Exam NURS6550 Ihuman Tom Bradford case study QUESTIONS AND ANSWERS TESTED AND CONFIRMED A+ ANSWER

Exam NURS6550 Ihuman Tom Bradford case study QUESTIONS AND ANSWERS TESTED AND CONFIRMED A+ ANSWER

NURS6550wk6Ihuman: Tom Bradford
Admission Orders (do not write an explanation of the order(s), ONLY the order)
1. DX: (1) primary dx (2) secondary “relevant” dx
2. Admit to: , stable/unstable/critical/etc., Dr. “you pick the name”, call upon
arrival with rm #
3. Isolation/Precautions:
4. Allergies:
5. Diet:
6. Activity:
7. IV: how many? SL
8. IVF:
9. LABS: only what you need done upon arrival (not a repeat of prev. ordered meds)
10. AM LABS:
11. RADS (US, CT, XRAYs)/Diagnostic tests:
12. PT/OT/Nutrition/SW/Pysch/etc. Consults?
13. Consult: Specialty services
14. Screening (s): HIV, TB, PNA vaccine, flu shots, etc.
15. Medications:
• Medication (full instructions, no nicknames) and END date
• Medication
• Medication
Plan Rationale and Supporting Documentation
1. DX: why?
2. Admit to , why?
3. 3. Isolation/Precautions, why?
4. Allergies: no rationale/sup. Documentation needed
History
Tom Bradford 71-year-old
6’0 180 BMI: 24.4 Normal
severe sharp abdominal pain for the past four hours
not radiating
history ofsmoking
hx of HTN Afib
on aspirin at times
metoprolol Lisinopril
Provoking: ate oatmeal
Does not follow regular diet
nausea and vomiting
1 loose stool
Assessment
mild tenderness to palpation
Afib
Irregular pulse rate
T:97.9
P:120
R:24
BP:119/64
HPI: 125 words
Tom Bradford is a 71-year-old male patient who presented with an acute onset of severe
abdominal pain for the past four hours. He described his pain as sharp and non-radiating with the
severity of 10/10 and reported that his symptoms started after eating oatmeal for breakfast.
Associated symptoms include one episode of loose stool, nausea, and vomiting with shortness of
breath and palpitations. The patient is a chronic smoker for the past 50 years, and his medical
history includes hypertension, CAD and atrial fibrillation status post cardioversion. He has no
known allergies and is currently taking Metoprolol, Lisinopril, and Aspirin. Clinical findings
during physical examination revealed tachypnea, tachycardia with irregularly heart rhythm, mild
diffuse abdominal tenderness and positive stool for occult blood.
Lab test:
WBC:18
Potassium: 3.2 (low)
ECG:
Afib 150
Abd CT:
• Abdominal CT: pneumatosis intestinalis (air in bowel wall)
• No evidence of pneumoperitoneum
CT Angio:
image study not available
Findings: The CT angiogram of the abdomen shows occlusion of superior mesenteric artery
(SMA)
Admission Orders:
1. DX: (1) Acute Mesenteric Ischemia with thromboembolic occlusion of mesenteric
arteries
2. Admit to: ICU due to unstable and high risk hemodynamic instability second to acute
occlusive mesenteric ischemia. Under Dr. YM call upon arrival with rm #777.
3. Isolation/Precautions: Standard
4. Allergies: NKA
5. Diet: NPO
6. Activity: Bedrest
7. IV: Insert peripheral line to start medication and IV Fluids resuscitation.
8. IVF:
20 mEq/L Potassium Chloride in 0.9% Sodium Chloride Injection @ 100cc per hour
9. LABS:
Recheck potassium level after completing first bag of IVF
Blood type and cross match
PT, PTT and INR after six hours
10. AM LABS:
Recheck CBC BMP in AM
Recheck PT, PTT and INR in AM
11. RADS (US, CT, XRAYs)/Diagnostic tests:
CT angiogram of the abdomen to confirm diagnosis (if not done)
Continuous telemetry monitoring
Central line insertion for hemodynamic monitoring

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