NRNP 6566: Advanced Care of Adults in Acute Settings Paper

NRNP 6566: Advanced Care of Adults in Acute Settings Paper

NRNP 6566: Advanced Care of Adults in Acute Settings Paper

Admission Orders Sample paper
Primary Diagnosis: The patient has recently developed atrial fibrillation accompanied by a rapid ventricular response, commonly referred to as A-fib with RVR. The patient is undergoing transfer from the ED to the CTU for the purpose of receiving comprehensive monitoring of their heart rate, rhythm, and vital signs. The patient’s sinus rhythm was restored upon administration of 2.5 mg Metoprolol Tartrate via intravenous push in the ER (Vitolo et al., 2020).

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Status/Condition:Stable

Code Status: Full Code

Allergies: Sulfa Drugs, which cause anaphylaxis in patient

Admit to Unit: Cardiac Telemetry Unit: The clinician assigned to this unit is the admitting physician.

Activity Level:Ambulate as tolerated

Diet: Heart-healthy light diet; no additional salt. Depending on the patient’s tolerance, nursing may progress the diet to a complete Heart Healthy diet (Hindricks et al., 2020).

IV Fluids:

• 100 ml/hour of normal saline is used to hydrate patients and keep IV access open. 1 Leiter should be administered. After one Leiter, the patient will be reevaluated to see whether they are getting enough fluids by mouth; if not, more IV fluids will be recommended (Vitolo et al., 2020).
• Critical Drips:None as of yet. When 2.5 mg of metoprolol tartrate IV was first pushed into the patient’s vein at the emergency department, the patient’s heartbeat returned to sinus rhythm. Continuous heart rate monitoring will be used to determine if further pharmaceutical treatments are necessary if the patient returns to A-fib (Romiti et al., 2021).

Respiratory:For comfort and cardiac support, a 2 L nasal cannula is used. For the patient’s comfort, reduce oxygen as tolerated. Contact a doctor if the patient’s respiratory distress or oxygen needs rise (Romiti et al., 2021).

Medications:
• Lisinopril 10 mg Orally once daily (home dosage is 20 mg daily; when hospitalized, try 10 mg daily with metoprolol tartrate) (Hindricks et al., 2020).
• Metoprolol tartrate 12.5 mg Orally two times per day.
• Daily dose of 81 mg aspirin (Anticoagulant).
• Every 12 hours, Subcutaneous Heparin 5000 Units (DVT Prophylaxis Anticoagulant).
• 650mg of Tylenol every 6 hours if needed (Mild Pain or Fever).
• Metoprolol tartrate 2.5 mg through intravenous push for persistent A-fib with a heart rate of >140, inform the doctor (Vitolo et al., 2020).

Nursing Orders:
• Monitoring of cardiac rhythm and rate continuously. Get a quick EKG and call the doctor if the patient’s heart rate stays in A-fib for a continuous period of time over 140. (Vitolo et al., 2020).
• For the first 12 hours, vital signs such as oxygen saturation, blood pressure, temperature, and respiration rate must be checked every 4 hours. If stable, vital signs may subsequently be checked once each shift.
• To avoid skin deterioration when lying in bed, encourage regular position adjustments. As tolerated, bob.
• As permitted, ask to go to the bathroom.

Follow-Up Lab Tests:
• TSH, CBC, and CMP findings from the first lab tests performed in the ED were all within the normal range.
• Additional first laboratories to be gathered and evaluated at first include: BNP, cardiac troponin, D-dimer, urine analysis, and urine drug test.
• On admission morning, a fasting lipid profile is taken.
• CBC,MAG, BMP, and PHOS 5 labs must be conducted each morning while in the hospital (Romiti et al., 2021).
• Diagnostic testing: Consider 2D echo, 2 chest X-ray views, CT, CTA, and MRI if D-dimer

Consults:
• Newly diagnosed atrial fibrillation evaluation by a cardiologist, including discussion of anticoagulant therapy options and planning for post-hospitalization outpatient care (Vitolo et al., 2020).
• Consult a dietitian for guidance on how to go back to a heart-healthy diet after leaving the hospital.
• Get in touch with discharge planning to begin working on a discharge strategy and assess the patient’s home resources to ensure she will have all she needs to return home safely (Romiti et al., 2021).

