Help with Case Study and Nurses' 1st Response

[chevyv, BSN, RN]

I'm working on a case study and could use a nudge of yes or no as to going in the right direction. I also posted this on the specialty nurses tab, and then found a student help tab so here I am.

Male (49yrs) pt on med surg unit, nurse walks in to find him lethargic and dyspneic. BP 106/66, P 110 rapid, thready, T 99.2, Resps 30 labored, crackles, wheezing in lung fields, skin is pale, cyanotic, cold, and moist. Ekg shows sinus tach with PVC's (frequent).

I've determined that pt is experiencing cardiogenic shock. Now I need to determine the nurses' first initial response using prinicples of collaborative care. I know that my priority is always ABC's. His breathing is labored, but his circulation is also a biggie. I would think a nurse would first put him on O2 and check his O2 sats. If using a mask at 10-12 L/min to get and keep him at 97-98% O2 is a nursing priority, would I need a docs order or is there usually some sort of hospital protocol? I also know that he needs some IV fluids pretty quickly as well. What would you do first? I know that I would not elevate the legs (no Trendelenburg), due to the abdominal organs shifting to put pressure on the diaghragm, which limits respirations. I'm leaning towards using O2 and attempting to maintain the airway. Thoughts?

[UM Review RN, ASN, RN]

Just curious, but what led you to the cardiogenic shock dx? I'd be leaning toward heart failure (even though this patient is pretty young for that) or pneumonia. Not that I'm all that great at dx'ing.

Anyhow...as a staff nurse on a tele floor, this is what I would actually do:

I would get the patient's head up, apply O2 *get the order later, the patient is in crisis*, call the Respiratory Therapist for more support, get vitals (including a blood sugar), do an EKG, call the doc and ask for ABG's, a Chest XRay, a bunch of stat labs, including cardiac enzymes and a BNP.

I'd be thinking about moving toward blood cultures, lasix, and more respiratory support if the O2 didn't improve his sats to about 92% immediately, and moving him to the CCU for more intensive treatments.

With a patient that young and with those symptoms, I might even be tempted to call a Rapid response so we'd have more hands to help with getting him stable.

[chevyv, BSN, RN]

The case study is asking what type of shock he is in. I'm sorry, that was a question before this one. He has all of the s & s of cardiogenic shock.

He is young, but overweight, high cholesterol, and a fm hx. I should have given more info, but I believe the priority would be to stabalize the airway. I know I have to get blood gases, 12 lead, echo, and other things, but I just wanted to make sure the best initial response is to get the O2 going and find out if he needs to be bagged and then move on to fix the cause. Considering vs have already been done, I now have to act on what I'm seeing and what my data tells me. My first thought is O2.

[Daytonite, BSN, RN]

this is not my field of practice, but i know enough about critical thinking and prioritizing to know that the nursing process works for solving any problem.

1. assessment - information is given to you. i reorganized it a bit.
   • lethargic
     
   • dyspneic
     
   • resps 30 and labored
     
   • crackles
     
     
   • wheezing in lung fields
     
     
   • cyanotic
     
     
   • bp 106/66
     
     
   • p 110
     
     
   • pulse thready
     
     
   • ekg shows sinus tach with frequent pvc's
     
     
   • t 99.2
     
     
   • skin is pale
     
     
   • skin is cold
     
     
   • skin is moist

[*]diagnose - i am not a doctor, but i can see there is a cardiac output problem and gas exchange problem right off the bat. the lungs are gunky and the heart is struggling. the cyanosis is a symptom of systemic hypoxia; the pvcs of cardiac hypoxia.

[*]plan - go with abcs. oxygen is #1 on maslow's hierarchy of needs. get oxygen in. if the airway is in anyway blocked, get it cleared by suctioning or intubating the patient (he has crackles and is wheezing). get o2 started. get the hob up and get the patient in a position that will help him assist his breathing. assume bronchodilators will be ordered and/or call the doctor for an order for them. the doctor may want to order inotropic drugs to assist the heart in pumping more effectively.

[*]implement

[*]evaluate

[chevyv, BSN, RN]

Thank you both for the input. I always think back to ABC's and go from there, but I'm so new at really putting it all together, that I start to question my own sense. I appreciate the help. :redbeathe