suprnurs40

Hello; I have been out for seven months and 80% of my shifts have been twelve hour days (0700-1900). This is where a majority of learning occurs as it is the busiest time of day in my hospital. I work on a post stroke acute/long-term (placement) floor that is very heavy. I love the night shift! it is a break for one's back! However, you only have one other RN and 2 LPN's on with you (fewer seasoned nurses to turn to).

Thanks for your interest; The patient's Glasgow Coma Scale is likely about 14 or 15. The slightly dilated pupils could be the result of analgesic treatment for the lung resection. His neuro seems ok, but what about the agitation? His respiratory rate is very high. As he is not intubated, I feel that this is at the root of his agitation. What is causing such a high RR? As to the chest tube situation, does he have internal bleeding, perhaps? The seal where the chest tube is going into the patient may be loose. He is febrile, HR is high, BP is not good, and he is diaphoretic. I began to suspect a pulmonary embolus, but palpable pulses have me thinking maybe not... but now feel that this man is in septic shock! No bowel sound on auscultation, so what is blocking his colon? Why no peristalsis? I do not know at this time. His lab values show a low blood values that need to be addressed (the transfusion. his potassium is worrysome. His ABGs show, in my opinion, metabolic acidosis. This would account for the hyperventilation as the body strives to blow off excess CO2 and conserve HCO3. The xray shows a left pleural effusion. I would put him on broad spectrum antibiotics (temp = infection from septic shock); I would continue ventilation support; fluid resuscitation; and give Levophed and Dopamine to increase BP. I would value any input from experienced nurses on this. I truly think this gentleman is in septic shock. How far off the mark am I, folks? Thank you. I would request a cross match and screen from the lab as to the blood.

Hello, everyone; I am looking for input from experienced nurses as to how to handle the patient situation in the following case study. I value experiential knowledge, and feel that a student like myself will benefit from information gleaned from seasoned nurses. I thank you. Here is the Case study in question: 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. Patient's 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's blood 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? Mr. Brown 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?

The actual scenario is this: 76 year old woman suffering from incurable brain tumour. Informed opinion said that she would die within two weeks. With her consent, a DNR order had been placed on her chart. One afternoon, this partially conscious patient patient grabbed the nurse's arm and and began mumbling, "I don't want to die. Please don't let me die." She lapsed again into unconsciousness and quickly began to arrest. Remembering the DNR, the nurse let the arrest take its course, and the lady died. So, should we always resuscitate if there is any question about the patient's continued consent to a DNR order, even if resuscitation continues to be futile? I need your opinion!!!

This is a scenario for Ethics class (BScN degree) in which I am looking for the experiential views of real world nurses. Who better to ask than the experts?

What is your opinion on this: A terminally ill patient is given two more weeks to live. There is a DNR order in place. On your shift, the patient goes into cardiac arrest and says "I've changed my mind, I don't want to die!" What do you do, perform CPR or let die, as was stated in her DNR?