Mr. Santos, a 72-year-old Hispanic man, is admitted to your unit because of a clotted arteriovenous shunt. He has been on dialysis for 3 years and is on Prednisone for COPD. In 2002 he had a stroke due to a blood clot thrown during a dialysis session and he has residual left-sided weakness. Since that time he has been on anticoagulation therapy (warfarin 5 mg daily) and comes to the clinic biweekly for lab checks (INR). He lives at home with his wife and his son’s family.
On admission his lab values are:
- INR = 1.6
- WBC = 18.7
- RBC = 3.6 million/mL
- Hemoglobin = 10 gm/dL
- Hematocrit = 31%
- BUN = 57 mg/dL
- Creatinine = 5.9 mg/dL
- Potassium = 6.0 mEq/dL
- What other pertinent data would you want to have? (List 2)
- Two hours into your shift, Mr. Santos complains of palpitations but is otherwise asymptomatic. B/P is 98/65. The telemetry tech informs you that the patient is having multiple runs of non-sustained ventricular tachycardia. Call is placed to the Primary Physician.Based on this assessment, which of the following would be your FIRST recommendation to the Physician?
You are working in the emergency department when you hear a woman (Angelina) yell at the triage nurse. As you approach her she is saying, “I don’t care what you say, they are coming to get me!” She is 32 and her husband and son are with her. Angelina is restless, unable to stay seated, and looks frightened. She stares at the wall and seems to be listening to something. Her husband states she has not been sleeping well lately and that he has never seen her behave like this. He says her medical history includes asthma, depression and mild arthritis.
You introduce yourself and ask her what is happening to her. She says, “All I did was throw a knife at the wolf, and you bring me here! I have to protect myself from the wolves!” The nurse asks Angelina, “Do you feel safe here right now?” and “Are we safe with you?” Angelina looks at the door and says, “I’m OK for this minute, I’m not scared of you.” You take Angelina and her family to a private exam room, asking security to stand by.
What other information or data might help determine what has caused this sudden onset of psychosis? (List 2)
Mr. Anthony is an 84-year-old who was admitted with urosepsis and dehydration. He has been hospitalized for 4 days, is on ciprofloxacin, and has been rehydrated. He has been doing well and the plan is to discharge him back to the assisted living facility where he lives in the next day or two. He has a history of heart failure, type 2 diabetes, and GERD. His BP had been lower (systolic 70s-80s; diastolic 50s) during the evening, and he received a fluid bolus of 500 ml normal saline for this. His BP after the bolus was 100/60 and heart rate was 84.
You are assessing him at the start of your shift the following morning and notice that his blood pressure is 78/50.
As you go in to reassess this patient, his BP is now 66/40, respirations are 32 and becoming more labored, and he is less responsive. He has crackles on auscultation in the lower half of his lungs. You call the primary physician, and he tells you to give the fluid bolus as ordered. You tell the physician that you think this patient needs to be seen, and the physician tells you to call him back after the fluid bolus.
Would you give the fluid bolus? yes or no (Why?)
What would be your next steps? (List 2)
Ms. Whoopi is a 64-year-old female on chemotherapy who was admitted to your unit the day before with an acute central line infection.
On admission she had a WBC count of 13,000 and a temperature of 96.8° F. The central line has been cultured and she has been started on IV cefazolin.
Later into your shift, the patient complains of a racing heart; you assess her heart rate at 180. An electrocardiogram shows rapid atrial fibrillation at 180 bpm. The physician is notified and treats the patient with diltiazem. The heart rate decreases to 120. During this time the patient also tells you she is not feeling well.
Are there any other reasons why this patient would have changes in heart rate? Yes or No (why?)
Ten minutes later, The nurse’s aide informs you that the patient has become confused. She does not know where she is or why she is in the hospital. You go in to check on the patient and she does not respond to you.
What actions would you take? (List 2)
Mr. Larry is a 72-year-old male that came in for dehydration and gastroenteritis. He has been on antibiotics and IV fluids at 125cc/hr for the past 2 days. He is now tachycardic with a heart rate of 126. He is sitting straight up in the bed and complaining of shortness of breath. You auscultate his lungs and hear crackles throughout his lung fields. His O2 Sat is 86% on 2 lpm nasal cannula and his RR is 36. Blood pressure is 178/98. Skin is pale and diaphoretic. He begins coughing and expectorates pink frothy sputum. You realize that he has not voided in more than 8 hrs.
What do you think is happening to Mr. Larry? (a. septic shock; b. Cardiogenic shock; c. Pulmonary edema; d. Stemi)
What would be your next steps? (List 2)