Need help with this Case Study

[UCCBRN]

hi, everyone;

i would like input from experienced icu or ccu nurses on a case study i am researching. please advise as to what you would do if this were your patient. as a novice about to graduate, i want to look at it from an experiential view as opposed to taking it from a book. any advice would be greatly appreciated. here is the case study in question:

patient was 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.

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'sblood 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?

patient 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?

[Phishininau]

Source of agitation is likely dyspnea with hypoxia. Causes level of conciousness changes.

Tachypneic with hypoxia. First thought is PE, but that is not supported in the ABGs. Neurological problems, possibly, but not likely with OX3 etc. I think the problem is sepsis. Early sepsis gives you tachynia with hypoxia. Sounds like decompensating sepsis with the cold/clammy stage.

I am concerned that is this is sepsis...the pt is probably dry. Remember 1. Fill the tank, 2. Squeeze the tank, 3. Kill the bugs. They need a lot more fluid that than, and D51/2 isnt the best choice. NS is the way to go...probably somewhere around 200cc/hr for 24 hours. I would also bolus them 500cc over the next 30 min if their LV fxn will allow it.

Hypokalemia...good tx to give some KCL. No more than 20mEq/hr, even though 10mEq/hr is safer and what I like to use. 40mEq should get them up to about 3.8 or so.

The PRBCs need to given first. Good volume expander, blood. That will pull some of the fluid that the pt has third spaced back into the vessels, as well as causing an increase in BP and providing a means to transport O2. Unfortunately, 3-DPG doesnt activate for about 24 hours so the new blood wont actually start carrying blood until tomorrow. That will eventually help the hypoxia.

Is this a good start for you?

[gizelda196]

I would look at that chest tube more closely! Call the surgeon stat.

As for filling this tank I would first start with a squeak of neo . Lungs are always kept DRY. The chest tube findings are troublesome as with the xray. Fix the chest tube issue and you"ll probably fix him. Check a glucose just in case . I know it sounds weird . His hgb is under 8 so hence the blood. You are worried about a reaction with the transfusion and he already has some pretty vague s/sx that mimic many things. premedicate with benadryl and apap.

As for the kcl you could kill somebody if you give too much to fast. 20 meq an hour in 100cc bolus is good. on a pump. always always always. with central access because it irritating to veins

He is febrile with a white count . But he is post op and dry and he has had a big surgery .what is the diff? Are the wbc's inflammatory for infection or surgery? Also he has some renal insufficiency by lab work . His urine output is marginal. How much fluid did he get intraop and preop? remembering lungs are kept dry?

[UCCBRN]

Thanks. It pays to ask questions. You are a great help, and I truly appreciate it!