cdl766

Thanks so much for all your help!

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!!!

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

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?

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?

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

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. -------------------------------------------------------------------------------------------------- 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!!!!