Please help with Case Study Scenario!!

[cdl766]

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. As you approach the patient for assessment you notice 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.

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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!!!!

[lmccrn62, MSN, RN]

They probably placed the nasal airway when he became I tundras in the field in a way to protect his airway.

[Esme12, ASN, BSN, RN]

what is "tundras" in the field?

[cdl766]

Since the pt. is hypothermic, I think we should start warm Lactated Ringers bolus running to try and bring his BP back up, assuming he is hydrated. Could we get an abdominal CT and a stool occult test to check for a GI bleed?

We would want to do a neuro check. Look at the pupils. Are they equal, fixated, dilated? If unequal and/or dilated, could be a neuro issue, hemorrhagic bleed. Did he fall and hit his head? Then we would start to think about increasing ICP and possible seizure. You'd want to raise the head of bed and send for a CT scan stat.

If the pt. has cirrhosis, you would expect him to have an elevated bilirubin, ALT, AST, PT, PTT and a decreased albumin. If the CT head scan comes back negative for a bleed and his blood alcohol is his, is it safe to assume that he lost consciousness based on his alcohol toxicity? Then, would the plan become to get him stable via fluids, banana bag and expect him to start having alcohol withdrawals?

[cdl766]

oops...I meant, assuming he is "dehydrated" in the comment above...

[cdl766]

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.

3. Thiamine?

4. Not sure what to do for the Pancreatitis?

5. I know alcohol has an effect on sodium. Is there more?

6. Would you suggest getting an ABG on this patient right away as well?

Thanks for your input! I really appreciate!!!

[Esme12, ASN, BSN, RN]

Probably not ringers because it is metabolized by the liver.....and there are many things that do not go with ringers.....0.9 would probably be best.

Yes ABG/s would be with the ABC's right? You have documented hypoxia? You would have to consider hypoxia. What does hypoxia do to the acid base system? What does hypothermia do to they system? What does severs ETOH intoxication do to the acid base balance?

You need to look up all of the disease entities by themselves know what they do and decide the common things that need to be tested and watched?

Yes a complete neuro check you had a combative patient that is now nearly comatose. Being obtund is deeply unconscious. Yes you would use the Glasgow coma scale for you patient.

What other labs? If you don't know why someone is unconscious AND abuses ETOH and is HepC positive....would you consider that maybe there might be other substances on board? Would this patient need a tox screen for other substances? Are you afraid of aspiration of gastric contents on a unconscious patient? What would you do for that? Would a NGT be helpful?

Look up pancreatitis......but he doesn't have pancreatitis right now does he?....just a history of this. What labs would you need?

Look up these diagnosis....we have given you a huge head start I have given you a few great links so you can look up these symptoms.

Look up shock....how would you treat that. Alcohol is very dehydrating. He has been exposed to the elements...he is hypothermic it is clear that is isn't water that he has been drinking.

Go to your care plan book now and look at the nursing interventions for these symptoms/complaints of this patient. Google is your friend.

[cdl766]

Thanks so much for all your help!

[Esme12, ASN, BSN, RN]

You are welcome!

[NYCRN16]

So, yes airway airway airway. If he is at 97% on 15L non rebreather, doesn't that mean his airway is holding up fine? QUOTE]

This is a dangerous assumption to make. This is exactly the type of patient that gets put on a stretcher in the hallway because he stinks and is drunk and when you go back in an hour to see him he is dead.

Remember, saturation is not a good indicator of resp effort. A patient can be apnec for 2 minutes before having a drop in saturation, by the time he drops its pretty late. I have seen this with my own two eyes in the PACU, the sat is fine but the patient is not breathing at all or taking breaths so shallow that he has no breath sounds because he is not moving air.

The nasal airway is in place to keep his airway open until arrival at the hospital. This patient would have to be closely watched if the doctor decided not to intubate on arrival. Depending on the doctor, you may have some that would intubate right away and others that would just watch him closely and see if he improves.

Personally, if the patient did not have active shingles I would not put him in an isolation room where I can't see him.

[nurseprnRN, BSN, RN]

" became I tundras in the field"

I think that's autocorrect for "obtunded," :) .

The hypothermia is just about at the life-threatening level. You need orders fr active rewarming, e.g., to give heated humidified (not dry room-temp) gases to breathe and warmed (not room-temp) IV fluids, in addition to nursing measures like removing ongoing routes of heat loss (wet clothes, skin, and hair in a nice air-conditioned place) because merely instituting measures to preserve body heat (hat, warm dry clothing) will not do a thing to warm him.

When you look up hypothermia, what does it say to worry about with rewarming? What are some of the other effects of hypothermia? Hint: additive effects with other factors to increase risk of bleeding, lousy oxygenation, electrolyte imbalances, arrhythmias ...

[Esme12, ASN, BSN, RN]

I figured...but I wanted to be sure the student knew what the term was.

[psu_213, BSN, RN]

I figured...but I wanted to be sure the student knew what the term was.

Here I was thinking it was some slang term for hypothermic.