I took a quiz yesterday in which our instructor was just assessing our overall 'critical thinking'. She said she wasn't concerned with us knowing specifically which interventions to use for these patients, just how we would go about it. So I really felt like I knew they were bad situations, but didn't know what I was supposed to do, and was just looking for a little bit of help
1) You receive a patient who had a recent bowel resection and is complaining of pain at 8/10 even though just having received pain meds. The patient's systolic pressure rose from 70 to 130. What would you do?
2) You receive a patient who is post surgery, and has a chest tube. 800 mL of dark red discharge have gone into the chamber in the last hour, and the current vitals are 170/100, pulse 130. What do you do?
3) You receive a patient who is 2 hours post stent placement. They complain of a sharp chest pain at 5/10, and current vital signs are 160/84. What would you be doing for this patient?
Thank you! My inexperienced intuition was just assess and call the doctor. Lol.
Mar 11, '11
1) you receive a patient who had a recent bowel resection and is complaining of pain at 8/10 even though just having received pain meds. the patient's systolic pressure rose from 70 to 130. what would you do?
try another quick acting pain medication if possible (something iv). patient's blood pressure rises with pain. i wouldnt want bp to get back to 70 because that is awfully low. sometimes it helps to put pressure on the surgical site. i mean nothing like huge but our hospital has those bean type pillows. you know...kind of looks like those rice bags you heat in the microwave. it's not heavy enough to cause damage but just enough to sometimes promote a little comfort. also a 130 systolic is not terribly high either, so i wouldnt want to give a bp medication.
2) you receive a patient who is post surgery, and has a chest tube. 800 ml of dark red discharge have gone into the chamber in the last hour, and the current vitals are 170/100, pulse 130. what do you do?
well, 800 is quite a bit of discharge. and it should be seroussangenous, not bright red. that is telling you it is just blood. its interesting the blood pressure is that high, usually with loss of blood there is a decreased blood pressure and an increased heart rate. i work on a cardiac floor, and have seen some similar situations. but with the blood pressure and the heart rate like that there is alot of workload on the heart, so i would call the physician and attempt to lower that blood pressure and heart rate. at this point metoprolol, or something like that, would probably be ordered ivp, get labs ordered for a hct or hgb. if all is stable i would just watch closely. (i'm not sure how long this has been over...if it's been only an hour, then that is way too much blood loss. notify physican)
3) you receive a patient who is 2 hours post stent placement. they complain of a sharp chest pain at 5/10, and current vital signs are 160/84. what would you be doing for this patient?
i was taught in nursing school that any chest pain is chest pain! a chest pain of 1/10 needs to be treated the same of 10/10. the only number of pain that is acceptable with chest pain is 0. again, i work on a cardiac floor so i get patients with stents. i've never had a patient who has had major complications with it. however, with a stent placement sometimes tissue can regenerate around the stent placement and occlude an artery 100%. this is why a patient is always always always placed on plavix with a stent placement. first step i would do is apply oxygen 2-3l nasal cannula, give aspirin obtain an 12 lead ekg, give nitro (remember to check bp's with nitro), morphine. remember with chest pain the accronym mona (morphine, oxygen, nitiro, aspirin). also...make sure the patient is taking their plavix. it's only 2 hours post stent placement so this shouldnt be too much of an issue. but i would be really worried about something ischemic going on. needs to be acted upon immediatly.
Last edit by Jenni811 on Mar 11, '11
Mar 13, '11
All these questions should trigger more assessment before interventions and leave a lot of information out, but that's pretty typical for Nursing school questions.
1) I'd be curious how long the patient had an SBP of 70. Post bowel resection followed by significant hypotension followed by an increase in pain would be concerning for a bowel infarct. Was their BP improved due to interventions? What was their pain prior to this? It would be nice to know what type of pain meds and how long ago they got them, if you gave them something PO 5 minutes ago, then no it wouldn't be surprising that their pain has not changed.
2) What type of surgery? It's not unusual for post OHS patients to have up a couple hundred mls an hour of CT output in the first few hours. 800cc out in an hour or even a day on post op day 2 would definately be concerning. In the first few hours after surgery, the color is important (bright red is worse) and you also need to look at more than just that hour. Some mediastinal CTs can be very positional, you may get a small amount of drainage at first and then you turn them to move their leads to the front and they dump into their CT. Dumping a few hundred CC's with repositioning isn't that unusual if they haven't drained much for the previous few hours. No matter what though, 800 cc/hr would earn a call to the Doc.
3) You would get an EKG first, nitro only if indicated by the EKG, they should have already had their aspirin. Cardiac enzymes immediately post PCI are useless; a tropnin I doesn't rise until about 4-6 hours post event, if they were stented due to a current MI then a positive trop could well be due to the original MI, and the stenting itself cause a rise in enzymes. Some Docs might do q 8 hour trops just to make sure they trend back down, but a positive by itself doesn't tell you much.
On the EKG you'd be looking for signs of new ischemia or signs of true ischemia in the culprit vessel vs reperfusion changes. It's not at all unusual for patients to have chest pain after stenting due to either "stretch" pain or reperfusion pain. An EKG that is consistent with reperfusion changes to the territory that was stented would only warrant treatment of the pain for patient comfort as the cause is non-ischemic. One study suggested that half of all patient who undergo PCI have post-cath non-ischemic chest pain, although that seems high, except possibly for CTO interventions which didn't exist at the time of the study. This particular study supposedly showed that this pain was primary due to stretch pain, although it didn't seem to consider reperfusion.
It is very possible for a stent to clot up immediately post-cath, the stent damages the endothelial cells which triggers an inflammatory response that encourages platelet aggregation, which is why many post stent patients have integrilin, reopro, or angiomax running for a few hours post-cath.
No matter what, the BP deserves treating. Some Docs will want an SBP >140 treated, others may allow up to 160 or 165.
Last edit by MunoRN on Mar 13, '11