Case study has a history of hypertension and osteoarthritis Allergies

Case study has a history of hypertension and osteoarthritis Allergies: No known drug allergies Medications: Celecoxib and hydrochlorothiazide Code Status: Full Code Social/Family History: Lives alone in a small home without air conditioning. Married daughter visits regularly. Daughter at the bedside. Handoff Report Situation: This patient is a 72-year-old male who is being transferred from the ED. A diagnosis of rhabdomyolysis is suspected, precipitated by heat exhaustion. In the ED, an IV was started, an indwelling urinary catheter was inserted and labs were drawn. He was hydrated with a 500 mL 0.9% normal saline (NS) bolus. Due to his low urine output, cola-colored urine, altered level of consciousness and pending labs, he is being admitted to the Medical Unit. Admitting orders have been written and are on the chart. Background: The patient’s daughter found him on the floor of his kitchen this morning dressed in the same clothes he had on yesterday. He was on his back, incontinent of urine, confused and speaking gibberish. It is believed that he was lying on the floor most of yesterday, unable to call for help. There has been an extreme heat wave for the last several weeks. The patient’s home does not have air conditioning. The patient lives alone and has had the flu, along with vomiting and anorexia for the past week. It is unclear why or how he fell. According to his daughter, he is in relatively good health but has hypertension and osteoarthritis. He is alert but disoriented to time and place. He is anxious and asking for his daughter. He complains of dizziness, muscle pain, cramps and fatigue. He has no known allergies. Assessment: Vital Signs: HR 118, BP 80/60, RR 22, Temp 39.80C General Appearance: Anxious, appears older than stated age Cardiovascular: Sinus tachycardia Respiratory: Breath sounds clear bilaterally Program for Nursing Curriculum Integration (PNCI®) Heat Exhaustion (C 2009 MeT.Sarasota. METI Learning Heat Exhaustion PNCI – Learner Gl: Active bowel sounds, complains of nausea, no vomiting GU: A urinary catheter was inserted in the ED and is draining 30 mL/hour, cola-colored urine Extremities: Cool, pale, sluggish turgor. Movement is weak in all four extremities, complains of muscle pain and severe cramps in legs and lower back when extremities are moved. Skin: Cool, ashen gray, sluggish turgor Neurological: Alert, drowsy, oriented to person, disoriented to place and time. Pupils equal, round and reactive to light and accommodation. No neurological deficits noted Is: 20-gauge IV to saline lock in the right forearm. Insertion site non-reddened Labs: Lab values are pending Fall Risk: High-risk Pain: Complains of pain in legs and lower back Recommendations: Implement admission orders and monitor for instability. Orders Initial Healthcare Provider’s Orders: Admit to Medical Unit Vital signs every 2 hours Telemetry monitoring Continue cooling measures until temperature is less than 38.3°C • Icepacks to groin, neck and torso

• Evaporative cooling with a high-speed fan in room Notify healthcare provider if patient starts to shiver Notify healthcare provider if heart rate less than

 

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