Use of critical thinking skills!!

When viewing the next slide consider the following priorities: 1. How would client have been managed initially at the scene of accident? 2.How would this patient have been prioritized in ER (rate as ESI-1 to ESI- 5) 3. What actions would trauma team take initially to stabilize this patient… what priorities? 4. What type of shock would this patient initially experience…what other type of shock do you anticipate for this patient? 5. What potential complications

 63 yo male  Stab wounds to left upper abdomen  Fighting off intruder in his home What questions come to mind? Trauma.org

 What will you expect to see on arrival?  What assessments will you complete?

 LOC: ◦ No response to commands  Response to pain: ◦ No response to pain  Vitals: ◦ BP 72/52 -HR 114 ◦ RR 8, irreg, periods of apnea -Temp 97.8

Dr. G  Dr. G is the new medical resident in the ER, first day is today.  Which action by Dr. G would require you to intervene? A. Orders for STAT ECG B. Dr. G orders 1/2NS to run 200mls/hr C. Dr. G orders urinary catheter placement D. Dr. G orders STAT CBC, Mg, & COMP WHY?

 2000ml LR infused before arrival  Taken to Surgery hr procedure ◦ 3L LR & 6 units PRBC’s ◦ Antibiotic therapy started ◦ Right thoracotomy  Chest tube placement – 500mls bright blood noted ◦ Right upper laparotomy  Liver & Duodenal laceration repaired  Cavity irrigated with antibiotic solution  3 drains placed Then transferred to ICU

Vitals  BP 92/52RR 12  HR 114Temp 97.1  PAWP 6CO/CI 5/2.5  SVR 1040 CVP 4 CBC  WBC 13.6  Hgb 10  HCT 31 ABG  pH 7.34 PaCO2 36mmHg  HCO3 21mEq/L PaO2 84mmHG  O2 sats 88%

Is this patient showing signs of shock? What types of shock might he develop? What are some signs & symptoms of each?

 You must assign an ICU staff nurse to care for this patient. Who is most appropriate? A. A temporary agency nurse, with extensive previous ICU experience, who has been in your ICU for 3 days B. A LPN with 10 years of experience in your ICU, who is in the last semester of an RN program C. A RN who has worked in your ICU for 2 1/2 years after transferring from the mother-baby unit D. A RN who has 12 years experience in the ER and has been floated to ICU today

 Client remains stable until post-op day 2. ◦ Vent Settings  Rate 12 FiO TV 800 ◦ NG drainage  200ml/8hr ◦ JP drains xs 3  Total 60ml/8hr ◦ UO  40-50ml/hr ◦ LOC  agitation ◦ Resp  SaO2 64

Vitals  BP 90/62RR 12  HR 126Temp  PAWP 10CO/CI 6.0/3.1  SVR 820 CBC  WBC 4.2  Hgb 9.4  HCT 27 ABG  pH 7.30 PaCO2 48mmHg  HCO3 25mEq/L PaO2 65mmHG  O2 sats 86%

 Wedge?  CO?  SVR?  WBC?  UO?  ABG’s? What additional information do you want?

 What do you expect the CXR to reveal?  What lung sounds do you anticipate?

 Resp ◦ FiO2 inc (100%) ◦ PEEP 7.5cm  CV ◦ 4 fluid boluses of 250ml NS ◦ NS 175ml/hr  GU ◦ <30ml/hr

Vitals  BP 80/50RR 28  HR 132Temp  PAWP 4CO/CI 8.2/4.3  SVR 560PAP 14/7  CVP 2 Coags & CBC  WBC 22 PT 22PTT 98  Hgb 9.4 Platelets 75  HCT 27  Drain culture – gram negative bacilli ABG  pH 7.14 PaCO2 49mmHg  HCO3 12mEq/L PaO2 46mmHG  O2 sats 83% COMP & Enzymes  Na 152K 5.9Creat 3.4 BUN 104  Amylase 290Lipase 3.9AST 82ALT 102  CK 640

 Diagnosis?  What orders do you expect? Why these potential orders IV Ceftin ( cefuroxime), Flagyl ( metronidazole), Gentamycin cefuroxime metronidazoleGentamycin IV XigrisXigris IV Dopamine at 5-10mcg/kg/min (see next side - difference between dobutamine and dopamine)Dopaminedifference between dobutamine and dopamine Possible TPN, Tube feedings

 Integ ◦ cool clammy  HEENT ◦ Sclera yellow tinged  LOC ◦ Unresponsive to stimuli  GU ◦ UO 3-5ml/hr  GI ◦ Abdomen grossly distended & bowel sounds absent  Resp ◦ Crackles in all fields  CV ◦ Norepinephrine gtt, Lidocaine gtt, ◦ Dobutamine gtt & dopamine gtt ◦ ST w/ episodes of VT, with T wave inversion

Vitals  BP 72/46RR 12  HR 140Temp 95.9  PAWP 24CO/CI 2.1/1/3  SVR 2015PAP 44/26 Coags & CBC  WBC 2.2 PT 32PTT 108  Hgb 8.4 Platlets 75  HCT 37 ABG  pH 7.10 PaCO2 49mmHg  HCO3 10mEq/L PaO2 46mmHG  O2 sats 80% COMP & Enzymes  Na 152K 5.9Creat 4.2 BUN 104  Amylase 330Lipase 5.2AST 91ALT 202  CK 1040

 What stage of shock is present? ◦ What info supports this?  Which organs are dysfunctional? ◦ What info supports this?