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By: Amy Barboza
Melissa Sanchez
Justin Therrien
Stefanie Lavalle-Fontaine
Alysse Connors
35.8 mL/hr
We will not perform live saving intervention we will
provide comfort care for your mother.
Mrs. B.s daughter is aware of her mother’s deteriorating condition and requests a team meeting.
Mrs. B. has an advance directive and designated her daughter as Power of Attorney. She asks what will change in her mother’s care if the status is changed to Comfort Measures/DNR. The medical resident looks to you to answer the question.
Signs and symptoms;
Lungs show dysfunction of normal exchange of gas,
normally in arterial hypoxemia
Kidneys show oliguria despite fluid resuscitation as evidenced by rising creatinine and serum electrolyte levels.
Cardiac - impaired delivery of O2 to other organs
Hepatic – excess bilirubin in blood as lack of bile flowing from the liver
Hematologic- thrombocytopenia
Neuro - Altered LOC, Reduction in Glasgow
Prediagnosis of sepsis
Change in mental status
Increase in temperature, pulse,
respirations and WBC.
Over the next week, Ms. B’s condition continues to deteriorate.
She is determined to be experiencing Multiple Organ Dysfunction Syndrome (MODS).
The one that has not been accessed.
Document the NG drainage and urinary output on the ICU flowsheet
and administering insulin.
Ms. B. is also to receive 2 units of packed red blood cells (PRBCs). 275 mls are in each unit and the order says to administer them over a total of 3 hours.
The patient has the triple lumen catheter. TPN is running in one lumen, dopamine is in the other, and the other one is heparinized but not accessed.
183.3mL/hr
The traveler nurse because she has 5 years experience in the ICU
Ms. B. is ordered to begin TPN via a triple lumen central venous catheter (TLCVC).
Normal Values
PaCO2: 35-45
PaO2: 80-100
HCO3-: 22-26 (21-28 hesi)
O2 saturation: 92-100%
pH: 7.35-7.45
Respiratory acidosis uncompensated
Hbg 9.9 because HGB is needed for oxygenation
An arterial blood gas (ABG) sample is obtained by
the physician. The results are as follows:
PaCO2: 62 mm Hg
PaO2: 50 mm Hg
HCO3-: 22 mEq/L
O2 saturation: 87%
pH: 7.23
The results from initial lab work are:
Na 130 mEq/L Cl 95 mEq/L Glucose 190 mg/dL
BUN 38 mg/dL Creatinine 1.6 mg/dL
WBC 17,000 mm3 Hct 29% Hgb 9.9 g/dL
Platelets 120,000
Providing O2, monitoring central arterial pressure for hemodynamic support.
Monitor mental status for changes
b/p and pulse within normal range.
O2 with in normal limits
Urine output at least 30 mL/hr
No significant change in LOC
Metoprolol – beta blocker
Amiodarone – antidysrrythmic
They help maintain the heart rate in case it was to increase.
Be there for her, hold her hand, rub her head, talk to her and reminisce about the past.
Communication between family, patient,
and doctor to keep them up to date.
Atrial Fibrillation
Some signs are;
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LaCharity, L.; Kumagai, C. & Bartz, B. (2013). Prioritization, delegation, and
assignment. 3ed. St. Louis, MO: Mosby.Resolving Diabetes-Related
Bladder Problems - Diabetes Self-Management. (2013, December 16).
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Early goal-directed therapy in the treatment of severe sepsis and septic shock.
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What You Need to Know About UTIs - Diabetes Self-Management. (2014, March 24).
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blog/what-you-need-to-know-about-utis
After her mother’s death, her daughter thanks you and the ICU team for your help and support in making the difficult time a little easier.
Cardio version is the best option with these options to hopefully shock the rhythm back into a normal pace, monitoring cardiac rhythm is necessary to make sure the cadioversion has been completed .
According to the david manual for ECG cardioversion, this is indicated for unstable tachy with an altered LOC, dizziness, chest pain or hypotension.
Ms. B.’s daughter also asks how she will know
when her mother’s death is imminent.
The following bags of fluid are in the med room:
500 ml of 0.45 NaCl
1000 ml of 0.45 NaCl
1000 ml of 0.9 NaCl
500 ml of D5.45 NaCl
Continue to monitor the cardiac rhythm
Administer lidocaine (Xylocaine) 1 mg/kg IV push
Prepare to perform cardioversion at 50 Joules
Administer adenosine (Adenocard) 6 mg IV push
Monitoring central arterial pressure through central line for hemodynamic support.
Obtain cultures of blood, urine and any relevant specimen.
Monitor O2 saturation constantly, while Providing O2
She should tell her mother that she is dying but she should ensure her mother that we will stay with her as long as possible. This will help the family and patient be prepared for the impending death.
The nurse needs to provide honest information to maintain the credibility of our profession.
