Critical Thinking Snapshots - page 2

Those of you who have been posting these I want to say thanks. I have been enjoying them. Although I do not post to them for fear of looking like the complete dumba** that I am:) Keep them... Read More

  1. by   jadednurse
    Dehydration? Hypernatremia? UTI? But his sats are creeping down too...hmmm...What are his loung sounds like?
  2. by   stella123 rn
    What is his bowel status?
  3. by   jadednurse
    Oops, good point?
  4. by   stella123 rn
  5. by   gwenith
    still all good replies - when it comes to assessment he have to maintian a high index of suspicion. i am almost tempted to make it come out as nothing much - but you know me too well.

    lab results are back - only anomalies are a high white cell count and a high glucose level. he is not know to have diabetes. (i wont give actual laboratory results as some of our values differ form those used in usa. ) he has been incontent again and a catheter is placed, he is still confused slightly tachpnoeic, hypertensive and tachycardic. saturations reamin around 95 - 96% but it is difficult to assess as he is intolerant of the probe. temperature is still climbing now 38.5. medical officer concedes that he may "have an infection somewhere" and orders antibiotics to be stated as well as urine adn sputum screens. oh and ps - his lung sounds are clear.
  6. by   jadednurse
    Well, since we've done cultures and started abx, let's give him an antipyretic to get his temp down and hopefully lower his HR. BTW, is he in pain? How does the incision site look? Any central line? Do we need blood cultures too? And what is his urine output after the Foley was inserted?

    Ooh, this is fun!
  7. by   gwenith
    actually it is fun writing them too! trying to stay true to form and the clinical picture while keeping everyone guessing until i drop the anvil. up until this point there it shoud read like a conventional sepsis in an elderly male - at this point the origin is unknown.

    his urine output has remained good - 100 mls over the last hour. his temp is continuing to climb - now 39.1 despite panadol pr. his loc has decreased to where he is mostly just muttering to himself if he is responding at all. he is not only tachpnoeic at 34 but seems hyperpnoeic as well. almost "chuffing" breathing. his lung sound though remain clear. his sats have fallen to 94% and you start 02 via nasal prongs at 3 lpm he is definitely flushed with a warm dry skin. his bp is still elevated at 160/80. problems within the ward take you away from thsi patient for over an hour. when you retrun he no longer looks flushed but pale and cool.. his temp per axilla is now down to 36.5 his bp is down to 90/60. his puse is still tachycardic around 110 and he is still tachypnoeic around 32 with sao2 still around 94%. he has had only 5 mls urine output over the last hour.
  8. by   jadednurse
    Increase a little dopamine headed his way? What are his BUN?CREAT?
  9. by   jadednurse
    I'm also still concerned that, despite his lung sounds being clear, he is tachypneic and his sats are still dropping. CXR? ABG?
  10. by   gwenith
    next installment:-

    loc continues to decrease and he comes gooll bp rapidly becomes unreadable with manual sphygmo . urine output remains poor to anuric.

    although an inotrope is a good suggestion this pateint requires fluid and a lot of it.

    the picture i have been describing is the classic warm/cold phases of septic shock. very difficult to assess and diagnose as iseptic shock is simply the end of the sepsis spectrum. the patient will soften pass rather rapidly from the hyperdynamic warm phase of sepsis to the hypodynamic cold phase. fluid will start to shift form the intravascular space into the extravascular space at this stage and they will need more fluid to maintain bp. inotropes are also required but fluids are a first liine.

    i am logging off now for a couple of days so if anyone lelse wants to come in and finish the story they will be welcome