Smart Cardiac Nurses

jmgrn65, RN · Jan 30, 2008

Dehydration is probably one of her problems: Bp low hr up bun up. what do you think? there is alot more there, but part of nursing is critical thinking and that is what this is trying to get you to do.

putmetosleep · Jan 31, 2008

Agree with the previous poster, there is a lot of vital information presented in this case study--the point being for you to develop critical thinking skills. One hint though--as the previous poster said, this pt is hypovolemic (low Bp, high HR); her HgB is low; the pts O2 sats are fairly low; what would you replace the volume with?

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SEOBowhntr · Feb 1, 2008

agree with the previous poster, there is a lot of vital information presented in this case study--the point being for you to develop critical thinking skills. one hint though--as the previous poster said, this pt is hypovolemic (low bp, high hr); her hgb is low; the pts o2 sats are fairly low; what would you replace the volume with?

exactly, signs and symptoms of moderate to severe anemia, hypotension, hypoxia, tachycardia, add in the elevated bun, you may also be looking at a potential upper gi bleed, as when a patient has and upper gi bleed, they metabolize some of the blood, and it causes and elevation in bun. certainly, the recognizant physician is likely to replace the volume with blood, which carries a k+ level around 5.5 per liter if i remember correctly, however, it's likely more k+ will also be needed. irregular hr could also be an atrial fibrillation d/t the hypokalemia. i'd also like to know what her mg++ level is. i think her code status would be important to know as well, before you bring her back from the brink, it's important to know if you are following what her wishes were. 90% sat's on a 30% vm doesn't sound overly good, especially for a lady we might assume is hypovolemic, hgb of 8.9 or not. other concerns you may have for her might be the possibility of c. diff with a prolonged course of diarrhea, which can in some cases lead to issues with ischemic bowel, and gi bleeding, more lower than upper.

hope some of that mumble helps, though it may just muddy the water more.

healingtouchRN · Feb 1, 2008

I am thinking 0.9% NS & some PRBC's. wondering if she has a CV history, depends on the rate to rehydrate. I forget the formula, sorry. I agree on the C.Diff. assay on the stools. Aggressive pulmonary toilet for this lady.

All to common type of patient from nursing/ LTC facility to our ICU's... Hope she fairs well.

UM Review RN, ASN, RN · Feb 1, 2008

Exactly, signs and symptoms of moderate to severe anemia, hypotension, hypoxia, tachycardia, add in the elevated BUN, you may also be looking at a potential upper GI bleed, as when a patient has and upper GI bleed, they metabolize some of the blood, and it causes and elevation in BUN. Certainly, the recognizant physician is likely to replace the volume with blood, which carries a K+ level around 5.5 per liter if I remember correctly, however, it's likely more K+ will also be needed. Irregular HR could also be an Atrial Fibrillation d/t the Hypokalemia. I'd also like to know what her Mg++ level is. I think her code status would be important to know as well, before you bring her back from the brink, it's important to know if you are following what her wishes were. 90% Sat's on a 30% VM doesn't sound overly good, especially for a lady we might assume is hypovolemic, Hgb of 8.9 or not. Other concerns you may have for her might be the possibility of C. Diff with a prolonged course of diarrhea, which can in some cases lead to issues with ischemic bowel, and GI bleeding, more lower than upper.
Hope some of that mumble helps, though it may just muddy the water more.

Gee, SEO, I didn't know an Upper GIB would cause an elevated BUN. I'm always learning here. I love it.

Wouldn't the patient's oxygenation be helped with a unit of PRBC's? After all, there are more PRBC's to carry O2. Though with the CHF hx, I'd assume she'd get any fluid replacement slowly and with thoughts of Lasix and Potassium not far away.

kleona · Feb 1, 2008

Thank you sooooo much for the great responses. You are Smart!!!!!!

Dinith88 · Feb 1, 2008

Here I have this case scenario that I don't know how to put the whole picture together. I will appreciate your help. Thank you!
One of your assigned patients is an 84year old white female admitted the evening before with pneumonia. She has had a past h/o CHF & CAD and early dementia. Additionally she has had intermittent diarrhea for the last 10 days at the nursing home in which she is a permanent resident. When you start your day shift she seems confused and lethargic. Her BP is 84/68. HR 124. Pulse is irregular,. She is not on a monitor. She is on 30% VM.because she is a mouth breather. Sp02 90%. What should you do next and what sort of information may you need to gather. Some lab work has been done.Hbg 8.7, Na:132, K: 3.4. Bun: 49, Crt: 1.6.

yeah...what everyone else said.

Now...if you want to know what you SHOULD do first...