Infuse 1 Liter of normal saline over 30 minutes
Start a dopamine (Intropin) drip at 15 mcg/kg/min
Draw blood for cultures from three separate sites
Administer gentamycin (Gentacidin) 60 mg IV
Acetaminophen (Tylenol) 650 mg rectally
Fluid infusion because of decrease urine volume and history of not taking in fluid, in addition sepsis is associated with massive vasodilation resulting in hypotension and decrease tissue perfusion so increase the circulation volume.
Dopamine is used next for cardiac stimulation and renal perfusion.
Blood draws to figure out invading organism to specifically treat the infection.
Gentamycin is a broad spectrum antibiotic. Acetaminophen to reduce the fever.
Take vital signs every 15 minutes
Monitor urine output hourly
Some UAP are trained to start cardiac monitoring but it is in the discretion of the nurse
Mrs. B.’s daughter asks if she should
tell her mother that she is dying.
Peak levels – 30 minutes after infusion (4-12mcg/ml)
Trough level should be drawn just before the next given dose (0.5-2mcg/ml)
Used to determine whether an IV administered medication is consistently with in therapeutic range
At 11 pm In the ICU, new orders are written.
They are as follows:
Acetaminophen (Tylenol) 650 mg rectally
Draw blood for cultures from three separate sites
Infuse 1 Liter of normal saline over 30 minutes
Start a dopamine (Intropin) drip at 15 mcg/kg/min
Administer gentamycin (Gentacidin) 60 mg IV
Ms. B.’s medical diagnosis is septic shock.
Ototoxicity
Nephrotoxicity
Vertigo
Muscle paralysis
Hypersensitivity
Recommendations:
Elevate her blood pressure so she has adequately perfusion.
Monitoring respiratory status and sedation.
Start to treat her infection.
Treat pain if needed.
Maintain adequate oxygenation.
Stablize blood pressure.
Resolve the infection.
Nonrebreather mask because it
gives you a fraction of inspired O2 of close to 100% . This patient is severely hypoxic therefore needing this device.
Monitor kidney functioning
Situation
166.7mL/hr
Could be more;
Assessment
EB. Is a 54 year old female who came into the ED with Nausea, vomiting, back and abdominal pain, and a decrease in level of consciousness. Vitals were done showing significant hypoxemia where O2 was applied, UA and ABG’s were obtained, Telemetry monitoring was conducted. Upon telemetry monitoring pt. was in A-fib and shocked at 50 joules to return the rhythm into normal sinus. ABG’s showed patient was in severe uncompensated respiratory acidosis therefore pt was intubated and PEEP was applied to ventilation. As a result of using PEEP, blood pressure dropped to 86/40, HR 112, O2 – 93%. Patient is now adequately oxygenated but blood pressure is dropping. We are still waiting on results from the UA but the patient has a temp. of 103, urine is cloudy and dark amber with red streaks showing signs of possible infection.
PMH: Hypertension, peripheral arterial disease, diabetes mellitus type 2
Medications: enalapril (Vasotec), 40 mg daily, insulin Lispro (Humalog) on a sliding scale for elevated glucose levels, metformin (Glucophage) 500 mg twice daily, and atorvastatin (Lipitor) 10 mg daily.
Vitals: 86/40 BP, HR 112, 32 Respirations, 93% O2 and 103 temp.
Heart sounds irregular and distant. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies chest pain. Breath sounds audible bilaterally with crackles present in left lung base. Grimaces with light abdominal palpation above pelvic bone. Urine is amber and cloudy with red streaks. 100 ml urine output when Foley catheter inserted. Opens eyes and moves to command. Pupils equal, round, and reactive to light.
Background
Nasal cannula
Nonrebreather mask
Venturi mask
Face mask
Insert a Foley catheter and send a urine specimen for C&S
Start oxygen and titrate to maintain oxygen saturation at 90% or higher
Place the patient on telemetry
Check the blood glucose level
You are preparing to administer 60 mg of gentamycin IV. The bag has been delivered from the pharmacy:
60 mg in 250 ml of NS to run in over 1 ½ hours.
Oxygen, telemetry, glucose, foley
O2 first – because of ABC’s and because the patient is severely hypoxic and needs additional O2 to prevent damage to organs. Telemetry to monitor cardiac status, Glucose because she has a history of diabetes and not eating today.
Cardiac monitor indicates a heart rate of 156 bpm.
High doses of dopamine are sympathomimetic and increase cardiac conduction and automaticity.
This increases the cardiac workload and can damage the heart.
-The noninvasive BP monitor shows a BP of 102/48 mm Hg
-The data screen on the ventilator indicates a respiratory rate of 44 breaths/min
-Pulse oximitry is 90%
-The cardiac monitor indicates a heart rate of 156 beats/min.
Because she was unable to oxygenate herself independently we had to insert the ETT to help her breathe.
Peep will help with the exchange of oxygen in her body by opening up her lungs more.
