You, an RN, are assigned the following patients for total care today. Report is over at 0720. Prioritize these four patients and provide rationale for your decisions.
401 Mr. A: 65 year old, same day surgery admission at 0630 for a herniorrhaphy this morning. He's been NPO since midnight. The admission is complete and the OR permit is signed. His temp was 97.8, pulse 78, respirations 20. BP was 132/68. Pre-op med is due at 0800.
402 Miss B: 71 year old, diabetic with a left femoral-popliteal bypass, first post-op day. Temps during the night were 99.2 and 99, pulses 88 and 84, respirations 20 and 18. BPs142/88 and 144/88. Pedal pulses are 80 and 84 on the right and not palpable on the left. The left foot is somewhat cooler than the right, but there is good capillary refill. Her dressings are clean and dry. She has an IV of D 5 1/4 NS at 100 ml/hr with 320ml to go and remains NPO. She has a foley that drained 125 ml of concentrated urine since midnight. She is on sliding scale insulin. Her glucometer check was 240 this morning, and she got 10 U of regular insulin. She has an IVPB antibiotic at 0800.
403 Mr. C: 42 year old, had a gastric resection and returned from PAR at 0430 yesterday (27 hours ago). He has a Salem sump pump on low intermittent suction that drained 675 ml of bloody/green drainage during the night. He has an IV of lactated ringers at 150 ml/hr with300 ml to go. He has 2 units of blood on call. Hourly BP's have ranged from 112-120 over 64-70. 0600 BP was 112/64. Pulse has been 80-98 and was at 98 at 0600. He was cathed for 250 ml at 0400. He's been turned q2h. He coughs and deep-breathes poorly. He had Demerol 75 mg IV at 0345. His dressing had a large amount of sero-sanguinous drainage when it was changed at 0400.
404 Mrs. D: 59 year old, with lung cancer, had a scalene node biopsy yesterday afternoon to check for metastasis. She is to be transferred to her home by ambulance this morning at 0830. She has 0800 and 0900 meds. She had a poor night, developing a new onset of SOB with O2 sats at 0200 of 94 % and at 0600 of 90%. She was placed on O2 at 2 L at 0200.
Okay so here goes nothing...
1. Mrs. D in room 404 - Pt has a new onset of SOB and O2 sats have been dropping. I would consider her first priority due to breathing.
2. Miss B in room 402 - Pt is lacking peripheral pulse after surgery is displaying signs of decreased circulation. Also, foley has only drianed 125 mL in about 7 hours, definitely having perfusion issues. Temp also elevated.
3. Mr. C in room 403 - Pt's vitals appear stable. Will probably need dressing change and possibly pain meds.
4. Mr. A in room 401 - Pt is stable and just waiting for pre-op med and OR.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
The trend is subtle and may be nothing, but his most recent VS reveal his highest HR of the night and his lowest BP.
I am a bit concerned about his poor coughing/deep breathing. I would want to get on him early about using his IS and see if there is a flutter valve (I am thinking of the correct thing, right? ) and get those secretions mobilized.
I definitely agree with seeing the scalene bx. first, preop last...I would go with this gentleman before the fem pop.
(and for the record, I don't think he is necessarily a bariatric pt--the OP said he had a gastric resection...this could be for stomach CA or something like that)
I have NO idea why that stuck in my mind
I don't think he is necessarily a bariatric pt--the OP said he had a gastric resection..
I must have been doing something else at the time. My misread.
Yall are certainly entitled to your opinions, but the resection is stable, the fem pop may not be, he would die FIRST over the man who needs encouragement and reinforcing of pulmonary toilet. You cannot get a trend off only 2 bps, or a short range, youd have to see many over a day or so.
And again hes only urinated 125 in the last 7 hours.
I work with vascular patients every day, like I said, it could be an emergency.
You cannot get a trend off only 2 bps, or a short range, youd have to see many over a day or so.
The HR range for the night was listed as 80-98, with 98 as the most recent. That is trending up. While this is not a huge increase, it could indicate a fluid volume deficit or the first sighs of infection. Yes, it is a subtle increase, and may be nothing...and I certainly would not wait a whole day before I decided a trend existed.