Check her code status. Then get on the horn with the family and see if they want her just kept comfortable or (the wrong decision) continue the full-code heroism. She's a dehydrated, demented nursing-home resident with pneumonia. Will you really be doing her any favors by fixing her and sending her back to continue her demented nursing-home existence?...just to come back again in a few months...until she's 94 maybe?... Hospice is a wonderful thing...

Is this for a class? You should read this post to your instructor. Lots of good ethical debatable stuff in it. You can get all flowery and mushy about it...

Then speak poorly of the burnt-out nurse who would spout such a terrible ramble... :innerconf

Diary/Dairy, RN · Feb 1, 2008

In addition to rehydration/PRBC's and increasing her O2, she may be more confused because of her sodium - I would be interested in determining her baseline mental status to see if this is a change for her. Just a thought.

SEOBowhntr · Feb 2, 2008

in addition to rehydration/prbc's and increasing her o2, she may be more confused because of her sodium - i would be interested in determining her baseline mental status to see if this is a change for her. just a thought.

diarygirl,

generally, you can tolerate a na+ level down into the low 120's to high 110-s before confusion becomes too much of a problem. i've seen several patient with sub 110 na+ levels that were completely a&o x 3, surprisingly so, but i don't believe i've ever seen one that had a hyponatremia associated confusion with a level above 120.

angie,

certainly a little bump on the hemoglobin would help, another thing i suppose i would have liked to have known was what did her lungs sound like, does she have an s3, jvd, etc. i learned the bun thing several years ago from a renal doc consulted on an upper gi bleed patient. he was less than impressed, and was everso willing to tell us and the gi doc his opinion.

and i agree with dinith, if this is a no-code patient, them keep her comfortable, and let nature take it's course. all to often, we get so wrapped around the axle trying to save people, sometimes we don't even consider what their desires are.

SusanKathleen, RN · Feb 2, 2008

Wow. This conversation is so good - I saved it in my cardiac files!

JohnW · Feb 3, 2008

Here I have this case scenario that I don't know how to put the whole picture together. I will appreciate your help. Thank you!
One of your assigned patients is an 84year old white female admitted the evening before with pneumonia. She has had a past h/o CHF & CAD and early dementia. Additionally she has had intermittent diarrhea for the last 10 days at the nursing home in which she is a permanent resident. When you start your day shift she seems confused and lethargic. Her BP is 84/68. HR 124. Pulse is irregular,. She is not on a monitor. She is on 30% VM.because she is a mouth breather. Sp02 90%. What should you do next and what sort of information may you need to gather. Some lab work has been done.Hbg 8.7, Na:132, K: 3.4. Bun: 49, Crt: 1.6.

In my view, this is a very sick patient. As others have posted, you would need to check her code status ASAP, she is a hair away from being tubed and on pressors. It's a big problem that she is not on a monitor and probably a liability. It's not OK for someone to be hanging out with a BP in the 80s and a HR in the 120s, espically an elderly person with a bad heart with an unclear MS. Also, this poor person has PNA - this is bad stuff here.

It's not accpetable to just let her hang out with those vitals. With that said, here's the other info we need:

1.) Some BL stuff: does she have a recent echo (i.e. how bad is her heart), do we know her baseline creat (i.e. does she have baseline renal insuff or has being deydrated in the NH beat up her kidneys). 1.6 isn't that bad, but it's signifcant. Home meds: she's probably in A-fib (also probably having PVC with that K), what does she take?

2.) Is she septic? What's her temp, what's her WBC, how bad are the infiltrates on her CXR . She was just admmitted so her sputum is probably not back, most hospitals have a criteria for a dx of PNA. She needs ABX, and she needs a central line.

3.) Does she have COPD, does she wear home ? If the answer is no, we need to fix that Sat ASAP - we are beating up her heart. Time for an ABG right away. Brace yourself for a very ugly gas. Send it wil lytes to, those labs could be "high dries" - look for her K to even lower.

4.) Do we want to consider cardiac enzymes? Probably not going to do much, but you can be sure with that BP and that HR, her heart is really being workedver.

5.) What is her fluid status? Given the Hx, we assume she is dry, but she could also be in failure as well(time for an echo or time to atleast draw a BNP). Maybe blood with lasix (espically if she takes it at home).

6.) We need to fix her HR. It could be just that she is dry, but it is more likely she is now in A-fib. We need a 12lead to see what's going on. She doesn't have the pressure to give BBs or CCBs. But, she is not tolerating the fast rate, she needs that atrial kick and she needs a slow rate to perfuse her coronary arteries. We need need to consider cardioverting her. Bottom line, it's unlikely that there will be a simple fix here (such as giving her a few liters of NS). What are going to do if here BP drops to 70 and her rate goes to 150?

7.) Don't forget saftey. This woman is a fall risk at baseline and now if she's hypoxic, things are going to get worse.