Karen is a 28 year old female who just arrived on the ward via ED this evening. She is currently receiving treatment for acute myeloid leukaemia and self-presented to ED with fevers, chills, and pain with urinating.
Vital signs in ED were:
- Temp: 37.8ºC
- BP: 100/60mmHg
- HR: 110bpm and regular
- RR: 20bpm
- SpO2: 98% on room air.
- IV fluids: Hartmann’s 1L flask running at 125mls/hr commenced 4 hours ago via a PICC line.
Collect Cues/Information
Your assessment on arrival to the ward finds the following:
- Mucous membranes are dry with poor skin turgor
- Temp: 38.5ºC
- BP: 95/55mmHg
- HR: 115bpm and regular
- RR: 20bpm
- SpO2: 98% on room air.
What further cues and information would be useful? Why?
– Pain assessment
– Urine MSU and urinalysis to determine if there’s any abnormalities
– Blood cultures to determine if there is an infection
– Her recent fluid intake to determine if dehydrated
– Bladder scan to see if she is retaining any urine
– Full medical and social history
Process Information
What changes do you notice in the cues and information provided?
– BP has decreased from 100/60mmHg to 95/55mmHg, now hypotensive
– Temp has increased to 38.5 from 37.8, hyperthermic
– Mucous membranes are dry with poor skin turgor
– HR has increased from 110bpm to 115bpm, tachycardic
Which changes are significant for this patient and why?
– The increased temperature is significant as it can show that she is fighting off an infection. Decreased BP and mucous membranes being dry with poor skin turgor can be a result of dehydration. Each of these is important as Karen is undergoing treatment for myeloid leukaemia and can therefore not fight off infections (Advances in Cancer Treatment, 2021).
What do you think these changes could indicate and why?
– These changes could mean she is dehydrated and fighting a possible Urinary tract infection (Yang, & Foley, 2020).
What could be the outcome of these changes?
– Patient deterioration
– Urosepsis
Identify Problems/issues
Given the facts that you have available and comparing those to what you think the changes could indicate identify one potential patient problem/issue.
– One potential patient problem as identified above is dehydration. Due to the painful urination, Karen may be limiting her fluid intake which has therefore resulted in dry mucous membranes and poor skin turgor
Establish Goals
Describe what you want to happen.
– Increase Karen’s fluid intake orally and maintain their current IVF
– Increase blood pressure to normal ranges
– Decrease temperature to be between the normal ranges
– Manage pain when urinating
– Chase urine MSU results
– Chase blood results
Who do you want to be involved and what do you want them to do?
– Nurses: to do regular observations, manage IVF, administer analgesia as per chart or as requested
– Doctors: read blood culture and MSU results, chart fluids, chart analgesia
– Karen: maintain good oral intake
In what timeframe?
– Next 1-4hrs
Take Action
What nursing actions will you take?
– Keep the fluid balance chart updated
– Regular vital signs
– Patient Education
– Discuss with the doctors and create a plan with them
– Complete a urinalysis and bladder scan
– Collect urine for MSU
What will be your nursing priorities?
– To stabilise her vital signs – BP, HR and temp
– Increase fluid intake
– Manage pain when urinating
Evaluate Outcomes
What do you expect to achieve from the actions have taken?
– Improve skin turgor and moisture in mucous membranes
– Improve the fluid intake
– Vital signs which are between the flags and normal for the patient
– Identify the cause of pain when urination i.e., UTI
– Create a patient-centred treatment plan
Reflect on Process and new learning
– This has taught me the importance of looking at the whole patient situation and not focus in on just the one issues
What have you learnt from this exercise?
– This exercise has taught me the importance of implementing the clinical reasoning cycle when managing a deteriorating patient.
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