Page 323 - Critical Care Nursing Demystified

308 CRITICAL CARE NURSING DeMYSTIFIED

ANSWERS

CASE STUDY 1

Roy should be started on LR with a total fluid replacement aimed at around 3 L (1,000 mL
loss × 3 mL of fluid replaced = 3,000). Successful fluid resuscitation would be indicated by
stabilization of vitals by a drop in pulse to less than 100, a drop in respirations to 18, and
a BP between 110 and 120. His urinary output would also be light yellow with 30 cc/hr.
Complications the nurse should monitor for include pulmonary edema from third spacing,
hypothermia from rapid infusion of a room-temperature solution, and coagulopathies due
to rapid dilution of the blood.

CASE STUDY 2

After an x-ray, E.B.’s shoulder is manipulated back into alignment and placed in a sling for
comfort and support. He is admitted to a Critical Care Unit for observation of his moderate
concussion and for continued neurological assessment of spinal cord damages resulting
from a partial C5 fracture.

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Risk for ineffective airway clearance due to loss of gag reflex
Risk for ineffective breathing patterns due to spinal cord injury and swelling
Risk for impaired spontaneous ventilation due to swelling in the area of the spinal
cord that controls respiration
Risk for decreased cardiac output due to lack of innervation to the spinal cord
(spinal shock)
Altered Level of Consciousness related to a contact sports head injury

CORRECT ANSWERS AND RATIONALES

1. B. The head tilt chin lift would compromise the spine, leading to possible worsening
of a spinal cord injury. The modified jaw thrust allows opening of the airway without
added compression on the spinal cord. Endotracheal tubes can be placed without hy-
perextension of the neck.
2. D. There can be significant stretching and distortion of the spinal cord due to a down-
ward and backward motion of the head, caused by rear-end collisions or diving acci-
dents. Typically, a whiplash injury results from this type of trauma, with minimal to no
bony disturbances.
3. C. A spinal cord injury above the level of C5 causes diaphragmatic and vagal nerve
paralysis. Without the innervation to stimulate breathing, the patient will need to be
placed on a ventilator.