© 2013 Keith Rischer/www.KeithRN.com

I. Data Collection

Unfolding Reasoning Case Study:Synthesis Scenario: Cardiac

Arrest

Chief complaint/History of Present Illness (HPI):John Williams is a 42 year old male with chronic back pain who receives Oxycontin 40 mg bid at home. He

had surgery today for posterior spinal fusion of L5-S1. He came from PACU to the surgical floor 4 hours ago. He is currently receiving Hydromorphone (Dilaudid) PCA for pain control. PCA settings: 0.2 mg continuous, 0.1 mg bolus every 10” with 4 hour max of 6 mg. He has been complaining of increased pain the last 2 hours despite using the PCA every 10” so you have increased the bolus to 0.2 mg every 10” which is the high range the physician has stated in the initial post-op orders.

What data is RELEVANT that must be recognized as clinically significant to the nurse?RELEVANT data from HPI: Rationale:

Your shift continues…Two hours later he states that he is feeling more nauseated, and you administer Ondansetron (Zofran) 4

mg IVP prn. Five minutes later he puts the call light on again. You are not able to respond immediately because you are helping your other patient get on the commode. Little do you know that John is going to depend on your ability to THINK LIKE A NURSE and clinically reason to save his life. When you arrive in his room you observe the following…

Your Initial Nursing Assessment:GENERAL APPEARANCE: Lethargic, unresponsive, ashen pale in colorRESP: Minimal spontaneous respiratory effort present. When you arrive at the bedside you observe that his mouth is full of liquid emesis that is drooling out the side of his mouthCARDIAC: Unable to palpate radial pulse, you go straight to the carotid pulse on the neck and note a weak pulse with 2 palpable beats in 5 seconds. Calculate pulse rate: 24 beats/minuteNEURO: Unresponsive, does not arouse or awaken to vigorous physical stimuli GI/GU: not immediately assessed

What assessment data is relevant that must be recognized as clinically significant to the nurse? RELEVANT assessment data: Rationale:

Your Initial VS:T: not immediately assessedP: 24…use calculated rate aboveR: 4/minuteBP: 72/40

-Need to know what surgery was done with what approach to assess postoperatively, need to establish baseline pain and pain medications in order to make pt comfortable

-Chronic back pain, posterior spinal fusion, Oxycontin 40 mg bid at home, Dilaudid PCA, Settings: 0.2mg continuous, 0.1 mg bolus every 10” with a 4 hour max of 6 mg, increased pain, increased bolus by 0.2 mg

-Lethargic, Unresponsive, ashen pale in color-Minimal spontaneous respiratory effort-Mouth full of liquid emesis drooling out of mouth-Pulse of 24 bpm

-Pt too sedated to turn his head when needing to vomit and aspirated emesis into his lungs.-Obstructed airway has caused his body to have lack of oxygen leading to lethargy and unresponsiveness.-Due to lack of oxygen in his system his heart cannot keep up with the demand to pump.

Amanda CooleyCase Study Exam 1

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O2 sats: 76%

© 2013 Keith Rischer/www.KeithRN.com

What VS data is relevant to this patient that must be recognized as clinically significant to the nurse? RELEVANT VS data: Rationale:

Identifying Clinical Relationships…What are the clinical relationships between the need to increase hydromorphone PCA, nausea/emesis, and decreased LOC?-Increasing the hydromorphone PCA can decrease the LOC of a pt and if they are nauseated they possibly may have some emesis. This puts the pt at risk for aspiration which is what has happened in this case.

II. Clinical Reasoning Begins…1. What is the primary problem that your patient is most likely presenting with?

-The pt has aspirated emesis into his lungs and obstructed his airway.

2. What is the underlying cause /pathophysiology of this concern?

-The pt was too sedated to be able to turn his head or move when he vomited so he aspirated emesis that is obstructing his airway. -The lack of O2 in his system has caused him to go into cardiac arrest.

3. What nursing priority will guide your plan of care?

-First an airway needs to be established. Raise the HOB and suction his mouth with a yankauer to prevent any more aspiration of emesis.-Second call a rapid response or code blue. Whatever is necessary to get more hands there.

