Please help with Case Study Scenario!! - page 3

I would appreciate any insights and thoughts on this case study scenario! I will write my thoughts after the study, but I'm hoping for some help on this one!!! CASE STUDYYou are an ED nurse and a... Read More

  1. Visit  Esme12 profile page
    1
    what is "tundras" in the field?
    psu_213 likes this.
  2. Visit  cdl766 profile page
    0
    Since the pt. is hypothermic, I think we should start warm Lactated Ringers bolus running to try and bring his BP back up, assuming he is hydrated. Could we get an abdominal CT and a stool occult test to check for a GI bleed?

    We would want to do a neuro check. Look at the pupils. Are they equal, fixated, dilated? If unequal and/or dilated, could be a neuro issue, hemorrhagic bleed. Did he fall and hit his head? Then we would start to think about increasing ICP and possible seizure. You'd want to raise the head of bed and send for a CT scan stat.

    If the pt. has cirrhosis, you would expect him to have an elevated bilirubin, ALT, AST, PT, PTT and a decreased albumin. If the CT head scan comes back negative for a bleed and his blood alcohol is his, is it safe to assume that he lost consciousness based on his alcohol toxicity? Then, would the plan become to get him stable via fluids, banana bag and expect him to start having alcohol withdrawals?
  3. Visit  cdl766 profile page
    0
    oops...I meant, assuming he is "dehydrated" in the comment above...
  4. Visit  cdl766 profile page
    0
    Quote from psu_213
    Some thoughts:

    1. Contact isolation: important but probably not my first priority. An instructor (or infection control nurse) may say otherwise, but I'm not going to worry about this first.
    2. Tape: yes, remove it for various reasons...go with soft wrists if pt is combative.
    3. IVF: in addition to the bolus, what other fluid would you expect to see (hint: think Wernicke's encephalopathy).
    4. For the pancreatitis, what might be ordered instead of the CT?
    5. What lab work would you expect to be ordered and why? Think about the chronic etOH use. What electrolytes might be off? What are the cardiac implications thereof?
    6. Re: the sats/airway/intubation. Pulse ox is a quick way to get an idea of someone's oxygenation status, but it is not the entire story. In addition, it tells you virtually nothing about someone's ability to protect their airway. I have seen individuals who's respective sats. have been fine on minimal supplemental oxygen, yet they have still be intubated. While the pulse ox is useful, having a good reading does not mean you are out of the woods vis-a-vis intubation.

    Otherwise a good start on a complicated study.
    3. Thiamine?
    4. Not sure what to do for the Pancreatitis?
    5. I know alcohol has an effect on sodium. Is there more?
    6. Would you suggest getting an ABG on this patient right away as well?

    Thanks for your input! I really appreciate!!!
  5. Visit  Esme12 profile page
    0
    Probably not ringers because it is metabolized by the liver.....and there are many things that do not go with ringers.....0.9 would probably be best.

    Yes ABG/s would be with the ABC's right? You have documented hypoxia? You would have to consider hypoxia. What does hypoxia do to the acid base system? What does hypothermia do to they system? What does severs ETOH intoxication do to the acid base balance?

    You need to look up all of the disease entities by themselves know what they do and decide the common things that need to be tested and watched?

    Yes a complete neuro check you had a combative patient that is now nearly comatose. Being obtund is deeply unconscious. Yes you would use the Glasgow coma scale for you patient.

    What other labs? If you don't know why someone is unconscious AND abuses ETOH and is HepC positive....would you consider that maybe there might be other substances on board? Would this patient need a tox screen for other substances? Are you afraid of aspiration of gastric contents on a unconscious patient? What would you do for that? Would a NGT be helpful?

    Look up pancreatitis......but he doesn't have pancreatitis right now does he?....just a history of this. What labs would you need?

    Look up these diagnosis....we have given you a huge head start I have given you a few great links so you can look up these symptoms.

    Look up shock....how would you treat that. Alcohol is very dehydrating. He has been exposed to the elements...he is hypothermic it is clear that is isn't water that he has been drinking.

    Go to your care plan book now and look at the nursing interventions for these symptoms/complaints of this patient. Google is your friend.
  6. Visit  cdl766 profile page
    0
    Thanks so much for all your help!
  7. Visit  Esme12 profile page
    0
    You are welcome!
  8. Visit  NYCRN16 profile page
    1
    [QUOTE=cdl766;7314742]

    So, yes airway airway airway. If he is at 97% on 15L non rebreather, doesn't that mean his airway is holding up fine? QUOTE]

    This is a dangerous assumption to make. This is exactly the type of patient that gets put on a stretcher in the hallway because he stinks and is drunk and when you go back in an hour to see him he is dead.

    Remember, saturation is not a good indicator of resp effort. A patient can be apnec for 2 minutes before having a drop in saturation, by the time he drops its pretty late. I have seen this with my own two eyes in the PACU, the sat is fine but the patient is not breathing at all or taking breaths so shallow that he has no breath sounds because he is not moving air.

    The nasal airway is in place to keep his airway open until arrival at the hospital. This patient would have to be closely watched if the doctor decided not to intubate on arrival. Depending on the doctor, you may have some that would intubate right away and others that would just watch him closely and see if he improves.

    Personally, if the patient did not have active shingles I would not put him in an isolation room where I can't see him.
    GrnTea likes this.
  9. Visit  GrnTea profile page
    1
    " became I tundras in the field"
    I think that's autocorrect for "obtunded," .

    The hypothermia is just about at the life-threatening level. You need orders fr active rewarming, e.g., to give heated humidified (not dry room-temp) gases to breathe and warmed (not room-temp) IV fluids, in addition to nursing measures like removing ongoing routes of heat loss (wet clothes, skin, and hair in a nice air-conditioned place) because merely instituting measures to preserve body heat (hat, warm dry clothing) will not do a thing to warm him.

    When you look up hypothermia, what does it say to worry about with rewarming? What are some of the other effects of hypothermia? Hint: additive effects with other factors to increase risk of bleeding, lousy oxygenation, electrolyte imbalances, arrhythmias ...
    psu_213 likes this.
  10. Visit  Esme12 profile page
    1
    I figured...but I wanted to be sure the student knew what the term was.
    GrnTea likes this.
  11. Visit  psu_213 profile page
    1
    Quote from Esme12
    I figured...but I wanted to be sure the student knew what the term was.
    Here I was thinking it was some slang term for hypothermic.
    GrnTea likes this.
  12. Visit  GrnTea profile page
    0
    Tundra ... cold place ... I get it!



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