Amanda Cooley
Case Study Exam 1
Unfolding Reasoning Case Study:
Synthesis Scenario: Cardiac Arrest
I. Data Collection
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:
-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
-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
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 color
RESP: 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 mouth
CARDIAC: 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/minute
NEURO: 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:
-Lethargic, Unresponsive, ashen pale in color
-Minimal spontaneous respiratory effort
-Mouth full of liquid emesis drooling out of
mouth
-Pulse of 24 bpm
Your Initial VS:
T: not immediately assessed
P: 24…use calculated rate above
R: 4/minute
BP: 72/40
O2 sats: 76%
© 2013 Keith Rischer/www.KeithRN.com
-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.
What VS data is relevant to this patient that must be recognized as clinically significant to the nurse?
RELEVANT VS data:
Rationale:
-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.
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:
Rationale:
Expected Outcome:
1. Call a Code Blue
1. To get extra help there ASAP
Pt will have a patent
2. To get resuscitation equipment
airway and O2 will
2. Call for a Code Cart
there
circulated through
A : To get rid of the airway obstruction
the vascular system.
Airway Priorities: Clear airway of emesis
Circulatory Priorities: Get the heart back to
pumping blood
C: To circulate blood through the body
that the heart cannot right now.
Breathing Priorities: Get O2 in and out of
the body
B: Get O2 to the organs like the heart to
prevent ischemia and permanent
damage.
C: Circulate oxygenated blood to feed
vital organs
Circulatory Priorities: Use compressions
to circulate that O2 and get the heart
pumping again
© 2013 Keith Rischer/www.KeithRN.com
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) Priorities
Rationale for Treatment & Expected Outcomes
ACLS 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
Rationale:
1. Depolarize and repolarize the heart
2. 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.
5. Proceed w/2” CPR
6. Assess rhythm… is it
“shockable?”
© 2013 Keith Rischer/www.KeithRN.com
Expected Outcome:
1. Convert the heart back
into a rhythm that will
perfuse.
2. Perfusion
3. To get the heart to
perfuse the rest of the
body and itself.
4. Blood and O2 will get to
the vital organs.
5. Perfusion
6. To get the heart to
perfuse the rest of the
body and itself.
7. Amiodarone 300 mg IV
push
7. To treat the arrhythmia that was unresponsive
to shock delivery.
7. Convert the heart back
into a rhythm that will
perfuse.
ACLS Medication Dosage Calculation:
Medication/Dose:
Epinephrine
1:10,000
1 mg IV push
Normal Range:
(high/low/avg?)
Medication/Dose:
Amiodarone 300
mg IV push
Normal Range:
(high/low/avg?)
Mechanism of Action:
-Epinephrine binds directly to
alpha-1 adrenergic receptors of
the blood vessels causing
vasoconstriction
-It also binds to beta-1adrenergic receptors of the
heart. This indirectly improves
cardiac output by: increasing
HR, increasing contractility, and
increasing conductivity through
the AV node
Mechanism of Action:
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.
Volume/timeframe to
safely administer:
-2-10 mcgs per minute via IV
infusion
-Endotracheal Tube: 2-2.5 mg
IV Push:
-1 mg IV every 3-5 minutes
Volume/timeframe to
safely administer:
Nursing Assessment/Considerations:
-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.
Nursing Assessment/Considerations:
-Monitor rhythm closely.
-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.
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
pH (7.35-7.45)
pO2 (80-100)
pCO2 (35-45)
HCO3 (18-26)
O2 sats (>92%)
Oxygen delivery
Current
7.15
64
78
22
90%
100%
© 2013 Keith Rischer/www.KeithRN.com
High/Low/WNL?
Low
Low
High
WNL
Low
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 reg
R: ambu at rate of 12/minute
BP: 128/88
O2 sats: 92% ambu bag
Nursing Assessment:
GENERAL APPEARANCE: Color slightly improved. Is pale/pink
RESPIRATORY: Coarse crackles/rhonchi scattered in both lung fields even after suctioning. No spontaneous
resp. effort. Requires ambu bagging
CARDIAC: 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 pain
ABDOMEN/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 +.
© 2013 Keith Rischer/www.KeithRN.com
Medical Management: Rationale for Treatment & Expected Outcomes
Physician Orders:
 Obtain stat. portable
CXR
 Obtain stat EKG
 Repeat ABG’s
 BMP, CBC, Lactate
 Transfer to ICU
Rationale:
Expected Outcome:
 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
Radiology Reports: Portable CXR
What 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
pH (7.35-7.45)
pO2 (80-100)
pCO2 (35-45)
HCO3 (18-26)
O2 sats (>92%)
Oxygen delivery
Current
7.29
102
48
23
100%
100%
High/Low/WNL?
Low
High
High
WNL
WNL
High
Most Recent
7.15
64
78
22
90%
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
WNL
Potassium (3.5-5.1)
4.1
WNL
Glucose (65-100)
152
High
Calcium (8.5-10.5)
8.6
WNL
Magnesium (1.8-2.6)
1.9
WNL
Lactate (<2.6)
4.2
High
BUN (7-25)
22
WNL
Creatinine (0.5-1.3)
1.2
WNL
GFR (>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.
© 2013 Keith Rischer/www.KeithRN.com
CBC
WBC (4.5-11.0)
HGB (12-16)
PLTS (140-440)
Neuts. % (42-72)
Lymphs % (20-44)
Current
8.9
10.2
148
85
18
High/Low/WNL?
WNL
Low
WNL
High
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.
© 2013 Keith Rischer/www.KeithRN.com