Jump to content

What's the RIGHT answer to this clinical scenario?

Posted

Hey all -

I had an interview the other day and they gave me the following clinical details:

74 yr old diabetic male, O2 84% on 2L of oxygen, HR 144, BP 80/58 - What would your assessment be? What orders would you expect from the doctor?

I'm a new grad and I was totally caught off guard by the clinical question aspect of the interview and rambled off some details about heart failure, focused assessments and about anticipating an increase in oxygen prescription.

Was I anywhere near correct? What's your clinical opinion? Thank you!

RNNPICU, BSN, RN

Specializes in PICU. Has 13 years experience.

Look at the BP... Is that normal? What can you do for abnormal vitals?

Is there something elseyou can think of?

This is just to help guide your decision making,

Take a look at each of the vital signs... Decide is it normal range or out of range?

Then think what could you do for each of the vitals either normal or out of range.

So try that and post it here

osceteacher

Specializes in Practice educator. Has 15 years experience.

In the UK here so might be slight changes in procedure but we would instantly trigger an immediate review from the doctor and our nurse outreach team. Those numbers are an early warning score of 10+ which is our peri arrest warning scores, whatever is the cause he is in bad shape and needs an urgent review.

Edited by osceteacher

@RNNPICU when I researched it last night I finally decided that I should have said potential Afib and/or heart failure..? If it’s HF, Heart is obviously pumping poorly, which leads to a drop in ox, system is responding with a high HR to try to get better blood/ox flow. If it’s Afib, you have an erratic heart rate which leads to inefficient blood flow, low ox, low BP. Depending on which one it is, you may get different heart drug prescriptions and have to do different focused assessments; edema, Wright gain, chest pain, WOB etc.

I assumed there was a very clear answer and I completely missed it.

Oxygen is definitely a good start. On 84% is the patient short of breath? Might need a non rebreather if so. Listen to lungs. Blood pressure is low so think of perfusion issues. Also patient is diabetic with a low bp and high hr...first thing that comes to my mind is sepsis. High risk of infection for these patients. On 84% may be good to ask about RR (would trigger SIRS). So sepsis protocol (fluids, cultures, cbc, lactate, broad spectrum antibiotics). Also high hr low bp could be a cardiac issue. Stick on an ekg. Normal or abnormal?

3 minutes ago, OregonRN91 said:

@RNNPICU when I researched it last night I finally decided that I should have said potential Afib and/or heart failure..? If it’s HF, Heart is obviously pumping poorly, which leads to a drop in ox, system is responding with a high HR to try to get better blood/ox flow. If it’s Afib, you have an erratic heart rate which leads to inefficient blood flow, low ox, low BP. Depending on which one it is, you may get different heart drug prescriptions and have to do different focused assessments; edema, Wright gain, chest pain, WOB etc.

I assumed there was a very clear answer and I completely missed it.

I don’t think they’re looking for an exact diagnosis here. As long as they see you thinking. It could be none of those things you mentioned, but at least that’s what you were thinking.

Did you address the BP in your interview? If so, what did you say?

13 minutes ago, OregonRN91 said:

I assumed there was a very clear answer and I completely missed it.

There isn't. They just wanted to assess you're ability to critically think. This scenario could have just as well been sepsis. They wanted to know that you were able to recognize the acute nature of the situation and respond accordingly.

LibraNurse27, BSN, RN

Specializes in Community Health, Med/Surg, ICU Stepdown. Has 8 years experience.

Yes, I don't think they could expect anyone to diagnose a pt just by vitals. The good thing is you were able to show that you knew those vitals are unstable. My response would be two fold; what I'm doing immediately to stabilize acute symptoms, while simultaneously thinking about next steps.

If this were my pt, I'm calling a rapid response, which means, ICU charge nurse, a doctor, a lab tech, ekg tech and RT. Very important to know your pt's history. For example, if this was a CHF pt in fluid overload, bolus is not going to help. If it is a pt with an infection and we're thinking sepsis, then bolus will likely be ordered. Be prepared with your pt's past history and why they're admitted.

Always start with airway, breathing, circulation. Luckily this pt has an open airway but their breathing is abnormal (low O2 sat). Know the pt's goal O2 sat and ask RT what type of O2 device and fiO2/LPM to use. Assess for shortness of breath. MD may order CXR and/or chest CT. If any history of DVT or PE, that's important to mention. Circulation: assess pulses and ask about chest pain. Know if any cardiac history. MD will likely order EKG, possibly troponins depending on symptoms. If high suspicion for STEMI/ACS based on symptoms and/or EKG, prepare for those orders and stat transfer to Cath lab. If EKG shows an abnormal rhythm, prepare for meds and/or cardioversion.

Even if it's likely a respiratory/cardiac issue, pt may still need to be ruled out for sepsis. If they are here for an infection, post-op, etc, be ready for sepsis protocol for sure: know if any fevers, what type of infection or surgery they had, previous vitals. Expect orders for lactic, blood cultures, fluids, antibiotics.

Sorry for long response, just wanted to show an example! Basically, the answer is not to try to diagnose the patient, just show you know what to do when you an encounter an unstable patient: rule out an impending intubation/code, call for help, know your pt, anticipate orders, and (when you have more experience), you can offer suggestions!

Grande_latte04

Specializes in Long term care. Has 2 years experience.

I think the first thing you would want to anticipate is the o2 stat with either an increase in NC 02 or non-rebreather. I would want a blood sugar as they are diabetic and labs with culture stat. With the low blood pressure and high heart rate I may anticipate dehydration and an order of IV fluids and/or to push fluids. But you would also need to assess their periph pulses. If they're weak and thready: dehydration, if bounding and SOB then maybe anticipate EKG to look for heart failure. elderly tend to get dehydrated very quickly.

RNNPICU, BSN, RN

Specializes in PICU. Has 13 years experience.

20 hours ago, OregonRN91 said:

@RNNPICU when I researched it last night I finally decided that I should have said potential Afib and/or heart failure..? If it’s HF, Heart is obviously pumping poorly, which leads to a drop in ox, system is responding with a high HR to try to get better blood/ox flow. If it’s Afib, you have an erratic heart rate which leads to inefficient blood flow, low ox, low BP. Depending on which one it is, you may get different heart drug prescriptions and have to do different focused assessments; edema, Wright gain, chest pain, WOB etc.

I assumed there was a very clear answer and I completely missed it.

I don't think you missed it. You were right about needing oxygen. Now take a lok at the HR, high HR and low BP - potentially sepsis, might need some fluid resuscitation. Aso, h/o diabetes - may need a glucose level. With these scenarios it isn't about guessing the diagnosis rather anticipating what orders might be needed. As you gain more experience it is often the nurse who makes a recommendation to the physician but that comes with time and experience.