4. Nursing Interventions: (identify clinical & BLS priorities-place in order to best rescue)Nursing Interventions:

1. Call a Code Blue

2. Call for a Code Cart

Airway Priorities: Clear airway of emesis

Circulatory Priorities: Get the heart back to pumping blood

Breathing Priorities: Get O2 in and out ofthe body

Circulatory Priorities: Use compressionsto circulate that O2 and get the heart pumping again

Rationale: Expected Outcome:

-Pulse: low>too low

-Respirations: low>too low

-BP: low>too low

-O2 Sats: low>too low

-Heart cannot keep up with demand to pump because of lack of oxygen in system. The heart has to oxygen to work.-Decreased respirations due to obstructed airway form emesis that was aspirated.

-Blood Pressure has decreased because the heart is not pumping and therefore cardiac output has significantly decreased.-O2 sats are low because of obstructed airway and the inability for the pt to breathe in O2.

1. To get extra help there ASAP2. To get resuscitation equipment

thereA : To get rid of the airway obstruction

C: To circulate blood through the body that the heart cannot right now.

B: Get O2 to the organs like the heart to prevent ischemia and permanent damage.C: Circulate oxygenated blood to feed vital organs

Pt will have a patent airway and O2 will circulated through the vascular system.

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5. What body system(s) will you most thoroughly assess based on the patient’s chief complaint and primary/priority concern?- Circulatory and Respiratory systems would be thoroughly assessed based on the priority and primary

concern right now.

6. What is the most likely/worst possible complication to anticipate?- Cardiac Arrest

7. What nursing assessment(s) will you need to initiate to identify and respond if this complication develops?- Cardiovascular and respiratory assessments with need to be done.

A crash cart is brought into the room, and is placed on the cardiac monitor/defibrillator. The following rhythm is displayed:

Interpretation: V-Fib

Is this rhythm shockable? Yes

Clinical Significance: NO PERFUSION

Medical Management: Advanced Cardiac Life Support (ACLS) PrioritiesRationale for Treatment & Expected OutcomesACLS Priorities:1. Administer shock: 200

joules

2. Proceed with 2” CPR

3. Assess rhythm… is it “shockable?”

4. Epinephrine 1:10,000 1 mL IVP

5. Proceed w/2” CPR

6. Assess rhythm… is it “shockable?”

Rationale: Expected Outcome:1. Depolarize and repolarize the heart2. Continue to circulate the blood (keep it

going round and round)3. If the rhythm is shockable then shock if

not give meds.4. To vasoconstrict and increase cardiac

output.5. Continue to circulate blood and O2.6. If rhythm is shockable then shock if not

continue with CPR and meds.

1. Convert the heart back into a rhythm that will perfuse.

2. Perfusion3. To get the heart to

perfuse the rest of the body and itself.

4. Blood and O2 will get to the vital organs.

5. Perfusion6. To get the heart to

perfuse the rest of the body and itself.

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7. Amiodarone 300 mg IV push

ACLS Medication Dosage Calculation:Medication/Dose:

Epinephrine 1:10,0001 mg IV push Normal Range: (high/low/avg?)

Mechanism of Action: Volume/timeframe to safely administer:

IV Push:

Nursing Assessment/Considerations:

Medication/Dose:

Amiodarone 300 mg IV push

Normal Range:(high/low/avg?)

Mechanism of Action: Volume/timeframe to safely administer:

Nursing Assessment/Considerations:

Ten minutes into the code, after one dose of Epinephrine and Amiodarone and the third defibrillatory shock at 360 joules, the following rhythm is present on the monitor:

Interpretation: SVT

Clinical Significance: Now there is a sinus rhythm but is at a very fast rate. We need to slow the rhythm down to be able to perfuse the entire body.

What is the FIRST thing that the nurse should do if this rhythm is present?

