iHuman Amka Oxendine- Pre-work & All Sections with Answer & SBAR note.

iHuman Amka Oxendine- Pre-work & All Sections with Answer & SBAR note. 19 y/o F, 5’3”, 127 lbs. Dx: Acute acetaminophen ingestion Brought vis EMS to ER with c/o abd pain with nausea. EMS reports ingestion of acetam ...

iHuman Amka Oxendine- Pre-work & All Sections with Answer & SBAR note. 19 y/o F, 5’3”, 127 lbs. Dx: Acute acetaminophen ingestion Brought vis EMS to ER with c/o abd pain with nausea. EMS reports ingestion of acetaminophen for SI. 58 kg. Full Code. VS q1hr x4, a2hr, q4hr. NPO. NKDA. SI precautions until psychiatrist Denies ingestion of salicylates, ETOH or other substances within in 24 hr. Four hours later after waking up had second thoughts and call EMS. 58 kg. Full Code. VS q1hr x4, a2hr, q4hr. NPO. NIKA. SI precautions until psychiatrist 1. What is your primary concers for this patient and what assessments and interventions would be associated with your concerns and why? My primary concern would be to assess for Airway Breathing Circulation- SOB, CP, and palpitations. I would assess for unusual bleeding as a priority. Next I would perform a neurovascular check, noting PERRLA. I would also be aware of s/s of liver failure: anorexia, n/v, fatigue, excessive sweating and confusion. The interventions I would perform: 1. Assessing time of ingestion***, Quantity/Strength, and reason. 2. Consider evaluating for other co-ingestions (e.g., salicylates, tricyclic antidepressants, ethanol, ethylene glycol, methanol) especially since this is a known suicide attempt. 3. Since patients with acetaminophen toxicity can develop not only liver failure, but also renal failure, coagulopathy due to liver failure, and acid base disturbances, will monitor for the following additional labs (serum creatinine, urinalysis, lactic acid level, arterial blood gas, venous blood gas). Serial labs will likely be needed to determine the clinical course of the patient. 4. Utilize oxygen therapy if pt is noted to be in respiratory distress. 5. Give IV fluid and draw labs for Paracetamol blood level. 6. Provide antidote of N-acetylcysteine as prescribed. 7. Activated charcoal should be administered as soon as possible, usually within 1- 2 hours of the exposure as prescribed. 2. What medications do you anticipate the health care provider would prescribe while the patient is in the hospital and why? 1. Activated charcoal to halt the absorption of acetaminophen in the stomach typically within 1-2 hours of exposure. It acts by binding to the pharmaceutical drugs or poisons i.e. organophosphates and decreasing the systemic absorption of toxic agents. 2. N-Acetylcysteine is a precursor of glutathione. It enhances sulfate conjugation of unmetabolized APAP, functions as an anti-inflammatory and antioxidant, and has positive inotropic effects. It increases local nitric oxide concentrations and promotes microcirculatory blood flow, enhancing local oxygen delivery to peripheral tissues. 3. Cimetidine to slow the effect of acetaminophen 4. Anti-emetics to assist with n/v 5. 0.9% NS to provide hydration from fluid loss due to nausea EHR findings: 58 kg. Full Code. VS q1hr x4, a2hr, q4hr. NPO. NIKA. SI precautions until psychiatrist IP MEDS: NAC 150mg/kg IV in 200 ml D5w over 60 mins IV, then 50mg/kg 500 mL IV in 4hr and 100,g/kg in 1000 mL over 16hr IV NS 75mL/hr Albuterol 2.5 mg q20min x 3 doses continuous prn bronchospasm Diphendrdraminine 50 mg IV prn rash EKG. Hx: Depression dx: age 15. On antidepressant therapy since 16. Meds: Fluoxetine 20 mg 1 tab po daily NKDA Social: Freshman at college, lives in dorms. Server at local restaurant. Single Denies etoh/cig. +exercise Tylenol level: 150 ug/mL **toxic >250 12 EKG: NSR EHR MC ANSWERS: Nausea, Abd pain, pale, warm, diaphoretic skin, elevated APAP levels, SI precautions HX FINDINGS: warm, diaphoretic skin, IV Site LAC is kind of itchy fatigue, depression since HS, SI attempt in HS. "too much going on" and mood not good failing classes, no friends in college. bf broke up with her depression depends on day: sleep -/+, appetite +/-, isolation. + hopelessness, +dad depression, +anxiety parents + hopelessness, +dad depression, +anxiety parents HX EXERCISE ANSWER: No risk for falls. Score 20 for IV. HX MC ANSWER: Depression, Nausea, Past SI attempt, recent stressors, Pruritus at IV site. PHYSICAL FINDINGS: LAC patients, erythema surrounding IV site, extending beyond dressing T: 99.7 P:66 RR: 12 Spo2: 96% BP: 116/72 Pain: 0/10 a/ox4 pale, warm and diaphoretic, multiple scarred areas of various lengths on medical thighs bilateral, eurythmic rash at IV site PHYSICAL FINDINGS EXERCISE: Exercise 1: Braden Skin Assessment: 20 -> mild risk Exercise 2: Diphenhydramine 50 mg Exercise 3: Does patient meet SIRS-> NO. PHYSICAL FINDING MC ANSWER: Non-tender abd, erythemic rash, warm, diaphoretic skin, scars on thighs Physical Findings: erythemic rash adverse event of