Help me, please! I am supposed to write a report for a doctor on a patient in ICU. Pt has AMI, DKA, metabolic acidosis. She is on several critical drips, her VS are not the greatest, you get the picture? Well, my problem is that I have no idea what all the doctor would be looking for. I prepared the report for the nurse coming on duty, but what does the information for the doctor look like??? I have not yet had to do one of these and do not want to forget any vital information that a doctor would need. Below is the report I prepared for the nurse taking over care of the client. Would you critique it and tell me what your doctors expect of you? Thanks a million in advance.
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Prepare report for nurse receiving client or assuming care. Prioritize appropriately.
Mrs. X is a 70 year-old female admitted with acute myocardial infarction, diabetic ketoacidosis, right upper lobe pneumonia, metabolic acidosis, and dehydration. She is allergic to Sulfa drugs. She’s sedated, paralyzed, her pupil reaction is sluggish, and she responds to painful stimulus. She is intubated. The tube measures 21 at the lip. Her ventilator settings are: TV – 500; rate – 16; FiO2 – 50%; PEEP – 3. She has coorifice crackles bilaterally. Her respirations are even and unlabored.
Her mean arterial pressure is 67. She’s been running a sinus-tach rhythm. Her BP has been in the 90’s/50’s, pulses are 1+ pedal and radial bilaterally. She has a Foley. Her urine output has been 8 ml/h for the last three hours. She has a central line on the right internal jugular. She has an arterial line in the right brachial artery and 2 IV lines on her left forearm above the wrist. She is receiving dopamine, 3 mcg/min; propofol, 45 mcg/min; Levophed, 16 mcg/min; amiodarone; 16.6 ml/h; and regular insulin, 4 units/h.
A Swan – Ganz catheter insertion was attempted unsuccessfully. Internal jugular vein was hard to visualize and International Normalized Ratio was 1.9. Three units of fresh frozen plasma were ordered and administered via open line at 1800 hours. A vitamin K injection (1 ml) was administered on the left lower abdominal quadrant. Vasopressin (50 ml) is to be administered 30 minutes before the doctor attempts the catheter insertion again at 2100 hours. It is in the refrigerator.
