Isbar- Complex Care
Assessment
Mr. M has been agitated and restless throughout the night. The patient’s temperature has been continually rising from 38 at 0600 to 39.1 at noon. However, I did not administer any Tylenol. Also, his blood pressure has dropped from 146/88 to 120/76. Besides, his pulse has continuously been rising from 98 at 0730 to 130 at noon. Mr. M seems to be sleepy and lethargic. The patient passes a scant amount of urine. Mr. M’s abdomen appears to be tender. However, his skin feels warm and flushed. As a geriatric patient, the neurological assessment indicates that Mr. M is quite disoriented. An examination of his lungs demonstrates that there are fine crackles audible on auscultation in the lower lung areas. His pulse oximetry at noon was 88%.
Request/Recommendation
In this case, it would be appropriate to administer Tylenol to help control Mr. M’s body temperature. Also, it is essential to carry out urine analysis tests; pyuria and hematuria, to determine the causes of the patient’s inability to pass urine. Meanwhile, a urinary catheter should be able to help in draining the urine and reduce instances of agitation and restlessness. Besides, a nurse station calling phone should be provided for Mr. M to avoid cases of physical injuries because the patient appears to be disoriented. Due to the fine crackles in Mr. M’s left lung area, it is reasonable to transfer the patient to the intensive care unit to minimize and difficulties in breathy and ensure adequate oxygen supply to all the body organs. Admission in the ICU will also ensure that Mr. M’s case of disorientation is minimal, thus reduces any chances of physical injuries and neurological issues.