRST: T: 98.8 F/37.1 C (oral) T: 99.1 F/37.3 C (oral) Provoking/Palliative: P: 74 (regular) P: 102 (regular) Quality: Sleeping, unable to determine R: 14 (regular) R: 18 (regular) Region/Radiation: BP: 114/64 BP: 155/65 Severity: O2 sat: 93% room air O2 sat: 95% room air Timing: John is resting comfortably and appears to be sleeping in his bed. He received a to

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HEALTH SCIENCE
NURSING
NURSING MEDICAL SU

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