Page 442 - Critical Care Nursing Demystified

Chapter 9 CARE OF THE PATIENT WITH CRITICAL HEMATOLOGIC NEEDS 427

13. Observe for signs of MI, which include increasingly frequent chest pain,
ST–T wave changes, and positive cardiac enzymes. MI can occur if clots
lodge in the coronary arteries.
14. Observe for symptoms of PE, which include pleuritic chest pain.
15. Monitor the urinary output for signs of renal failure. Output should be
greater than 30 cc/hr.
16. Keep the patient in a comfortable position, usually a semi-Fowler’s posi-
tion, to minimize energy and help diaphragmatic drop by gravity.
17. Provide emotional support to the patient and significant others.

CASE STUDY

Sixty-eight-year-old Patricia Cranton is admitted to the ICU through the ECU from
a nursing home. Her admitting diagnosis is septic shock possibly from a long-term
urinary catheter placed after a recent vulvectomy due to pelvic cancer. Her care
includes chemotherapy several times a week at a local cancer center.
Vital signs: TPR = 103°F-126-36, BP 170/100, SaO 89%
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ABGs: pH 7.30, pCO 55, pO 55, HCO 15
2 2 3
++
Labs: Na 150, K 5.5, Cl 130, Phos 3, Ca 5, BUN 60, creatinine 2, Hct 25%, Hgb 8,
+
RBCs 2,500, WBCs 2,500, neutrophils (segs) 25%, (bands) 9%
Urine culture: Pending

Chest x-ray: Patchy infiltrates in both lung fields suggestive of pneumonia

Body systems assessment reveals:
Neuro: A + O × 1 (disoriented to time and place; new onset)
Lethargic with progressive difficulty to keep awake

Only slight gag refl ex
Slow to follow commands; intermittent success in doing so
Denies pain but states, “I’m having trouble catching my breath.”
CV: Skin is warm and fl ushed
S1 and S2 audible at apex without rubs/murmurs
Peripheral pulses full and bounding with all +4/3
Brisk capillary refi ll
Pul: Diminished breath sounds at the bases
Unable to take a deep breath with coaxing
Equal expansion of chest wall