Is this necessary? What is his ionized Ca?

Never. Use an appropriate bag size (100, 150, 250, 500, 1L)...

are you sure? Is he at risk for GI bleed?

How often are you monitoring? What values or s/s are you monitoring? What are the critical values? And what's the plan if these things happen?

what are these?

how frequent?

such as? WBC? Fever? etc?

Include values for your monitoring parameters.... and how often you are going to monitor them

in what ways?

Are you sure? Can he take oral meds with his n/v? If so, cool, but consider these things.

Why not Ativan or Librium?

So this isn't a good reason to choose imipenem... you need to include a good reason... SEs? Cost?

for how long

In what forms? What doses? For how long? Are all of these necessary (Hint: Look at your patient's ionized Ca).

avoid ranges

avoid ranges

avoid ranges

What values do you look at to monitor these? How often?

Has not improved by when? What are you switching to?

lipid? you mean liver enzyme?

Is LR sufficient to raise your potassium this much? Your patient is at risk for cardiac arrest... I suggest considering this fact.

How often?

of

is lesser a word?

Is this really a word?

What specific side effects does it avoid?

What electrolytes are in LR? How much of each is in LR? Are these sufficient amounts to replace your patients deficiencies?

Consider any emergent electrolyte disturbances that you need to fix. Consider nutritional deficiencies you need to fix.

avoid ranges

What about Bactrim, Pepcid, and his enzymes??

how often are you monitoring? what values s/s are you monitoring for? what are the critical values? what is your plan if these things occur?

how often are you monitoring, what values or s/s are you monitoring for?

This whole part is adverse events... not therapeutic.

what are these

how often are you monitoring?

avoid ranges

Don't do this. Find specific reasons to back up your choice of using Librium....

What forms and what doses and for how long?

Good.

Oral? It's fine but remember to justify this route in rationale

I don't think this is recommended.... Look at this again. And are you really trying to sedate him? There are faster ways if thats you're goal.....

How? What are you giving him in this magic IV? KCl? Kacetate? MgSulfate? CaGluconate? CaCl? Are all of these necessary to replace? (Hint: what is his ionized Ca?)

What about fluid resuscitation and electrolyte status?

don't use ranges

Huh?

Can he tolerate oral meds? N/v? Is this appropriate for pancreatitis patients?

Are there emergent electrolyte disturbances present that you need to correct? Are there nutritional/vitamin deficiencies you need to correct?

What are the values you're looking at for this?

You are the pharmacist... make a recommendation about what to do....

Is the goal for inpatient?

Why? You're the pharmacist... the physician is likely to ask for your recommendation so go ahead and formulate one.

Excellent

Adverse events....

This should be in adverse events....

This should be in adverse events.... What are the s/s? What do you do if this happens?

Shorten this to "Abx therapy should be adjusted according to results of these"

Not entirely accurate.... Research what ALT/AST actually measure.

Is his liver function actually decreased? What are ALT/AST actually measuring? I like Ativan as the choice, but I don't necessarily agree with this portion of the rationale...

Look at how much of each of these it has... are they sufficient amounts for your patient??

can he tolerate oral meds?

Which electrolytes? LR doesn't contain every electrolyte... also look at how much of each electrolyte LR has and consider if this is sufficient for your patient.

I have never seen this.... Double check.

Is merrem renally adjusted?

Can he tolerate oral meds with N/V? Always consider this with every patient you encounter...

Consider the whole patient. Are there emergent electrolyte disturbances that need to be fixed? Are there nutritional/vitamin deficiencies present?

How often are you monitoring? What exactly are you monitoring? What are the critical values? And what is your plan if these things happen?

How is this defined? What are the values?

How are these assessed? This isn't Therapeutic. Move this to adverse event!!

How often and for what? What are the s/s of DT?

How often?

How often?

avoid ranges

Good. But you need to mention how this works.... what is the scale/tool used?

What are you basing his liver function off of? Can AST/ALT be falsely elevated in pancreatitis and AWS? What do AST/ALT measure anyways? Is his liver function actually poor? Things to consider. I like the Ativan choice though...

But why do hospitals prefer it? This isn't a good reason to use in your treatment plan... you need to find a specific benefit to merrem whether its the side effect profile or cost...

How much potassium is in LR? Is this a sufficient amount? Is it bad if potassium is low? You need to consider these things.