As for the woman who had the fem pop. I would want to know more. What were her pulses and her cap refill preop. The fresh vascular postops for whom I have cared have the pulse sites marked with Xs. They have the vascular status of the foot (assuming it was a procedure on the leg) checked at regular intervals. For instance, the surgeon would write for post tib and pedal pulse checks q 15 min x1 hour, q 30 min x1 hour, q hour x 6 hours--or something like that depending on surgeon preference. I would want to look back at that trend over the night. If they were not palpable all along, then I am not going to run it there right away. If they were 2+ for the entire night and the most recent check they were not palpable--then we have a potential emergency.
Also, I think the UOP is a bit of a red herring. Does it need to be addressed? Yes. Quickly? Yes. Immediately? Not so much...and going into that room first is not going to help that situation. Put a page out to the doctor and get the fluid turned up (perhaps, if he/she wishes, a bolus).
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Yall are certainly entitled to your opinions, but the resection is stable, the fem pop may not be, he would die FIRST over the man who needs encouragement and reinforcing of pulmonary toilet. You cannot get a trend off only 2 bps, or a short range, youd have to see many over a day or so.
And again hes only urinated 125 in the last 7 hours.
I work with vascular patients every day, like I said, it could be an emergency.
Ok good deal! I see your point. I personally would see the patient that hadn't been seen by staff recently when looking strictly at the scenarios.
Well first off just because the HR was up to 98 that doesn't really mean much, could just be pain.
But you cannot add "what ifs" or other possible info to this. You have to go off what is given. That is a big no no with questions and scenarios. Anything is possible, but you cant just go adding possible information.
But you cannot add "what ifs" or other possible info to this.
Why not? This is a critical thinking question, not an NCLEX question. I ask myself "what if?" all the time at work because not patient has just one or two problems in a vacuum.
School questions teach you how to answer NCLEX. These questions MUST be answered on the info given, nothing more. These are on NCLEX. Im not talking about thinking critical while on the job, thats a given. I just dont understand why people think perfusion is beneath fluids/electrolytes....that is basic
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Well first off just because the HR was up to 98 that doesn't really mean much, could just be pain.
But you cannot add "what ifs" or other possible info to this. You have to go off what is given. That is a big no no with questions and scenarios. Anything is possible, but you cant just go adding possible information.
AGAIN, CIRCULATION IS ABOVE FLUIDS AND LINES.
Ok...we disagree no big deal.
I don't think the CSM/circulation is affected on the fem pop...it clearly states good cap refill noted....I have cared for many fem pops over the last 35 years....I'm OK with a low U/O temporarily and a good B/P with a good cap refill on the affected extremity. This of course depends if being unable to palpate the pulse is a new finding. If this is a new finding that changes my thought process. This patient was just seen by staff. Now if that patient was a AF fem pop by pass the urine out our would be a big concern due to the location of the real arteries take off from the aorta.
The gastric resection by the scenario was last seen and medicated at 4AM with a drsg change at that time for drainage....the B/P is low...ish (depending on pre-op vitals) and the heart rate seems to be increasing a sign of dehydration or pain.... they haven't been seen or given anything for pain since 4 am (pain after all is a priority)....I would see them first after the diff breather lung resection with a low 02 sat....the fem pop was seen at 6 with her glucose and insulin administration, has good vitals and a good cap refill indicating CSM is ok...as long as being unable to palpate a pule isn't a new change.
I personally would see the surgical that is having drainage from the surgical wound and hasn't been seen since 4AM after the diff breather.
These priority scenarios are difficult for us who have been out of school for a long time for this is where sometimes the bedside isn't the book. I think when instructors give these scenarios they alkso want you to critically thing through them and if you have a good rationale it proves you are thinking on your feet.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
School questions teach you how to answer NCLEX. These questions MUST be answered on the info given, nothing more. These are on NCLEX. Im not talking about thinking critical while on the job, thats a given. I just dont understand why people think perfusion is beneath fluids/electrolytes....that is basic
If you patient is hypovolemic and is dropping their B/P with an increasing heart rate that is symptomatic presentation of volume deficit (last seen 4 hours ago) which is a priority over a absent pulse that has a good cap refill with normal vital signs (unless that change is new)just seen at 6AM.
I completely see your point and you might be right. You have made really good points
) and get those secretions mobilized.
Esme12, ASN, BSN, RN
20,908 Posts
I would LOVE to know what the answer was! OP?