Doctor

The patient is 61 old male with a history of HPN and hyperlipidemia. His home medications include
enalapril, atorvastatin and baby aspirin daily. He weighs 100kg and smokes one pack of cigarettes per
day. He is allergic to penicillin. The Patient presented to the ER three days ago with complaints of
abdominal pain and yellow skin and had an emergency open cholecystectomy for obstructive jaundice.
He was admitted to the medical- surgical unit post operatively. On the second Postoperative day, his IV
was converted to a saline lock and clear liquid diet ordered. On the third morning, he hags nausea,
vomiting, absent bowel sounds, urine output 250mL/12 hour shift, and low grade fever. He has not had
a bowel movement, His surgical wound is positive for methicillin resistant S.aureus(MRSA), which is now
being treated with vancomycin, He is in contact isolation.

Doctors order:
Vancomycin 1g IVPB q12
Enalapril 20 mg PO Once daily
Atorvastatin 10 mg PO Once daily
Hydromorphone 1-2mg every 2-4 hours IVP prn pain
Promethazine 12.5 mg IV every 6hours prn nausea
Oxycodone 5 mg/ acetaminophen 325mg 1-2 PO every 4-6 hours prn mild pain
Enoxaparin 40mg SQ once daily
Saline lock flush 0.9% NS every shift
CBC, electrolytes, Bun, creatinine, Glucose in AM
Incentive spirometer

Doctors order:
IV 0.9% NS 500ml Followed by: 150ml per hour
Discontinue vancomycin STAT ( if not already discontinued)
Continue to hold enalapril and enoxaparin
Urinary Catheter
Hourly Intake and Output
Nasogastric tube to low intermittent wall suction
NPO
Complete bedrest
O2 At 2LPM nasal Cannula; titrate to maintain O2sat greater than 92%
STAT electrolytes, BUN, Creatinine, Urinalyis, Urine osmolality, Urine sodium and call results

Doctors order:
Discontinue IV fluids, Saline lock IV
Continuous Cardiac monitoring
Consult nephrologist
Consult surgeon for dialysis catheter placement
Daily weights
Calcium gluconate 10% 4.5 mEq IVP slowly
Regular insulin 10 units IVP
Dextrose 50% 50 ml IVP
Sodium Polystrene sulfonate 50 g retention enema STAT
Potassium level Every 4 hours
Nurse
State#1: Initial assessment
HR= 110
BP=90/60
RR=28
02sat= 90%
Cardiac Rhythm= Sinus tachycardia
Breath Sounds= Muffled
Awake, alert, oriented x3
Pupils equal
Pain 1/10
Anxious related to vomiting
Bowel sounds absent
Urinary output=15 ml dark amber
Temp= 37.9 °C
Complains of nausea
Green and Yellow emesis

State#2: Condition deteriorating 3hours later

HR= 120
BP=100/70
RR=30
02sat= 89%
Cardiac Rhythm= Sinus tachycardia with PCVs
Heart sounds= S
Breath Sounds= rales
Restless
Pupils equal
Pain 1/10
Complains of shortness of breath
Urine output=10ml over past three hours

State#3; Slight improvement 1 hour later

HR= 110
BP=122/90
RR=24
02sat= 92%
Cardiac Rhythm= Sinus tachycardia
Breath Sounds= rales
Urine output= 10ml
Less restless

State#4: Improvement after dialysis

HR= 86
BP=110/68
RR=20
02sat= 98%
Cardiac Rhythm= Normal Sinus
Breath Sounds= Clear
Alert, oriented x3
Urine output= 10ml

Laboratory
State#1
CBC: WBC 12, Hgb 12, Hct 36%, Platelets 92
Chemistry: Na 150, K 5.2, Cl 116, CO2 18
Glucose 96, BUN 50, Creatinine 2.6

State #2
Chemistry: Na 141, K 6.7, Cl 109, CO2 22, BUN 40, Creatinine 3.2, Ratio 12.5:1, Glucose 122
UA: Dark Amber, Specific gravity 1.010, no WBC, no bacteria , brown granular casts and many epithelial
cells
Urine osmolality: 600
Urine Sodium: 10

State#3
The dialysis department is ready for the patient and will draw labs after dialysis is completed;
Weight prior to dialysis is 100kg

State#4
Chemistry: Na 143, K 4.5, Cl 103, CO2 23, BUN 38, Creatinine 3.1

IV supplies
20ga IV catheter 1
Saline Lock 1
Transparent dressing 1
Sterile water 1000 ml (label 0.9% NS) 1
Sterile water 250 ml (label D5W with 1g Vancomycin) 1
Primary Tubing 2
IV Pump 1
Oxygen supples
Oxygen flowmeter 1
Oxygen source 1
Nasal cannula 1
Oxygen masks 1 each
Incentive spirometer 1
Medications
Enema Bottle (label sodium polystyrene sulfonate 50g retention enema) 1
Bottle of water 100ml (label sorbitol) 1
Sterile water 10ml vial( label hydromorphone 2mg/ml, promethazine 25mg/ml, enoxaparin 8
40mg/ ml, regular insulin, NPH insulin, Humalog, dextrose 50%, Calcium gluconate 10%)
Sterile water prefilled syringe( label 0.9% NS) 8
Simulated oral medication ( label enalapril 20mg, atorvastatin 10mg, oxycodone 4
5mg/acemtaminophen 325mg x2)
Packet of lubricant (label Vitamin A and D ointment) 1
3ml Syringe 5
Insulin syringe 2
Catheter tip syringe 1
Dressing Supplies
6x9 Dressing 1
Gastrointestinal Supplies
14 Fr NGT 1
Tape 1
Irrigation kit or Catheter tip syringe 2
Water soluble Lubricant 2
Rectal Tube or 28 Fr urinary catheter with 30ml Balloon 1
Enema bag 1
Genitourinary Supplies
14 Fr Urinary Catheter insertion tray with Urimeter 1
Specimen Cup with label 1
Urinal 1
Sterile water 1000ml with 2ml, yellow food coloring for urine source 1
Miscellaneous
Egg whites 1
Bottle of yellow and green food coloring 1
Small jar of baby food peaches 1
Instant tea 1
Contact isolation sign 1
Emesis basin 1
Bedpan 1
Patient ID band 1
Chart with appropriate forms and order sheets 1
Nonsterile gloves 1 box
Stethoscope 1
BP cuff adapted for use with simulator 1
Sharps container 1
Video camera and tapes if recording 1
Monitor Required
ECG
NIBP
Sp02
Temperature