Smart Cardiac Nurses

[kleona]

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.

[kleona]

These are great responses. I appreciate your help. God bless your heart.

[Suninmyheart]

This conversation is a day in the life of my unit. Or should I say night because I work nights. I am learning so much as a new grad on this cardiac unit. I love all the contributions to this conversation. I can dig in and learn so much more from accessing this website. Thanks everyone!

Sun

[Suninmyheart]

These are great responses. I appreciate your help. God bless your heart.

Kleona, welcome to Allnurses!

[kleona]

Thank you suninmyeyes. This is my last semester until graduation and I have an interview on March 10th for nursing intership on CPCU floor. I am really excited to work as an RN there.

[cardiacRN2006, ADN, RN]

Did someone say nursing home + diarrhea?

C-diff, Dehydration, Sepsis.

In addition to the previously menitoned labs, I'd like to know a lactic acid level. If she's a full code, we'd get her on a monitor, start a central line, bolus her with some fluid, get a CVP, draw all those labs, and correct her lytes.

I agree with JohnW-this lady's gasses are going to suck.

[BBFRN, BSN, PhD]

Did someone say nursing home + diarrhea?

C-diff, Dehydration, Sepsis.

In addition to the previously menitoned labs, I'd like to know a lactic acid level.

Good point. :nuke:

[poppy07]

Great scenario... Could be pre-renal problem- dehydration, elevating the creatinine & possibly BUN. In turn, with less than optimal kidney function, the production of erythropoeitin may be decreased--so I'd want to know the RBC count, etc. This also affects oxygenation. Was the pt a smoker, have COPD, etc? She may live in the 90's, and it would be okay for her. Is she actually in distress? The low Na+ could be result of N/V. The "elderly are more prone to falls and unstable gaits with hyponatremia", per a recent CE article I viewed. Also, what is her baseline B/P...perhaps it's typically in the 90's if she is a small woman. Her HR is increased suggesting her body is demanding more output for perfusion/oxygenation of tissues. Her pulse is irregular...could be new onset a-fib, a-flutter, PVC's or PAC's, sinus arrhythmia...who knows: hook her up to a monitor! Give a liter bolus of NS, crank up the 02 a little bit if she's in respiratory distress/ using accessory muscles, etc. HAVE FUN!

[poppy07]

Great scenario... Could be pre-renal problem- dehydration, elevating the creatinine & possibly BUN. In turn, with less than optimal kidney function, the production of erythropoeitin may be decreased--so I'd want to know the RBC count, etc. This also affects oxygenation. Was the pt a smoker, have COPD, etc? She may live in the 90's, and it would be okay for her. Is she actually in distress? The low Na+ could be result of low-Na+ diet since she has CHF (or diuretic) + massive water loss from diarrhea. The "elderly are more prone to falls and unstable gaits with hyponatremia", per a recent CE article I viewed. Also, what is her baseline B/P...perhaps it's typically in the 90's if she is a small woman. Her HR is increased suggesting her body is demanding more output for perfusion/oxygenation of tissues. Her pulse is irregular...could be new onset a-fib, a-flutter, PVC's or PAC's, sinus arrhythmia...who knows: hook her up to a monitor! Give a 500 ml bolus of NS (as tolerated respiratory-wise), crank up the 02 a little bit if she's in respiratory distress/ using accessory muscles, etc. I'd also be curious to know her Ca+, Mg++. If low, could be affecting her B/P and rhythm. In that case, I'd anticipate giving amp of Calcium Chloride, some Mag Sulfate, and 20-40 mEq K+. HAVE FUN! If concerned about GI bleed, is she having a bloody stools? red or black, etc?

[Spacklehead, MSN, NP]

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.

I would definitely be placing her on the monitor, assessing her respiratory status and would obtain an EKG. I'd probably bump up her O2 some and I would also check a bedside glucose if diabetic and get a temp. Also, I would consider getting an order for a NS bolus of 250cc if her lungs sounded ok.

I would also probably get urine for a UA C&S and BC x 2 if her temp was elevated, plus an ABG. The other thing I would want to know is if the Hgb is less than her admission level - if so, maybe T & C for 2 units - also maybe check a d-dimer for poss. PE.

I'm just thinking that since she has had the diarrhea, she might have a UTI causing her to be confused. She might also be in septic shock. The Hgb wouldn't worry me too much if it hasn't drastically changed from admission.

Keep in mind, this is all coming from an ER nurse's point of view, though. :wink2:

[criticalHP, MSN, RN]

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.

UGIB will cause an increased BUN without an increase creatinine d/t the digestion and absorbtion of blood in the GI tract; Renal failure will show high BUN and Creat, high lytes. Hypovolemia high Hct, BUN, low lytes--Just a trick I learned when looking at labs to deternime causes for dehydration, renal failure, and hypovolemia. Anyway, I think this pt needs a unit of blood but given slowly. I would be very concerned about giving lasix to this lady due to her prolonged hypovolemic state and her hypoperfusion (for now).

This is what I would do: Check her ABG's and adjust O2 from venti to BiPap if needed (don't tube her until code status established). Control her HR by re-hydrating her slowly, replace her lytes, anticoagulate her if she's in a- fib (and it may not be a bad idea prophylactically anyway unless she has a GIB), get her on pepcid, social service consult and family consultation ASAP to discuss further care options and code status. After family decides to do everything possible :icon_roll , cry for pt, then have doc place a central line for CVP monitoring, continue efforts to re-hydrate, monitor Resp, cardio, renal, perfusion, ect...consider lasix when CVP >10.

If BP not responsive after first liter IVF begin pressor (cry again)

Oh how many times we've been around this block!

[Spritenurse1210, BSN, RN]

K is low too.