Patient Education and Health Promotion:
• Educate the client about their use of drugs and alcohol in the recent past.
• Explain to the patient how alcohol or drug use might bring on atrial fibrillation.
• Patients should be made aware of any potential new medications they may be sent home with (Romiti et al., 2021).

Discharge Planning and Required Follow-Up Care:
Discharge Plan:
• If the patient exhibits sinus rhythm and demonstrates stability in all other aspects of the examination for a period of 24 hours, discharge may be considered provided that sufficient assistance is available at home (Romiti et al., 2021).
• Check that the patient and their loved ones have read and understand the discharge instructions. If these symptoms persist or worsen, you should seek immediate medical attention by calling 911(Hindricks et al., 2020).
• It is important to address any new medications with the patient and their family throughout the medication reconciliation process. Delivering medications to the pharmacy where they are filled is also necessary.
Follow Up Appointment:
• Schedule a post-discharge appointment with the primary care physician within two to four weeks after leaving the hospital (Romiti et al., 2021).
• During one to two weeks after hospital release, cardiologist post-hospital discharge follow-up visit.

References:
Hindricks, G., Potpara, T., Dagres, N., Arbelo, E., Bax, J. J., Blomström-Lundqvist, C., Boriani, G., Castella, M., Dan, G.-A., Dilaveris, P. E., Fauchier, L., Filippatos, G., Kalman, J. M., La Meir, M., Lane, D. A., Lebeau, J.-P., Lettino, M., Lip, G. Y. H., Pinto, F. J., & Thomas, G. N. (2020). 2020 ESC Guidelines for the Diagnosis and Management of Atrial Fibrillation Developed in Collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). European Heart Journal, 42(5). https://doi.org/10.1093/eurheartj/ehaa612
Romiti, G. F., Pastori, D., Rivera-Caravaca, J. M., Ding, W. Y., Gue, Y. X., Menichelli, D., Gumprecht, J., Kozieł, M., Yang, P.-S., Guo, Y., Lip, G. Y. H., & Proietti, M. (2021). Adherence to the “Atrial Fibrillation Better Care” Pathway in Patients with Atrial Fibrillation: Impact on Clinical Outcomes—A Systematic Review and Meta-Analysis of 285,000 Patients. Thrombosis and Haemostasis, 122(03), 406–414. https://doi.org/10.1055/a-1515-9630
Vitolo, M., Proietti, M., Harrison, S. L., Lane, D. A., Potpara, T. S., Boriani, G., & Gregory Y.H. Lip. (2020). The Euro Heart Survey and EURObservational Research Programme (EORP) in atrial fibrillation registries: contribution to epidemiology, clinical management and therapy of atrial fibrillation patients over the last 20 years. 15(7), 1183–1192. https://doi.org/10.1007/s11739-020-02405-0

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Using the required admission orders template found under the Learning Resources: Required Reading.

Develop a set of orders as the admitting provider.

Be sure to address each aspect of the order template

Write the orders as you would in the patient’s chart. Be specific. Do not leave room for the nurse to interpret your orders.

Do not assume anything has already been done/order. Use the information given. Example: If the case does not mention fluids were given, the patient did not receive fluids. You may have to start from scratch as if you are working in the ER. And you must provide orders if the patient needs to be admitted.

Make sure the order is complete and applicable to the patient.

Make sure you provide rationales for your labs and diagnostics and anything else you feel the need to explain. This should be done at the end of the order set – not included with the order.

Please do not write per protocol. We do not know what your protocol is and you need to demonstrate what is the appropriate standard of care for this patient.

A minimum of three current (within the last 5 years), evidenced based references are required.

Please include introduction and conclusion