Patient Assessment - Deep trouble

  1. The aim of this "game" is to look at critical indicators in assessment.

    Some of the patients in the following scenario are in "deep trouble" but some may not be. Can you identify the ones in trouble? If you can write what you think on a piece of paper.

    If you feel happy to post about one of the patients please do so but don't let the cat out of the bag on all of them!!!

    If you want to add another "deep trouble" patient scenario please do so - I do not have the corner on these!!!

    Patient A)

    A forty year old man with a 25 year history of heavy cigarette smoking compalining of central chest pain. Pain score 10/10. Colour - normal not pale. Sao2 98% on 4 Lpm O2. Monitor sinus rhythm with occasional PVCS - Bp 160/80. He is very restless, moving around the bed loudly complaining and demanding immediate attention and threatening to walk out. ECG is normal.

    Patient B

    8 year old child came in with Mother who is distraught and keep s telling everyone that "young Jimmy" was alright when she checked on him only an hour previously. Jimmy is sitting upright, with his head forward and jaw protruding. There is saliva dripping form his mouth and it is obvious he cannot swallow. He looks sick - florridly pink cheeks. Resps and sats normal but temp 38.5C. Tachycardic.

    Patient C

    Oversdose Vital signs within normal parameters. Monitor - sinus rhythm. Sao2 99% on 100% O2 GCS 6/14 eye opening to painful stimuli.verbal respons - nil and Motor response 3 - flexing. When you see the patient tehy are in a lateral position with a guedel airway in place (oropharyngeal airway)



    I am getting tired so I might limit it to three patients for tonight but I will be back to post some more with the answers to these!
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  2. 66 Comments

  3. by   nowplayingEDRN
    More info on the child please.
  4. by   Nurse Ratched
    Patient C sounds not in too horrible a distress - what did the pt OD on and how long ago?
  5. by   fourbirds4me
    I would say patient B is in deep trouble and about to experience an occluded airway.
  6. by   Mkue
    I'm also looking at patient "B".
  7. by   student Staci
    Is the child experiencing epiglottis? With the sudden onset and protruding jaw and difficulty swallowing it sounds like it could be this to me
  8. by   memphispanda
    B sounds like croup to me even though no cough was mentioned.
  9. by   Gator,SN
    Does the child have all his immunizations? Pertussis??? not sure but this is what it sounds like.
    Patient c may be stable at the moment and I think that patient A needs a closer look too. Restlessness is always a sign of distress. maybe Unstable angina and some panic thrown in for good measure.



    Gwenith, please don't wait too long to give the answers, OK. PM if ya have to.

    Gator
  10. by   Gator,SN
    oops. I meant diptheria, not pertussis
  11. by   Mkue
    Patient "A" threatening to walk out but pain scale 10/10..

    I'm still concerned with patient "B" and I had thought of epiglottitis. Still sticking with "B".
  12. by   bestblondRN
    Patient B--definitely in some big trouble. Probably epiglottitis, peritonsillar abscesses or something obstructing the upper airway and throat.

    Patient C--sounds neurologically depressed from OD, but saturating OK with some help from an oral airway and 02.

    Patient A--need a little more information. Were enzymes drawn and what were the results?
  13. by   Tweety
    I agree with bestblond.....B sounds worst because of not being able to swallow, etc. But a patient who is restless and having severe chest pain needs to be investigated, could be esposhageal problems or could be a major MI.
  14. by   gwenith
    Thank-you all for responding!

    Yes B was the worst and yes KUDOS++++ to those who picked the epiglottitis because that was what I was trying to describe. They get sick fast and they can lose an airway fast.

    C is also a big potential trouble for although they are saturating well the very fact that they are tolerating a guedel airway means they have lost at least one of the three main protective mechanisms of the airway - the gag reflex. (The other two mechanisms are swallow and cough) It depends on how long ago the pateint took the OD and whether or not the GCS is mproving but it would be probable this patient would be tubed. Studies have actually proven that there is no correlation between GCS and gag so we would need to keep a VERY close watch on this patient.

    A) Yes would have you worried but as a GENERAL rule ( and believe ME there are exceptions) Cardiac patients who are expereincing true 10/10 chest pain are usually envervated. They have little or no energy.
    Still - all chest pain is guilty of being cardiac until proven otherwise.

    We had an interesting case recently with admission of central chest pain relieved by anginine tablets SL. ECG showed tall "t" waves. No troponin rise no CK change. Past ECG showed this pattern is normal for him.


    Talk about it while I think up a few more. Disagree with me if you like. Anyone who has had recent experience with epiglottitis please feel free to come in and talk about the latest management as my experience is a couple of years old.
    Last edit by gwenith on Jun 8, '03

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