- Stop CPR if an airway is established and administer Adenosine.The physician running the code orders a stat ABG right after Mr. Williams is successfully resuscitated and is now intubated. You obtain the following results:

Arterial Blood Gases Current High/Low/WNL?pH (7.35-7.45) 7.15 LowpO2 (80-100) 64 LowpCO2 (35-45) 78 HighHCO3 (18-26) 22 WNLO2 sats (>92%) 90% Low

7. To treat the arrhythmia that was unresponsive to shock delivery.

7. Convert the heart back into a rhythm that will perfuse.

-Epinephrine binds directly to alpha-1 adrenergic receptors of the blood vessels causing vasoconstriction-It also binds to beta-1-adrenergic receptors of the heart. This indirectly improves cardiac output by: increasing HR, increasing contractility, and increasing conductivity through the AV node

-2-10 mcgs per minute via IV infusion-Endotracheal Tube: 2-2.5 mg

-1 mg IV every 3-5 minutes

-Epinephrine increases heart rate and raises blood pressure.-It is the primary drug used in the pulseless arrest in hopes that returne of spontaneous circulations will occur.

The mechanism of action of amiodarone remains unkown, but within the framework of ACLS, amiodarone is used primarily to treat V-fib and Ventricular Tachycardia that occurs during cardiac arrest and is unresponsive to shock delivery, CPR, and vasopressors.

-300 mg IV/IO push>(if no conversion) 150 mg IV/IO push >(after conversion) Infusion #1 360 mg IV over 6 hours (1mg/min) > Infusion #2 540 mg IV over 18 hours (0.5mg/min). Maximum cumulative dose in 24 hours should not exceed 2.2 grams.

-Monitor rhythm closely.

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Oxygen delivery 100%

© 2013 Keith Rischer/www.KeithRN.com

Identify the relevant lab results to this patient and their clinical significance?- pH, pO2, and O2 sats are low.- pCO2 is high.- This all leads to Respiratory Acidosis most likely due to the time the patient was without O2.

VS:T: 99.1 (o)P: 128 regR: ambu at rate of 12/minute BP: 128/88O2 sats: 92% ambu bag

Nursing Assessment:GENERAL APPEARANCE: Color slightly improved. Is pale/pinkRESPIRATORY: Coarse crackles/rhonchi scattered in both lung fields even after suctioning. No spontaneous resp. effort. Requires ambu baggingCARDIAC: Pulses 2+ throughout. Strong femoral pulse. No edema in extremities. Heart rate regular-S1S2. NEUROLOGIC: Remains unresponsive. Responds to pain stimuli by bringing both hands towards the source of painABDOMEN/GI: Abdomen soft, non-tender with active bowel sounds

1. Has the status of the patient improved or not as expected to this point?- The pt has a patent airway and is now has good perfusions so that is as expected. The pt should have

never gotten to this point, but the outcome of the rapid response is as expected.

2. What data supports this evaluation assessment?- Improved color, 2+ pulses throughout

3. What is the rationale for the changes in your patient’s status that you have seen to this point?- Intubating established a patent airway. CPR and medications perfused the pts organs while the airway

was being established. Color has improved due to the improvement of oxygenation. The strong pulses throughout are due to perfusion being reestablished.

4. Based on your current evaluation of your patient, what are your nursing gaols/priorities and plan of care? Think ABC’s…

A-Airway- Maintain a patent airway via ET tube.

B-Breathing- Improve respiratory status and administer antibiotics as ordered because of aspiration. Will most likely

have aspiration pneumonia.

C-Circulation- Monitor ECG carefully to make sure the heart is able to do an adequate job and perfuse. - Maintain a Blood Pressure with a MAP above 65. - Maintain peripheral pulses of at least 1 +.

