Please help with Case Study Scenario!!

**NICU Guy, BSN, RN** · May 2, 2013

I don't understand why the scenario says that the pt has a non-rebreather mask and a nasal airway placed in his right nare that can be seen under the mask. Is that just a NC that EMS forgot to remove?

They are referring to a nasopharyngeal airway in his right nare. Like this one: http://webapp1.dlib.indiana.edu/cgi-bin/virtcdlib/index.cgi/4931363/FID1/DATA/operationalmed/Procedures/Nasopharyngeal%20Airway.htm It was used because he was unresponsive when EMS arrived to ensure an open airway

MendedHeart · May 3, 2013

I had a pt who took too much Benzos and also came up to floor with a airway in his rt nare with NC over it.

cdl766 · May 3, 2013

Ohhh! Thanks Don1984! Do you have any other insights regarding the scenario??

Esme12, ASN, BSN, RN · May 3, 2013

I would appreciate any insights and thoughts on this case study scenario! I will write my thoughts after the study, but I'm hoping for some help on this one!!!
CASE STUDYYou are an ED nurse and a patient arrives via EMS unresponsive, malodorous with the smell of alcohol, feces, urine, and strong body odor detectable from 50 feet in every direction. EMS says that an intoxicated man was laying in the parking lot cussing at and threatening people as they walked into the restaurant. Upon arrival EMS found the subject down on the ground in his current appearance and smell. He was combative with them and did not want to be moved. EMS proceeded to force him onto the gurney with assistance the police. During transport the man went from shouting profanities to an obtunded state. Anon-re-breathes you approach the patient for assessment you notice he has a he has a non-re-breather running at 15 liters. As you get closer to him you see through the mask that he has a nasal airway placed in his right nare. His hands are taped together at the wrists. EMS tells you they did this because he was swinging at them upon arrival. His body is covered with soaked clothing, he is cold, but does withdraw from painful stimuli. You must employ the help of other staff to move him as he is like dead weight. EMS hands you his driver's license with his picture on it, his name is Little Two Feathers a 47 year old Native American male. His vital signs just obtained upon arrival are: 90/59, 122, 20, 34.9 rectal, 97% on 15L. EMS reported his Room Air SPO2 to be 87% after he lost consciousness.
Medical History: HTN, Cirrhosis, Pancreatitis, Gastritis, Hepatitis C, GERD, HSV-2, Shingles, Wernicke's encephalopathy, hepatic encephalopathy, and IBS.
What is your course of action as the RN? What is the proper order of things you should do for your patient including things you anticipate from medical staff? What is/are the worst case scenario(s)? Include your initial assessment and any reassessments in the proper order if necessary. What is likely wrong with this patient? Include this and a detailed care map including anticipated treatment and realistic outcomes.
--------------------------------------------------------------------------------------------------
Here are some things that come to mind, but I would really appreciate any help with this!
Hook patient up to pulse oximetry. Due to 87% on RA and 15L sat at 97%.
May need to be put on Airborne Precautions and Contact until it is ruled out. Patient has history of Shingles and HSV-2.
Remove tape from patient wrists, because it is not legal to have patient on restraint without physician orders and it isn’t the proper restraint.
Patients Temp. is 34.9 (94.8 F) Remove soaked clothing from patient and warm patient with Bair Hugger to help bring up his body temperature to at least 37 C (98.6 F).
Need an order to Bolus patient, because BP is very low at 90/59.
Need an order for Blood draw for labs, alcohol level, blood sugar, liver function due to Hx, ammonia levels (history of hepatic encephalopathy).
If his ammonia levels are elevated, Dr. may place him on Lactulose because of Hx of hepatic encephalopathy.
Assess patient GCS
Make sure patient has IV access and probably 2, because one is for bolus and the other may be for emergency medications (such as Ativan).
May need an order for CT because of patient’s Past Hx, alcohol may cause the diagnosis to reoccur (Pancreatitis).
I don't understand why the scenario says that the pt has a non-rebreather mask and a nasal airway placed in his right nare that can be seen under the mask. Is that just a NC that EMS forgot to remove? Any thoughts would be greatly appreciated!!!!!
Thanks so much!!!!

I am curious.....What semester are you?