NAC, bronchospasm, dyspnea, hypotension. Pale warm and diaphoretic 4 phases. First phase: n/v, malaise. SBAR NOTE: S: 19 y/o F, 5’3”, 127 lbs. Dx: Acute acetaminophen ingestion. Brought vis EMS to ER with c/o abd pain with nausea. EMS reports ingestion of acetaminophen for SI. Reports taking 15 extra strength (500 mg each) pills of acetaminphone ~2000 after talking on the phone with her boyfriend. Denies ingestion of salicylates, ETOH or other substances within in 24 hr. Denies current use of drugs, OTC or herbal supplements. Four hours later after waking up had second thoughts and call EMS. C/o n/v, abd pain, feeling “hot and clammy”. Denies vomiting or unusual bleeding. Denies CP, palpitations, Sob. Labs taken and serum acetaminophen was 150 mcg/mL. Other labs WNL, including LFT. IV in LAC NAC initiated. Father has a history of depression and both parents have anxiety. Initiated suicide precautions. Patient reports feeling “tired, l Denies any nausea now, had earlier. Denies SOB, vomiting, palpitations, chest pain, or unusual bleeding. Patient feels “overwhelmed and a little stressed.” I feel so alone” I have not been out with friends.” B: h/o: depression since age 15 (during high school). On fluoxetine (Prozac) 20 mg daily since age 16, last dose yesterday morning. Current psychotherapy reported effective. Stressors in college: failing classes, no friends and boyfriend just broke up with her. Depressed most of time lately. Previous SI attempts in HS. States her depression depends on the day, her symptoms not every day and not all at once; sometimes sleeping more, sometimes less; sometimes appetite is less or wants to be alone or feels stressed. Denies normally having anxiety. No fever, chills, night sweats, or weight loss. A: A/ox4 c/o fatigue. No signs of respiratory or cardiovascular distress, but has erythema surrounding IV site on left antecubital region of arm, extending beyond transparent dressing and tape. Multiple scarred areas of various lengths on medial thighs, bilaterally. Skin is pale, warm, and diaphoretic. VS: BP: 116/74, P: 66, RR: 12, T: 99.6 [elevated], SpO2: 96% [decreased], Full Code status. R: Due to noted erythema administer Diphenhydramine 50 mg as prescribed and prn for urticaria from IV site from NAC. On SI precautions and obtain 1:1 sitter for patient. Inquire with patient if she would like me to contact any family and educate on coping strategies. Recommend support group for patient and family and psychiatry continuing on outpatient basis. Due to depression worsening from life stressors will recommend changes in prescribed medication of Prozac seeing it is a low dose of 20 mg. Nurses are on the front lines of mental care more often than many people realize. Depression is a disease that produces feelings of sadness or hopelessness that do not go away. Depression may cause those to lose interest in things they used to enjoy. These feelings may hinder their daily life. Numerous people rely on individual therapy for psychological support, but there are times when patients need more support than can be provided by individual therapy alone. It appears Ms. Oxendine requires more comprehensive mental health services, and I would refer her to an intensive outpatient program (IOP). One resource for IOP in San Diego is with Aurora Behavioral Health: https://www.aurorasandiego.com/programs/san-diego-outpatient-services. Intensive outpatient therapy is directed therapy that is given over longer treatment sessions. For example, intensive treatment might be concentrated into daily, three-hour sessions given five days in a row over a two to four week period. Seeing that Ms. Oxendine feels lonely, I believe going into an IOP can help her learn the appropriate coping skills to handle stress in the future. The second community resource I would provide her is telephone numbers that aid her when she feels suicidal and is available 24/7. Seeing that she has a strong history of SI attempts, I believe providing her a resource for when she is in a crisis can abate any future actions. National Suicide Prevention Lifeline: 1-800-273-8255 (1-800-273-TALK), and Suicide Hotline: 1-800-784-2433 (1-800-SUICIDE). I would also advise her to avoid alcohol and drugs since they can make depression worst and talk with a therapist or PCP regularly to monitor the progress of antidepressants. I would encourage a healthy diet with reguarly exercise because it releases "feel-good" endorphins that can enhance her sense of well- being. Due to COVID-19, most support groups that use to be available in person now have moved online to Zoom meetings, such as https://namisandiego.org/services/support-groups/. I find this a downfall in my community because many individuals experiencing depression feel locked in their homes and look for a change in scenery, so they do not feel alone. I believe in-person support groups aid those undergoing depression, and hopefully, as time passes, they will be open again.