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Medical Management: Rationale for Treatment & Expected OutcomesPhysician Orders: Obtain stat. portable

CXR

Obtain stat EKG

Repeat ABG’s

BMP, CBC, Lactate

Transfer to ICU

Rationale: Expected Outcome:

Radiology Reports: Portable CXRWhat data above is relevant to this patient that must be recognized as clinically significant? Results: Tip of ET tube 1 cm above the carina. Heart size normal.*This means tube has good placement and does not need to be advanced. Heart is not enlarged.Lab Results

Arterial Blood Gases Current High/Low/WNL? Most RecentpH (7.35-7.45) 7.29 Low 7.15pO2 (80-100) 102 High 64pCO2 (35-45) 48 High 78HCO3 (18-26) 23 WNL 22O2 sats (>92%) 100% WNL 90%Oxygen delivery 100% High 100%

Identify the relevant lab results to this patient and their clinical significance?- pH has improved and pCO2 has improved so the mechanical ventilation is helping the pt.- Saturations are up and pO2 is high so the oxygen delivery can be lowered and not to drive his ABGs in

the opposite direction.Basic Metabolic panel Current High/Low/WNL?Sodium (135-145) 138 WNLPotassium (3.5-5.1) 4.1 WNLGlucose (65-100) 152 HighCalcium (8.5-10.5) 8.6 WNLMagnesium (1.8-2.6) 1.9 WNLLactate (<2.6) 4.2 HighBUN (7-25) 22 WNLCreatinine (0.5-1.3) 1.2 WNLGFR (>60 mL/min) 58 Low

Identify the relevant lab results to this patient and their clinical significance?- Glucose is high because it is the body’s natural response to dump glucose into the system in times of

stress.- The pts GFR is slightly low, BUN & Creatinine are on the high end of normal because of the shock the

kidneys took during the pts resuscitation. - Lactate being elevated is to do with the body being deprived of O2 for some time.

to check for ET tube placement to make sure it is in the correct spot and to see how bad the infiltrates in the lungs are

to get a 12-lead view of the heart because of what it just went through and the pt is still in a arrhythmia

to see if the pts respiratory acidosis has improved now that he is being ventilated

to get an idea of wear his electrolytes, cell counts, and lactic acid stand after being resuscitated

transfer to be cared for closely while on ventilator and in critical condition

hopefully good position, but lots of infiltrates we partly knew this because of his lung sounds

sinus tachycardia improvements in pH

and pCO2 hopefully now too

skewed one on one care with

an RN and close respiratory monitoring

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CBC Current High/Low/WNL?WBC (4.5-11.0) 8.9 WNLHGB (12-16) 10.2 LowPLTS (140-440) 148 WNLNeuts. % (42-72) 85 HighLymphs % (20-44) 18 Low

Identify the relevant lab results to this patient and their clinical significance?- Hemoglobin in low most likely due to his blood loss during his spinal fusion.- Neutrophils being high and Lymphocytes being low are part of the inflammatory response the body is

having to the trauma it just went through.- Expect WBCs to go up with those lung infiltrates.

It is now time to transfer to ICU. Effective and concise handoffs are essential to excellent care and if not done well can adversely impact the care of this patient. You have done an excellent job to this point, and have RESCUED your patient, now finish strong and give the following SBAR report to the nurse who will be caring for this patient in the ICU:

Situation:- Mr. Williams was over sedated when he had some emesis that he aspirated into his lungs. We called

a rapid response because his breaths were 4 per minute pulse of 24. We suctioned and ended up coding him. He was V-fib so we shocked him, gave epi, and gave amiodarone before we got him back at sinus tach which is what he is in now. He was intubated and should be getting hooked up to the vent and showing signs of improved respiratory status.

Background:- He is post-op from a lumbar spinal fusion today L5-S1. He has chronic pain and was on a Dilaudid

PCA. He normally takes Oxycontin 40mg bid at home. He was having nausea and emesis.Assessment:- We checked placement of the ET tube it is good position. His ABGs are showing improvements. His

lungs have crackles/ronchi scattered in both lungs. He is at 100% oxygen delivery. He is in sinus Tach with good peripheral pulses. He is still sedated and only responsive to painful stimuli. Since he has been back from surgery I have not looked at his dressing and that should be addressed.

Recommendation:- If mechanical ventilation has not already been initiated do so. Monitor sedation and administer

sedatives if pt becomes aware enough to pull ET tube. Start some antibiotics for the lung infiltrates that were aspirated. Monitor ECG and BP closely. Pt should stay here in ICU until status improves.