Patient Assessment - Deep trouble

Nurses General Nursing

Published

The aim of this "game" is to look at critical indicators in assessment.

Some of the patients in the following scenario are in "deep trouble" but some may not be. Can you identify the ones in trouble? If you can write what you think on a piece of paper.

If you feel happy to post about one of the patients please do so but don't let the cat out of the bag on all of them!!!

If you want to add another "deep trouble" patient scenario please do so - I do not have the corner on these!!!:)

Patient A)

A forty year old man with a 25 year history of heavy cigarette smoking compalining of central chest pain. Pain score 10/10. Colour - normal not pale. Sao2 98% on 4 Lpm O2. Monitor sinus rhythm with occasional PVCS - Bp 160/80. He is very restless, moving around the bed loudly complaining and demanding immediate attention and threatening to walk out. ECG is normal.

Patient B

8 year old child came in with Mother who is distraught and keep s telling everyone that "young Jimmy" was alright when she checked on him only an hour previously. Jimmy is sitting upright, with his head forward and jaw protruding. There is saliva dripping form his mouth and it is obvious he cannot swallow. He looks sick - florridly pink cheeks. Resps and sats normal but temp 38.5C. Tachycardic.

Patient C

Oversdose Vital signs within normal parameters. Monitor - sinus rhythm. Sao2 99% on 100% O2 GCS 6/14 eye opening to painful stimuli.verbal respons - nil and Motor response 3 - flexing. When you see the patient tehy are in a lateral position with a guedel airway in place (oropharyngeal airway)

I am getting tired so I might limit it to three patients for tonight but I will be back to post some more with the answers to these!

Specializes in midwifery, ophthalmics, general practice.
Originally posted by Scis

karenG:

Never let your guard down, at any time you may be presented with one of these types who waited to see the primary care physician instead of go to the ER. Just when you least expect it.....be prepared! These tips may come in handy!

Patty

yes thats true!!! dont what gear yoy have in primary care- I have me!! (ok I have a defib, stethacope, otoscope and ophthalmascope, sphig as well) I will admit to being a jack of all trades but I (gulp) have only seen one arrest in 15yrs!

one I had recently.......what would you all have done?

lady presented c/o severe abdominal pain, 11 0n 1-10 scale! nothing made it better/worse. pain in left upper quadrant. apyrexial.............and she threw up over me. diagnosis?

Karen

These are great practice...thanks.

karenG:

OK, to think the worst first---dissecting aortic aneurysm? acute MI? Was this the one arrest?

Let us know!

Patty

Specializes in Cardiolgy.

This is a great thread, one I am learning so much from just by reading, Some of the paeds cases threw me, as I have no training with paeds, and no completed adult training!!!, I would probably send kid B first, If they are already on treatment and it is not working, that seems more severe some how than the other child.

Any chance of the answer canadian?

Whisper

Specializes in ICU.

Karen G One of the many reasons why I keep wanting to have everyone play the game without recourse to lab values is that sometimes you just don't have teh access to the information. It is about working out probabilities and plotting interventions based on those probabilities.

Perhaps if Canadian doesn't come back to give us the answer we can copy the questions onto the paediatric forum and get one of the Paeds nurses to answer them for us!:chuckle

I am going to let a couple more members have a go at answering case six before I give you the real inside information on him.

Hint:- In real life this guy would be AMAZED at how disinterested we would be in his broken arm!!!

lady presented c/o severe abdominal pain, 11 0n 1-10 scale! nothing made it better/worse. pain in left upper quadrant. apyrexial.............and she threw up over me. diagnosis?

Appendicitis??

You all are doing great, I'm learning alot from you:)

Specializes in ICU.

lady presented c/o severe abdominal pain, 11 0n 1-10 scale! nothing made it better/worse. pain in left upper quadrant. apyrexial.............and she threw up over me. diagnosis?

____________________________________________

Acute cholecystitis is usually right upper quadrant and this woudl be a favourite especially if she fit the fair, fat and forty type. Occasionally people are born with the organs reversed so it is just because it is right (oops I meant LEFT) sided doesn't rule it out entirely.

Upper quadrant - couldn't rule out acute pancreatitis but my money would have to be on a gut obstruction. Esp if the vomiting was projectile enough to actually hit you ( I presume you like me can move at olympic speeds when it comes to body fluids heading your way)

After I went back to study, I thought about cholecystitis(gall bladder). I think most here would just call it a cystic duct because that is where the conditions etioligy is from. The formation of crystaline structers in the cytic duct.

You can't digest fat and I guess it would be like passing a kidney stone but from your cystic duct to your hepatopancreatic ampula instead of your urethra.

I think that would make me regurgitate too.:p

Specializes in midwifery, ophthalmics, general practice.

well- she acutually had acute pancreatitis. gave her IM maxalon to no effect and admitted her stat! she was a non drinker as well!! have to admit my differential diagnosis was obstruction because she had no bowel sounds. so I let the surgeons sort her out!!

Karen

Specializes in ICU.

Silent gut is not unknown in acute pancreatitis. A significant number of acute pancreatitis is idiopathic or associated with obstruction by infammation or stones. They can get VERY sick VERY fast. It is one of those strange disorders in that there is almost two distinct types. Med/surg nurses are used to seeing the chronic pancreatitis and wonder why ICU nurses go pale at the mention of an acute fulminating pancreatitis.

Since I've not ever worked in an ER..........yet

From Gwenith

Esp if the vomiting was projectile enough to actually hit you

Would that degree of severity of the vomitting cause you to consider bowel obstruction in any case? I mean, is it a hallmark of bowel obtruction?

I had forgotten that the pancrease produces bile salts for digestion of fats as well. The fats didn't digest and the ph would be all out of whack too.

The most obvious of my errors was that I wasn't thinking of Left upper quadrant when I described all the organs from the right upper quadrant now was I? I was thinking of the patient in an anatomical view and went right to the left..........................only in anatomy left is right.

Crap.

I need to do this for real soooooooooo bad.

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