Reference no: EM133657148
Situation: Millie Larsen is an 84-year-old female brought to the emergency department (ED) with confusion by her daughter.
Background: When Millie Larsen's daughter stopped by yesterday evening at 180, and found that she was not making sense or acting like herself. She brought her to the ED around 2000 and a decision was made to admit her, but she remained in ED all night until a bed became available early this morning. Millie Larsen has a history of hypertension, glaucoma, osteoporosis, osteoarthritis of the right knee, hypercholesteremia and stress incontinence. It is unclear whether she has taken her medications properly the past few days; her daughter couldn't tell by looking at her medication box.
Assessment: Millie Larsen's last vital signs at 0630 were: respiration 16 per minute, oxygen saturation 96% on room air, heart rate 82 bpm, blood pressure 184/94 mm Hg, temperature 36.7 oC. She is not oriented to time or place and seems quite confused. She has an IV of Lactated Ringer's running at 60 mL/hour. An ECG with normal findings was done on arrived in the emergency department and abs were draw. She has 12,000 WBCs, sodium level of 152 mol/L, and a urine specific gravity of 1.050, and is voiding small amounts of dark amber foul-smelling urine. She was straight catheterized in the emergency department and the results of the urinalysis are on the first dose at 2100 in the ED. Her primary physician Dr. Lund was notified of her admission and wrote orders for her meds, I just gave her 0800 medications. I wanted to get her morning meds started as her blood pressure is starting to increase. She says she is not experiencing any pain. I started admission.
Recommendation: Please do vitals, perform a head-to- assessment, administer the CAM and SPICES tools and notify Dr. Lund of her condition.
1. Based on the information provided when gathering data using the confusion Assessment Method instrument, the informs Dina that her mother's delirium is likely related the UTI and should resolve as the infection is treated. Based on this finding, current vital signs, and lab values including a sodium level of 148, potassium level of 4.8, BUN of 30, and creatinine level of 1.5, the nurse recognizes the need to prioritize which of the following nursing interventions for Millie Larsen? (select all that apply.)
2. Millie Larsen's daughter Dina is requesting that Millie be relocated to an assisted living facility upon discharge, even if her current delirium resolves. In partnership with Dina, the nurse utilizes the SPICES assessment tool to assist in making appropriate discharge assessments. Which of the following questions would likely be asked as part of this assessment? Select all that apply.
3. The nurse begins asking Dina questions utilizing the confusion Assessment Method (CAM) tool. Which assessment questions asked of Millie's daughter Dina support the goal of the tool. (select all that apply)
4. The nurse is addressing Millie Larsen's high blood pressure and is providing education regarding the use of Captopril. Which of the following statements, when made by the patient's daughter, would indicate the need for further education? (select all that apply.)