Help needed with Case study

[suprnurs40]

Hello, everyone;

I am looking for input from experienced nurses as to how to handle the patient situation in the following case study. I value experiential knowledge, and feel that a student like myself will benefit from information gleaned from seasoned nurses. I thank you. Here is the Case study in question:

Admitted to the Intensive Care Unit following a Thoracotomy with Segmental Resection of the Left Lung for Carcinoma of the left Lung. As the nurse responsible for his care you are concerned about your most recent assessment findings.

Neurological

PERLA @ 4mm

Handgrips moderate and equal

Moderate and equal leg strength

Orientated to time, place and person

"Seems agitated"

What are the possible sources of Mr. Brown's agitation?

Respiratory

Respiratory Rate 28-32

Oxygen per high humidity @ 40%

Oxygen saturation of 89%

Chest Coorifice with decreased air entry to the left side

Chest Tubes * 2 # 28 Argyle connected via y-connector to Atrium dry suction system with -20 cm of wall suction. Chest tubes tidaling with respirations and bubbling noted in water seal chamber. Large amount of bloody drainage noted in collection chamber.

Large amount of serous sanguineous drainage noted on chest tube dressing.

Operative Dressing appears dry and intact except for small amount of shadowing appearing through outer layer of dressing

Are any of the above findings of concern to you? Why or Why not? Address each finding separately.

Cardiovascular

Heart Rate 120 - 130's

Blood Pressure 80's systolic

Temperature 39 degrees Celsius.

Monitor Sinus Tachycardia

Pedal pulses palpable (dorsalis pedis and posterior tibial)

Color pale

Skin diaphoretic

Peripheral IV D/5/W with .45 Saline at 100 cc/hr

Are any of the above findings of concern to you? Why or Why not? Address each finding separately

Gastrointestinal

Abdomen Flat with no audible bowel sounds

Genitourinary

# 14 2-way Foley catheter draining approximately 30-45mls per hour for the last three hours.

Patient's Most Recent Blood Work

WBC 29, 000

Hemoglobin 79

Platelets 165,000

Bun 4.7

Creatinine 112

Sodium 145

Potassium 3.2

Chloride 110

Arterial Blood Gases

PH 7.375

PO2 88

PCO2 40

HCO3 22

Base Excess -1.5

Chest X-ray

Reveals a left Pleural Effusion

After reviewing patient's blood work with the physician, an order is received to transfuse Mr. Brown with 2 units of packed cells. He has never received blood before. What are you going to do? Should you be concerned that he has not received blood before?

Mr. Brown will also receive a serum potassium bolus to correct his hypokalemia. As a beginning practitioner you are wondering what the hype is anyway about giving potassium IV bolus. You have been told that "potassium is dangerous if given incorrectly" Is this correct? Why or Why not? What does the evidence say? What is the correct way to administer potassium IV?

What else is of concern to you regarding Mr. Brown's Blood Work?

Should you be concerned about the reveals of the Chest-Xray?

Explain how your assessment findings correlate with a diagnosis of a Pleural Effusion?

[llg, PhD, RN]

Give us your thoughts so that we can comment on the them.

Is this a homework assignment or test question?

Many of us hesitate to do a student's work for them without some evidence that the student has made an effort to answer the questions for himself/herself first.

You are more likely to get more and better responses that way.

Please share your thoughts.

llg

[suprnurs40]

Thanks for your interest;

The patient's Glasgow Coma Scale is likely about 14 or 15. The slightly dilated pupils could be the result of analgesic treatment for the lung resection. His neuro seems ok, but what about the agitation? His respiratory rate is very high. As he is not intubated, I feel that this is at the root of his agitation. What is causing such a high RR?

As to the chest tube situation, does he have internal bleeding, perhaps? The seal where the chest tube is going into the patient may be loose. He is febrile, HR is high, BP is not good, and he is diaphoretic. I began to suspect a pulmonary embolus, but palpable pulses have me thinking maybe not... but now feel that this man is in septic shock! No bowel sound on auscultation, so what is blocking his colon? Why no peristalsis? I do not know at this time.

His lab values show a low blood values that need to be addressed (the transfusion. his potassium is worrysome. His ABGs show, in my opinion, metabolic acidosis. This would account for the hyperventilation as the body strives to blow off excess CO2 and conserve HCO3. The xray shows a left pleural effusion. I would put him on broad spectrum antibiotics (temp = infection from septic shock); I would continue ventilation support; fluid resuscitation; and give Levophed and Dopamine to increase BP.

I would value any input from experienced nurses on this. I truly think this gentleman is in septic shock. How far off the mark am I, folks?

Thank you.

I would request a cross match and screen from the lab as to the blood.

[zacarias, ASN, RN]

Good assessment skills suprnurse. He does sound like he's gonna crash. I would note that he's not getting enough O2 to his lungs. Also, because his HCT is low, that means he's even getting less O2 to his organs and tissue.

Agree with your reasoning for his restessness.

[jonear2, RN]

Also keep an eye on urine out put. Oliguria is