Patient is a 63-year-old man, Sam, who is a retired clown working in children’s

Patient is a 63-year-old man, Sam, who is a retired clown working in children’s’  parties. He stands 5’9″ and weighs 183lbs. He is a known smoker, hypertensive  and diabetic. He claims he is on amlodipine 10 mg and metformin 500 mg twice a  day for his hypertension and diabetes control respectively. His blood pressure and  sugar control were unknown prior to this day. Sam presented with a two-week history of fever, dry cough, shortness of breath,  diarrhea, headache and sore throat. On account of the above symptoms, he  managed himself with over-the-counter medications such as Biogesic, loperamide, and Bactidol with no improvement. Hence, medical consult. Nasopharyngeal and oropharyngeal swabs were taken for PCR test for COVID-19 which turned out  positive. Patient was referred to the isolation center at FUMC for further management. On arrival at the isolation center, Sam was in respiratory distress and was hooked on to a cardiac monitoring device. The following were obtained: a respiratory rate of 40 breaths/min, oxygen  saturation was 83% on room air, temperature was 36.4°C, pulse rate was 106 beats/minute, blood  pressure was 140/90 mmHg. The random blood sugar at presentation was 7.2 mmol/L. An initial  diagnosis of severe COVID-19 pneumonia was made. The following laboratory and diagnostic procedures were done: chest radiograph, complete blood  count, blood culture, electrolytes, urea and creatinine, fasting blood sugar and gene expert to  exclude pulmonary tuberculosis. The complete blood count showed a white blood count of 11.6 ×  109/L with a differential neutrophil count of 66% and lymphocyte count of 14%. His platelet count of 581 × 109/L. The liver function and renal function tests were essentially normal. Blood culture showed  no bacterial growth. Gene expert was negative for Mycobacterium tuberculosis; HIV, HBV and HCV  screen were all negative. Fasting blood sugar done the following morning was 10.4 mmol/L and he  was commenced on soluble insulin 6 IU pre-meal. C-reactive protein was 212 mg/L (normal range  0-5 mg/L). D-dimer was > 5 µg/ml (normal value < 0.5 µg/ml). Chest radiograph showed bilateral  ground glass opacities in both lung fields. He was started on intravenous Ceftriaxone 1 gram every 12 hours, hydroxychloroquine 400 mg every  12 hours on day 1, then 200 mg subsequently, Zinc sulphate 220 mg daily, Azithromycin 500 mg  daily, Lopinavir/ritonavir 400 mg every 12 hours, Vitamin C 200 mg three times a day. Intranasal  oxygen was commenced at the rate of 5 liters/min. He was also ordered for subcutaneous low  molecular weight heparin at 40 mg daily. Patient continued to deteriorate despite above measures with persistently low oxygen saturation  below 92%. Oxygen delivery was switched from use of intranasal catheter to mechanical ventilation. Feeding is now done via an intranasally-inserted feeding tube.TASKS: Complete the following activities to provide high quality, individualized care for the patient following proper and correct protocol / guidelines in the care of clients infected with coronavirus. 1. Comprehensive Assessment (15 mins) – Collect, organize and document information about  the patient. Data will be used to: a. Complete the client’s health record. b. Perform a quick and comprehensive assessment of the client’s hospital admission. c. Implement the relevant and appropriate assessment methods. 2. Implementing Care (20 minutes) a. Perform the necessary nursing procedures (not limited to): placing client on cardiac  monitoring, client oxygenation, feeding tube insertion, suctioning, obtaining specimen for  random blood sugar test. b. Prepare, administer, and document the ordered medications. (Recall correct procedure in  medication administration.) 3. Ongoing Care (15 minutes) – document the care that has been provided as follows: a. Using the FDAR format – so that this is communicated with the healthcare team. b. Discharge instructions (METHODS) WORKSHEET Patient Records PATIENT DETAILS  Name                 Sam                                        Age:Gender       Male              FemaleCivil Status      Single         Married          Divorced        WidowedAddress1 Sumulong Highway, Fatima Village, Antipolo CityDate of BirthApril 09,1958Hospital numberFUMC-123-456Attending PhysicianDr. MoHeight (cm) Weight (kg) 1. Admitting Diagnosis:   2. History of Present Illness  3. Family History4. Past medication5. Allergies6. Medication7. Social History Medication ChartPATIENT DETAILS                       DIAGNOSIS: ________________________ Name:                                                                      Age:  Gender:       Male               Female Civil Status:             Single             Married          Divorced        Widowed Address:      Date of Birth:Hospital Number:Attending Physician:Height (cm):Weight (kg): MEDICATION: dose, route, frequency TIME SUN MON TUES WED THURS FRI SAT                                                        Nurse’s NotesF: D:   A;                                     R:   Discharge PlanPATIENT DETAILS DIAGNOSIS: ________________________Name:                                              Age:  Gender:       Male                Female Civil Status:             Single             Married           Divorced       Widowed  Address:Date of Birth:Hospital Number: Attending Physician: Height (cm):Weight (kg):Discharge Goal: ______ Return to Home (self-care) ______ Return to Home but needs Assistance ______ Transfer to other Level of Institutional Care ______ Referral to Support Community Services’ ______ Home Against Medical Advice Discharge Plan Date: M    Time:  E     T     H     O     D     Kwaghe, V., et al. (2021). Fulminant COVID-19 Pneumonia in a 53-Yr Old Man: A Case Report, Journal of Infectious Diseases and Epidemiology. DOI: 10.23937/2474-3658/1510149 Rong-hui, D., et al. (2020). Predictors of Mortality for Patients with COVID 19 Pneumonia Caused by SARS-CoV-2: A Prospective Cohort Study, European Respiratory Journal. DOI: 10.1183/13993003.00524-2020 Chong, W., Saha, B., Chopra, A. (September-October 2021). Does COVID-19 pneumonia signify  secondary organizing pneumonia?: A narrative review comparing the similarities between these  two distinct entities. Heart & Lung, 50(5), pp.667-674.  https://www.sciencedirect.com/science/article/pii/S0147956321001734Nassar, Y., et al. (2021). Outcomes and risk factors for death in patients with coronavirus disease 2019 (COVID-19) pneumonia admitted to the intensive care units of an Egyptian University  Hospital. A retrospective cohort study. Journal of Infection and Public Health. https://www.sciencedirect.com/science/article/pii/S187 Health Science Science Nursing NUR MM21 Share EmailCopy link Comments (0)

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