Critical patient scenarios

rkitty198, BSN, RN · Mar 12, 2011

1) Give more pain meds. It can take up to 24 hours to catch up with severe pain. Bowel resections where I work buy patients an epidural for pain management. I work on a surgical floor and this is a common scenario.

2) Never should there be 800 out from a chest tube in an hour. I would worry about cardiac tamponade and a million other issues and get my crash cart ready! This happened to me before, after a chest tube insertion and they knicked an artery!

3) Post-stent....sharp pain at a 5 of 10 pain level? Dosen't seem to be alarming it's common to have cardiac pain after a stent. I think one should still consider a possible ischemic issue, but I would keep an eye on the patient and if there are pain meds I would give them, if not then call the MD to both get pain meds and to notify of the chest pain.

MomRN0913 · Mar 12, 2011

I agree, bowel ressections are very painful.

yeah, the second patient is about to crash. Call the doc stat!

Chest pain is always concerning after a stent placement. It can be re-flow pain, but always notify the IC, do a stat EKG and cardiac enzymes, and pain meds. These are usually standard orders post cath

nursej22, MSN, RN · Mar 12, 2011

1) I would add to verify that the route of pain med delivery is patent and working. If so, then they need additional pain meds, with careful observation of their respiratory status.

2) Our post-op CABG orders include notifying MD for CT output >200cc/hr. I would call a rapid response, and anticipate the patient returning to OR and transfusion. This patient has nearly lost a liter of blood, and they only had 5(maybe) to start with.

3) I would call for a stat EKG and page the MD. Could be stretching pain, could be an acute stent occlusion.

Jenni811, RN · Mar 12, 2011

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.

Jenni811, RN · Mar 12, 2011

Oh, and cardiac Enzymes for patient number 3(CKMB and troponin).

fsaav · Mar 12, 2011

I know this is a question from school...but I love the idea of keeping a thread like this going with other possible scenarios. I love reading answers like this from experienced nurses because, as a new grad, I'm at the point where I'm able to tell when something's not right with my patient but the "now what" is what I'm trying to get the hang of. Thanks for posting this!

K+MgSO4, BSN · Mar 12, 2011

8/10 pain in a bowel resection is alarming. There is a risk that the anastomosis has broken down. Assess for an acute abdomen and bowel sounds. Ensure that the pain meds have been given via an appropriate route eg IV or SC. PO meds may not be absorbed. An SBP rise of 60 is a concern. I would give more pain meds and recheck BP. Also call the surgeon for a review. see what the rest of his obs are doing. ^ RR decrease SaO2 decrease urine output.

800ml of dark red fluid is a lot! check the pulse by palpation so you can describe it bounding, thready, regular weak etc. Get a second IV line in before they crash. Call a rapid response and get the surgeon to review as well. Pull bloods for a Hb and X match.

Third one I cannot help you with as I have no cardio experience.

My tips would be to get a repeat set of vitals if you think there is anything going on with a pt even if you only got the first set 30 seconds ago. Get you charge to come and help you and for him/her to review the pt. Get a second IV in on anyone who you think is crashing. let you colleagues know if you are worried about a pt so that they can assist you if you need it. Get excess furniture out of the way so you have room to work and it will already be out in the hall if you have to call a MET /RR or Code blue. Read the pt post op notes for reportable parameters. Let the surgeon know what is going on, even if they are scrubbed on another case they can give you orders of what they would like done. If in doubt, shout!

mcleanl · Mar 12, 2011

1)
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)

a heart rate of 130 in this situation would never be treated with a beta blocker....this heart rate is most likely compensatory and needed. if the patient is truly bleeding his blood pressure will come down all on its own....and it won't be pretty. again, you would never beta block a fresh post-op patient that you suspect is bleeding.

Creamsoda, ASN, RN · Mar 12, 2011

A heart rate of 130 in this situation would never be treated with a beta blocker....this heart rate is most likely compensatory and NEEDED. If the patient is truly bleeding his blood pressure will come down all on its own....and it won't be pretty. Again, you would never beta block a fresh post-op patient that you suspect is bleeding.

Agreed, its hypovolemic shock, I would be anticipating on getting that patient down to the OR stat and hanging blood and IVF. I just dont get the elevated BP though unless its an initial compensatory thing where the body is still able to clamp down the arterys to maintain a BP, but I dont think it would last for long

CCL RN, RN · Mar 12, 2011

Q3- absolutely that stent can close up in 2 hrs!

Do MONA, 12 lead EKG, labs, and call the cardiologist or cards fellow. Also, verify that the pt received his plavix s/p stent.

MunoRN, RN · Mar 13, 2011

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.