What is your course of action as the RN? What is the proper order of things you should do for your patient including things you anticipate from medical staff? What is/are the worst case scenario(s)? Include your initial assessment and any reassessments in the proper order if necessary. What is likely wrong with this patient? Include this and a detailed care map including anticipated treatment and realistic outcomes.

I am going to start you out ........I have highlighted important facts in your case study. Your goal with this assignment its to prioritize the care of this patient....right? Use your books...use Google to find the information you are looking for.

If I was the nurse and I was given the following information.......

patient arrives via EMS unresponsive. was combative

he has a non-re-breather running at 15 liters.

nasal airway placed in his right nare

His body is covered with soaked clothing, he is cold, but does withdraw from painful stimuli.

hands are taped together at the wrists

His vital signs just obtained upon arrival are: 90/59, 122, 20, 34.9 rectal, 97% on 15L. EMS reported his Room Air SPO2 to be 87% after he lost consciousness.

Medical History: HTN, Cirrhosis, Pancreatitis, Gastritis, Hepatitis C, GERD, HSV-2, Shingles, Wernicke's encephalopathy, hepatic encephalopathy, and IBS.

So you have a hypoxic, hypothermic, hypotensive/shock, tachycardic unconscious/obtunded intoxicated patient with tied hands....What is your first move? Think ABC's.

First I would cut this mans hands free.....than I would assess the ABC's

Now you need to correct what's wrong what is life threatening.....This patient is unconscious and this occurred suddenly. He is intoxicated, hypothermic with known HTN and liver disease...cirrhosis and HepC

Airway Airway Airway....The patient is unconscious/obtunded can they maintain a patent airway? Are the passed out drunk? or do they have a Cerebral bleed from coagulopathy related to liver disease?

Hypoxia......what is a non-rebreather? What is a nasal airway/nasopharyngeal(also called a nasal trumpet)why would the EMS use this?

What is hypotension? What do you need to do to correct the hypotension? What can be causing the hypotension? ETOH intoxication? Can there be GI bleeding from the cirrhosis/hepC? Is he dehydrated from ETOH and obvious lack of care/compliance and possible homelessness? What do you need to do?

What is hypothermia? What can this cause? What do you need to do to warm the patient? Do the wet clothes accelerate temperature loss? How do you rewarm a patient?

This is a long assignment......Do you see where this is going? Now lets... Start head to toe....Airway Airway Airway...now tell me what you need to do first and why.

Care of hypothermic intoxicated patient

cdl766 · May 3, 2013

Thank you so much for your response! I have to put this all together to present to my clinical class by tomorrow morning!

So, yes airway airway airway. If he is at 97% on 15L non rebreather, doesn't that mean his airway is holding up fine? He won't need to be intubated, correct? Or would they intubate him anyways to be safe? As far as correcting his hypothermia, they could warm him with blankets and warm IV fluids.

So, they will need to figure out whether he is hypotensive because of the alcohol toxicity or whether he is having a gastric bleed related to the alcohol/gastritis?

Also, they need to determine whether he is unconscious due to the alcohol or a cerebral bleed due to his liver disfunction? Since his liver produces the clotting factors, he could be having a cerebral hemorrhagic bleed which is causing him to be unconscious and then possible intracranial pressure and then lead to seizures. So, to determine this, they would obviously do blood alcohol test and a CT scan or MRI of his head?

Esme12, ASN, BSN, RN · May 3, 2013

At 100% O2 he is saturating at only 97% while that is sufficient.....due to his LOC intubation might be considered to protect the air way. What is the most common thing that obstructs a patients airway? The patients own tongue right? So intubation is a strong consideration due to the patients LOC even if it is from ETOH. The nasal airway was place because of some possible compromise to the airway. It tells how deep this patient is because most people...even if they are passed out drunk do NOT like these in their nose.

Remember we care for the patients needs first before we delve into "history" per se because you must try to stabilize the patient first for if you don't you won't have a patient at all. But their medical history is always ever present in the back of our minds to help us further our investigation and ordering lab work

The patient is hypotensive....regardless of the cause they have a low B/P you need treat so that you will perfuse this patient properly and to ensure to have the most optimal end organ perfusion. So you would need 2 large bore IV's right? What fluids would you think be used...thinking that this is a volume loss whether that is blood loss or dehydration form the ETOH and exposure to the elements...right? You would consider getting blood type on stand by.