This is just a free piece of information... but CRP is kind of a poor marker to use because its not specific at all. So really LR's advantage is decreased inflammation....

dont use ranges

dont use ranges

until sensitivities you mean?

dont use ranges

dont use ranges

He can tolerate oral meds with N/V?

I know you ran out of room... but Adverse Events is a super important section... so I would revisit other sections and cut out parts that aren't absolutely necessary and abreviate where you can (it's fine to use LR for Lactated Ringers if you establish it first...)

How is this assessed? What are your critical values for sedation/resp depression? And what is your course of action if these are met?

How often?

Spacing issue.

and probably for susceptibility too?

Yes. Excellent. Thank you for including this.

How often?

Solid job mentioning all this. Your rationale section is fantastic. I would however revisit any emergent electrolyte issues or nutritional deficiencies that may be present and address them. LR doesn't necessarily cover all the electrolytes and it doesn't have a whole lot of some of the electrolytes, so look into this.

Why does this matter to your patient? What is his anion gap? Does he have an acid/base disorder?

Excellent.

Excellent job mentioning all the options and reasons you didn't choose them. Could shorten it if needed.

Consider the whole patient. Are there emergent electrolyte disturbances present that need correction? What about nutritional deficiencies related to AWS?

Bag? Lol

Can the patient tolerate oral meds? N/V?

Is this the right goal for inpatient?

This is a great line. Good job knowing this.

How often are you monitoring for these things and what is your plan if these things happen?

How often are you monitoring? What should you monitor in terms of electrolytes?

Why is this necessary? Why won't oral work? -- I only mention this because at the beginning you said he could continue oral Tylenol and Pepcid...

You're on the right track... Don't think too hard about this stuff. And focus on your major goals: 1) Patient stability (fluids/electrolytes) 2) Infection (ABx) 3) AWS (anxiety/agitation)

How do you measure this? What's the critical value? What's the plan if this happens?

What alternative drug would you recommend?

How often will you monitor? What are you critical values? What is your plan if those critical values are met?

You need to look at how much potassium LR contains... Is this a real concern?

which one? 5mg vs 10mg is a big difference....

good!

will these cultures be sufficient for pancreatitis?

goals?

Don't use a range.

How often is frequent?

What are your specific goals

Consider your whole patient. Are there electrolyte disturbances present that are cause for emergent concern? Are any of this nutrients/vitamins deficient due to AWS? Do you need to replace these things?

Note: Look into what and how much of each electrolyte LR contains and think about whether or not this will be sufficient for your patient or if additional replacement will be needed....

Need to mention why merrem over imipenem.... several reasons.

Good!

Excellent!

Excellent!!

Consider goal ranges for these

Consider your whole patient. Are there emergent electrolyte disturbances present? How is his nutrition? Do you need to do anything regarding nutrition or electrolytes?

How often are you monitoring, what values are you specifically monitoring, and what is your plan if things go south?

Excellent... But how are you using it? What value are looking for to ensure therapeutic effect?

How often?

How often?

How often?

MH is in the hospital and the doctor has asked for your recommendations... so what is your judgement in regards to insulin?

Is this your goal for inpatients?

By what mechanism? LR doesn't have Mag...

How often?

This doesn't matter if your Merrem is being infused over 5min (per New Drug Therapy section).... There are MANY reasons why Ativan is a good choice, so look into it a bit more and make a rationale argument for its use.

Is this really that big of a benefit if your patient is in the hospital? What is another benefit of Merrem?

You need to look into this.... Are you suggesting putting the Merrem into the LR solution? Or are you suggesting that it's Y-site compatible as an IV piggyback? Totally different things.

Look at how much of each of these it contains. Will this be sufficient for you patient? Are any of his electrolyte abnormalities life-threatening? Also, what's your plan for Mag?

Does he need renal adjustment? Merrem is one of the Abx that is renally adjusted...

5? Are you sure? Double check.

Which one?

What about pepcid....

Double check that this is the right goal for someone in the hosptial

You just tried to hurry and submit something so you could get comments, and I get it.... You need to consider this dude as a whole. What do his electrolytes look like? What is your plan to correct them? Does he really need fentanyl? What's the risk of giving fentanyl and diazepam together? How are you going to monitor this? What is his nutritional status? Are there concerns from a nutrition standpoint with AWS that you need to address?