Respiratory status and making sure the patient is adequately sedated.
She had ETT inserted and because she was in resp. acidosis therefore we are making sure that our interventions are doing what we want them to do.
Diabetes, peripheral artery disease, and HTN
When you recheck the dopamine drip, you notice that you have miscalculated the dopamine dose
and have set the rate too high.
You document the assessment findings as follows:
“Heart sounds irregular and distant. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses nonpalpable. Denies chest pain. Breath sounds audible bilaterally with crackles present in left lung base. Grimaces with light abdominal palpation above pelvic bone. Urine is amber and cloudy with red streaks. 100 ml urine output when Foley catheter inserted. Opens eyes and moves to command. Pupils equal, round, and reactive to light”
The current vital signs are as follows:
Blood pressure: 86/40 Heart rate: 112 bpm
O2 saturation: 93%
Respiratory rate: 32 breaths per minutes
Temperature: 103° F (39.4° C)
Hemodynamic changes
Decrease CO and
Venous return.
Using the form on which you recorded the patient’s information, prepare and give a report in SBAR format to your partner. Critique each other’s reports
It is used when the patient is on mechanical ventilation and cannot adequately oxygenate their body by themself.
It is a method of holding alveoli opening during expiration allowing for more adequate arterial oxygenation.
You are preparing to administer the dopamine (Intropin) drip as ordered at 15 mcg/kg/min.
The medication is available in an ampule containing 40 mg/ml or premixed 400 mg/250 ml NaCl.
Shock and possible septic shock related to UTI/pyelonephritis as evidenced by Increased WBC, decrease BP, Increase HR, RR and Temperature
The blood pressure needs to improve in order to promote adequate perfusion.
The interventions for the PEEP are working but it is affecting the hemodynamics of Ms. B.
Listen to Ms. B’s lung sounds. The most common complication to rapid infusion of fluid is fluid overload which leads to heart failure,
although peripheral edema, decreased urine output and JVD are indicative of HF, crackles occur much more rapidly.
PEEP
– positive end-expiratory pressure
2000mL/hr
Her presentation could be showing;
Briefly explain the intubation procedure to the patient and her daughter
Place the patient in supine position
Pre-oxygenate with bag valve mask at 100% oxygen
Insert the ETT orally through the vocal cords
Inflate the ETT cuff
Check end-tidal CO2 level
Auscultate breath sounds bilaterally
Tape the ETT in place
Obtain a chest X-ray
Vitals
Through the IV that you had already placed in ED.
It should be the primary fluid bag.
According to the order it says to run a full liter in 30 minutes.
Check with daughter about any other information related to health status. Surgeries, if she knew how long the symptoms were going on for, hearing issues, and recent falls. Doing a Glascow coma scale, FLACC pain scale. Blood electrolyte levels, 12-lead EKG, start 2 IVs.
Situation
At 11 am, Ms. E.B. a 54 year old female, is brought to the Emergency Department of the hospital by her daughter because of weakness and a decreasing level of consciousness. Ms. B. was complaining about abdominal and back pain. She also reported nausea and had vomited twice. Because of her lethargy and nausea, she has not had anything to eat or drink today.
Background:
PMH: Hypertension, peripheral arterial disease, diabetes mellitus type 2
Medications: enalapril (Vasotec), 40 mg daily, insulin Lispro (Humalog) on a sliding scale for elevated glucose levels, metformin (Glucophage) 500 mg twice daily, and atorvastatin (Lipitor) 10 mg daily.
Assessment
E.B. responds to brief commands to open her eyes and move her arms and legs, but she does not answer your questions. She is lethargic and sleepy.
At 11 am, Ms. E.B. a 54 year old female, is brought to the Emergency Department of the hospital by her daughter because of weakness and a decreasing level of consciousness. E.B. responds to brief commands to open her eyes and move her arms and legs, but she does not answer your questions. The daughter tells you that when she stopped at her mother’s house today for a visit, Ms. B. was complaining about abdominal and back pain. She also reported nausea and had vomited twice. She is lethargic and sleepy. Because of her lethargy and nausea, she has not had anything to eat or drink today.
Her medical history includes: Hypertension, peripheral arterial disease, diabetes mellitus type 2. Her daughter gives you a list of Ms. B’s medications which include: enalapril (Vasotec), 40 mg daily, insulin Lispro (Humalog) on a sliding scale for elevated glucose levels, metformin (Glucophage) 500 mg twice daily, and atorvastatin (Lipitor) 10 mg daily.
Insert an endotracheal tube and initiate mechanical ventilation
She is unable to maintain adequate oxygenation and ventilation independently.
Sodium bicarb – is for metabolic acidosis
Ongoing respiratory monitoring and Proventil maybe use but not indicated for severe ABG’s
1000 ml of 0.9 NaCl
It decreases the risk of fluid
shift in the body.