The patient is hypothermic.....how hypothermic are they? Certain core body temperatures require different first responses and considerations. If you click on the links I placed in my response you will get some of the answers. There is passive warming and active warming and invasive warming. and of course you would remove the wet and filthy clothes.

You want to know if the are producing urine and you need an accurate I/O so a foley would be placed. The aptient would be placed on a cardiac monitor, O2 sat and an automatic B/P if available...right? what other assessment would you consider? What are their pupils? Their lungs? Abdomen? Pulses? Edema?

So we need labs.....what labs do you think? I'll start.

CBC, Lytes (or chem's to include MGSO4, Ca+),BUN,Creat, PT, PTT, ETOH, Liver, Amylase, Lipase, NH4, CPK/isos, LHG SGOT,Type and screen

Tests think simple.....CXR, CT head

Your thoughts?

**NICU Guy, BSN, RN** · May 3, 2013

Thanks Esme!! You gave me flashbacks of my EMS days. Attempting to start 14- 16g IVs. That should be part of nursing school. If a student can slip in a 16 gauge angio into a patient without blowing a vein they pass that skill.

Esme12, ASN, BSN, RN · May 3, 2013

No kidding right???? :roflmao:

Once emergency medicine always emergency medicine....

psu_213, BSN, RN · May 3, 2013

Some thoughts:

1. Contact isolation: important but probably not my first priority. An instructor (or infection control nurse) may say otherwise, but I'm not going to worry about this first.

2. Tape: yes, remove it for various reasons...go with soft wrists if pt is combative.

3. IVF: in addition to the bolus, what other fluid would you expect to see (hint: think Wernicke's encephalopathy).

4. For the pancreatitis, what might be ordered instead of the CT?

5. What lab work would you expect to be ordered and why? Think about the chronic etOH use. What electrolytes might be off? What are the cardiac implications thereof?

6. Re: the sats/airway/intubation. Pulse ox is a quick way to get an idea of someone's oxygenation status, but it is not the entire story. In addition, it tells you virtually nothing about someone's ability to protect their airway. I have seen individuals who's respective sats. have been fine on minimal supplemental oxygen, yet they have still be intubated. While the pulse ox is useful, having a good reading does not mean you are out of the woods vis-a-vis intubation.

Otherwise a good start on a complicated study.

psu_213, BSN, RN · May 3, 2013

Also, they need to determine whether he is unconscious due to the alcohol or a cerebral bleed due to his liver disfunction? Since his liver produces the clotting factors, he could be having a cerebral hemorrhagic bleed which is causing him to be unconscious and then possible intracranial pressure and then lead to seizures. So, to determine this, they would obviously do blood alcohol test and a CT scan or MRI of his head?

They will almost certainly do and etOH level, but, speaking real world here, if you smell alcohol, they are drunk until proven otherwise.

As for the CT vs MRI--which of these tests is used to find an ICH?

On a related note, I am glad that a student realizes the link between liver dysfunction and coagulopathies...I have seen very good nurses overlook said link. :yes:

Esme12, ASN, BSN, RN · May 3, 2013

Some thoughts:
1. Contact isolation: important but probably not my first priority. An instructor (or infection control nurse) may say otherwise, but I'm not going to worry about this first.
2. Tape: yes, remove it for various reasons...go with soft wrists if pt is combative.
3. IVF: in addition to the bolus, what other fluid would you expect to see (hint: think Wernicke's encephalopathy).
4. For the pancreatitis, what might be ordered instead of the CT?
5. What lab work would you expect to be ordered and why? Think about the chronic etOH use. What electrolytes might be off? What are the cardiac implications thereof?
6. Re: the sats/airway/intubation. Pulse ox is a quick way to get an idea of someone's oxygenation status, but it is not the entire story. In addition, it tells you virtually nothing about someone's ability to protect their airway. I have seen individuals who's respective sats. have been fine on minimal supplemental oxygen, yet they have still be intubated. While the pulse ox is useful, having a good reading does not mean you are out of the woods vis-a-vis intubation.
Otherwise a good start on a complicated study.

But if you are following universal precautions...you should be good. In the ED you Wear whatever gear necessary to protect/prevent exposure. This patient would be up there with typical trauma gear/mask eye wear, gowns/gloves