Elizabeth Blair Archibald

February 13, 2018

Clinical ED Rotation

#1 Patient was 68-year-old male that has a history of potential bladder cancer. He
is seeing a urologist in Crescent City because of recent hematuria (no evidence of
urinary tract infection). The provider performed a cystoscopy 7 days ago. The
cystoscopy results made urologist suspect of bladder cancer, even though they
have not received the urine cytology results yet (urinary cytology is used to
diagnose high-grade tumors). The specialist instilled a foley catheter post
procedure to monitor urine output and quality. Today patient is present in the ED
because he has excruciating pain to urethra and meatus. Patient states the urine
output amount has been normal. Urine in bag is orange in color- likely due to
medications that patient is on. The ED doctor called the urologist that placed the
foley for his recommended. Per the urologist, we are to remove the foley. The
patient is to go in to see urologist for follow up ASAP. Patient is already on
prescription medications, including: Phenazopyridine (a urethral analgesic),
Ciprofloxacin (antibiotic), and Hydro/APAP 5/325 MG (pain, and inflammation).

02/13/2018; 0800-
Data: Acute pain R/T foley catheter placement AEB patient having a hard time
walking/walking very guarded, stating that it hurts to urinate, and reporting pain is
8/10.
Action: ED doctor spoke with urologist on the phone for treatment
recommendation. Removal of foley catheter is recommended.
Response: Nursing student prepped patient for procedure, by placing a towel
between his legs, and stating that it may be an uncomfortable experience. 9 ML of
NS removed from foley balloon, leg band removed from patient’s legs while foley
is supported with free hand, foley removed with one, gentle, but continuous pull.
Patient was uncomfortable, but tolerated procedure well. There was no
excoriation present around urethral meatus. Catheter intact. Small amount of
brown mucous present at tip of catheter.
Liz, Student RN

#2 65-year-old males arrived via ambulance because of hematuria twice this AM.
Patient has an extended history (COPD, fall 2 days ago, atherosclerosis, illicit drug
use, etc.), but patient’s chief complaint is pain and blood with urination. Urine is
collected via clean catch, and is bright red in color. 18 G IVC placed to left AC. 500
ML/HR bolus of NS administered, then fluid rate decreased to 125 ML/HR.
Urinalysis supports the diagnosis of cystitis. Pending culture. Patient has been
utilizing the EMS resources a lot for non-emergent situations. A case manager has
been assigned to this patient to assist patient with finding the appropriate care
needed rather than coming into the ED (only if not warranted). Patient discharged
with RX- Sulfamethoxazole/Trimethoprim OS PO BID for 10 days #20.

#3 2-month-old male patient present because mother is worried that he has an ear
infection. Patient has been congested for 3 days, and barely slept last night. He
has been fussy. Mother took is temperature last night, and patient was not running
a fever. He is afebrile in the hospital today, as well. Mother states that patient has
been crying a lot and pulling at his ears. In the triage room, patient is mobile, pink,
warm, and vigorous. Patient does not have any history of illness or injury, and was
delivered via C-section at 39 weeks. Patient has been consuming 40 ounces of
formula a day (4 ounces per feeding), and has approximately 8 wet diapers a day.
Doctor’s otoscopic exam does not support an ear infection. Canal is not erythemic,
and TM is intact/not bulging. The doctor states that patient’s throat is not
reddened, and that because the patient is very mobile, the doctor is not worried
about meningitis. The doctor recommendation is to care for baby at home with
comfort measures: feed regularly/monitor intake, count wet diapers, monitor for
fever/take temperature when fussy. Mother is to make a follow up appointment
with Dr. Harris (pediatrician), and abstain from giving baby Tylenol/Motrin. The
doctor states that this will mask a fever, and if one is present we need to know
when it occurs and find out the cause. If patient declines, or develops a fever, the
mother is to bring him back, or get a sooner follow up appointment with Dr. Harris.

#4 41 year-old-female present for facial swelling and redness after changing face
cream. Patient has a history of allergies to rubber and latex, and she was unaware
that the product that she used had one of these components in it. Swelling and
redness located around both eyes, forehead, and to left side mouth. Patient states
that when she gets this reaction Benadryl doesn’t work and she needs steroids. She
states that the last time this happened her symptoms extended for 6 months, and
did not resolve until she got steroids. Doctor discussed with patient trying Benadryl
combined with an H2 blocker (Pepcid or Ranitidine) in the future. He states that
they both have different effects, and may help her situation if needed in the future.
Patient’s airway is patent, and tongue is not swollen. Patient states that all of her
allergic reactions have been local, and have never required serious interventions.
Patient discharged with RX- Prednisone 20 MG 3 tabs PO SID for 5 days #15.

02/13/2018; 1300-
Data: Knowledge Deficit R/T use and effects of steroids AEB patient stating that she
takes NSAIDs on a regular basis.
Action: Student nurse discusses with patient the need to abstaining from using
NSAIDs with steroids, because the combination can cause stomach ulcers. Also,
discussed that she should take the steroids in the AM because they can cause an
increase in energy.
Response: Patient states understanding, will not take NSAIDs while on steroids,
and will take the Prednisone in the AM.
Liz, Student RN