Attn Nurses Help with CT?

I need help with a critical thinking exercise. Its my first year in nursing school: 67 y/o man admitted for dehydration. Has a recent hx. of shingles. On steroids x10d and is in the recuperating stage. Skin is very dry, oral temp is 100.4 His urine is very dk.amber and WBC's is 13,000mm.
Dr.s Orders are: IV D5% NS at 100cc/hr,
1gm of Ancef Q 8hr,
bld cults x2,
tylenol/rectum Q 4hr for temp> 101.4po
I have to prioritize and give rationale, this is what I THINK 1st I would give pt IV b/c of dehydration
2nd bld cults to see if he has an infection
3rd ONLY If he did I would give him antibiotic
4th Only if he had a temp >101.4 would I give Tylenol. Is this correct. My instructor said today in class that giving antibiotics when there is no infection present is not good b/c it decreases the bodies normal immunity to fight infection. What would you do.

Also what would make him susceptible for getting infection? I know one reason is b/c of the shingles and low grade fever, and maybe WBC count.

You have to give him the antibiotic because it's a dr. orders. That's not your call. You always give the med unless you think there would be something detrimental (too high dose, dangerous interaction, contraindication, etc.), then you'd call him. Yes, antibiotics are overused in general, but in this case he is seriously ill enough to get admitted, his white cells are up and temp is up, all showing poss infection. Oh, and having the shingles (a virus) shows that his immune system is already compromised.

You can give a possible rationale for the dr ordering the blood cultures, but you don't choose if it is done or not. AND it will show the type, if any, bacterial infection so that the dr. can be sure he is getting the best antibiotic for that particular bacteria.

Correct on the Tylenol.

The dehydration is the highest priority. Being low on fluids makes the blood more concentrated and might explain the high WBC and could even be a factor in the fever.

Good luck in your studies.

You have decent rationale but taking steroids makes your body suceptable to infection and it makes it difficult to show. Low grade fever can be a high fever in those of normal health.

i agree with your priority list. also keep in mind that the blood cultures should be obtained BEFORE administration of antibiotics because the culture results may be affected by the presence of antibiotics.

you're correct in that the steroids are immunosuppressants. giving the ancef in and of itself doesn't affect the patient's immunity- but what it may do is if the bacteria causing the infection is resistant to the ancef, then you're going to kill all the non-pathogenic bacteria, and that will allow the pathogens to propogate furthur.

His steroid therapy makes him more susceptible to infection because steroids supress the immune system. That he has an elevated white count says he already has an infection so you don't need blood cxs to tell you that. They will tell you what organism is at work and if he's septic. No CBC or metabolic panel???

1. Right. Hydrate him. This also gets a line open for IVPBs.

2. Cxs to r/o septicemia due to infection in some other part of the body. Monitor results and report.

3. Start ABT per IVPB.

4. Monitor temp q4 and give Tyl 650 q4 prn. In the real world you will follow your facility's protocol for this and not these orders. Personally, I give it at 100 because I don't need the headaches. I sometimes use ice packs alone for 99.8. 99.6 and less, I don't worry about. At any rate, increasing his fluid volume will help decrease his temp.

You actually did a pretty good job on your own. And may I add what a lovely question. A refreshing change from "I have bloody pus coming from my eye. Is this normal?"