Okay... but why did you proceed to give it over 30min? Don't do this.

Don't include this in your plan. Just jump into the goals you have for him.

Why did you choose to dose Lorazepam the way you did? Is there another way?

What critical value are you looking for?

How are you monitoring this? Is there a lab value, tool, or scale you can use?

How often?

How are you measuring this? Is there a lab value, tool, or scale you can use?

Check this level... Typically normal range for WBC is 4-11

Really?? Does LR have Mg in it? Check this out.

How frequently?

Can ALT/AST be elevated due to pancreatitis and AWS? Does it always mean that his liver isn't working? Look into this. What do ALT and AST actually measure....

Why did you choose to give it IV if you were cool with giving oral Pepcid at the beginning? Need to think about and address these things.

Is there another reason to use Ativan over Librium?

Specifically what effects are you avoiding?

What are these called? Crystalloids.... Will save you space.

Look at what electolytes LR contains and how much of each it has... is this sufficient for your patient to be restored to normal? Are any of his electrolyte depletions acutely dangerous?

I would stick to a normal bag size (100, 250, 500, 1L)...

Give these ranges... It's just as dangerous for levels to above the range so you need to list these ranges.

How are you monitoring sedation? Is there a scale?

What is the value you look at for this? Why would this occur? (Hint: what causes metabolic acidosis? how is that related to IV ativan?)

Technically respiratory depression can happen with just benzos too... so you need to be monitoring for this regardless of pain meds. What are you going to do if it happens? D/C ativan? Intubate? Bipap? Flumanezil?

What are the critical values you're assessing here? RR? O2sat?

Do you know what antibiotic you would recommend? I suggest knowing these things.

You need to mention how often you are monitoring each thing and what your plan is if these things happen.

How often are you monitoring for these reactions?

I don't know that I agree with you. Look into the sedation scales... If sedation is your goal then you wouldn't use mono-therapy with a benzo... But sedation really shouldn't be your primary goal here... I would leave sedation as an adverse event, not an assessment of therapeutic effect.

Is there a specific way like a scale to measure effectiveness of benzos in AWS?

Weird spacing again.

How often are you assessing this?

How often are you assessing the vitals?

Don't use a range. Also... May be better to put >0.5mL/kg/hr

Don't use a range.

How frequent? and what exactly are you assessing? specific values?

Why ativan over diazepam?

Weird spacing here.

Excellent mention of this!

Consider the electrolytes and the amounts of each electrolyte the patient is going to receive from LR and the banana bag... Are all his electrolytes covered? Are the amounts sufficient to his needs?

Is this really the purpose of using Ativan? Or is it to decrease anxiety/agitation?

Choose one, don't give a range.

Banana bags only have 3 electrolytes... Na, Cl, and Mg... Further more, what rate should you infuse the banana bag at? What volume is the banana bag? These are all important.

Not really the purpose of the banana bag... Look into this.

I love banana bags.... There is fascinating research out there about banana bags that you may want to look at for general life knowledge.

Look at Tylenol use in pancreatitis too...

Can he take this with N/V? Are oral meds his best option right now?

"Goal is to increase QoL...." Don't get bogged down in including all the extra words... you need the space.

You recommend this in New Drug Therapy, not in goals. His goal would simply be to lower glucose (include the specific value).

What are these? What are you looking to improve?

Graders have the case pages and don't need a summary of what's wrong... It's good to just jump right in with the goals.

Did you consider your patients electrolytes deficiencies and nutritional imbalances? Look into this and see if there is anything you may have missed.

It is important to know that acidosis is only caused by IV lorazepam... So if you're giving tablets this point is mute and can be deleted. IV lorazepam contains propylene glycol (thats the mechanism of its metabolic acidosis.... tablets don't have this). Free piece of knowledge.

This a good point. Include the values you're looking at. Also why is this a concern? (Hint: What else causes metabolic acidosis?... Alcohol toxicity?)

How frequent are you monitoring?? You need a frequency for every monitoring parameter.

What are the values for these?

Why else are you monitoring for this? (Hint: Electrolytes... )

Don't use a range.

Good!

Why? You're a pharmacist. Make a recommendation.

Why? You are a pharmacist. Make a recommendation to the physician regarding when insulin will be needed.

Is this the inpatient goal?

How often?