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1053.   You are an LPN working on a medical-surgical floor in a team that consists of an RN and a medical assistant. Read through some of the chart entries over a 48-hour period and answer the questions at the end. Please make sure you cite any sources using APA format. You will find when there is a major clue. 0130: Admission nurses note (RN): Client arrived via EMS from long-term-care for evaluation of “low blood sugar.” Pt. arrived confused (alert and oriented X 1) and is a known diabetic. Finger stick was 45. Orange juice and crackers, given repeat finger stick 104. Pt now alert and oriented X 4. Report from the charge nurse at the long-term-care facility indicates that the client has been having frequent bouts of hypoglycemia. 0530: (RN) Foley catheter inserted for incontinence–pt. “too weak” to get up to the bathroom and is experiencing bouts of incontinence. 600 mL clear yellow urine noted. The nurse indicates that the ER is “very busy” and “short-staffed.” 0545 (Admitting Physician) See history and physical. Pt. admitted to the medical-surgical service for evaluation of recurrent hypoglycemia. View the ER chart before the pt. is transferred to the floor: 0730: (RN) Report is given to RN on 3 North. Emergency Department Chart Client: Mabel Simpson DOB: 4/23/1941 Admission Date 8/16/2019 Medical Diagnosis: recurrent hypoglycemia Allergies: None Vitals/ Data Collection: Temp.- 97.3 PO History: Diabetes (insulin dependent)   Medications: Insulin R titrated to finger sticks Allergies: None Vitals/ Data Collection: Pulse- 68 History: Hypertension Medications: Furosemide 20 MG twice per day Allergies: None Vitals/ Data Collection: Respirations- 18 History: Atrial Fibrillation Medications: Warfarin 5 Mg Mon, Wed, Fri 2 Mg Tues, Thurs Allergies: None Vitals/ Data Collection: Blood Pressure- 122/86 History: Rheumatoid Arthritis    Medications: Enalapril 5 Mg once per day Allergies: None Vitals/ Data Collection: No C/O pain History: Mild Heart Failure (class 1) Medications: Proventil inhaler as needed for wheezing Allergies: None Vitals/ Data Collection: Alert and oriented X 4 History: Former Smoker- smoked 1 pack per day X 40 years- last smoked 10 years ago Medications: Methotrexate 2.5 Mg per day Allergies: None Vitals/ Data Collection: Lungs: No adventitious sounds History: Appendectomy as a child Medications: Tylenol 650 Mg as needed for pain or fever Allergies: None Vitals/ Data Collection: + Bowel sounds History: Mobility (baseline): able to ambulate slowly with minimal assist Clear yellow urine draining from Foley catheter in adequate amts. Medications:  Allergies: None Vitals/ Data Collection: Clear yellow urine draining from Foley catheter in adequate amts. History:  Medications:  Allergies: None 8/16/2019 10:00: (RN) Pt received on 3 North. Alert and oriented X 4. Fingerstick 81. Eating breakfast. Offering no complaints. 8/17/2019 (Medical Assistant) 0130: Sleeping Soundly 0700: (LPN) alert and oriented Finger stick 124. Offering no complaints. Medications given as ordered. Foley catheter draining cloudy yellow urine- RN notified. 1100: (Case Manager note): Pt. alert and oriented. Blood sugar stable. Will speak to the physician about discharge tomorrow morning. 1300: (Physical Therapy): Ambulated to the hallway 200 feet. Ambulates slowly- baseline as per long-term-care facility charge nurse. Recommend physical therapy after discharge, however, ambulated well enough for discharge. 1600: (LPN) Pt found to be confused (alert and oriented X 1). RN notified. Fingerstick 130. Vitals 97.5 (axillary), 110, 24, 98/64 1800: (Medical assistant) 400 cc’s emptied from catheter bag. 0100: (RN) Pt confused and combative. Attempting to pull out her IV and repeatedly removing her gown. Pt’s physician was paged- ordered Lorazepam 1 MG IM. Medicated as ordered and slept the remainder of the night with no incident. 0700: (RN) Pt awake and alert but combative. Finger stick-124. Vitals: 98.9 (axillary), 116, 28, 90/55 1730: (LPN) Unable to administer medication. Pt appears extremely confused. RN notified. 1200: (LPN) Pt’s daughter at bedside. Daughter indicates that her mother is not normally confused and is concerned that she may have had a stroke and notes that her mom feels “very warm.” RN notified. Foley catheter draining cloudy urine. 1230: (Medical Assistant) Vital signs: T 103.6 (rectal), P=130, BP=84/43, resp rate=28 1300: (RN) Rapid response called (because of the change in condition) and client transferred to the ICU. Update: The client spent 3 days in the ICU but unfortunately did not recover. Please answer the following questions: Why did this client become confused and combative? (5-10 sentences) What pivotal decision made in the ER directly caused this client’s worsening condition? (1-2 sentences) What type of incontinence did this client have? Explain your answer. (5-10 sentences) What factors in the client’s medical history contributed to the client’s change in condition? (5-10 sentences) How did communication (or lack thereof) contribute to the poor outcome for this client? (5-10 sentences)



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