Page 447 - Critical Care Nursing Demystified

432 CRITICAL CARE NURSING DeMYSTIFIED

ANSWERS

CASE STUDY

1. The elevated temperature, HR, breathing rate, and BP seem to indicate that Patricia is
experiencing SIRS. The results of the urine cultures are pending; if they are positive she
would have sepsis. Her urinary output is below that minimally accepted, and BUN and
creatinine and her positive lung sounds and ABGs show there is lung involvement. This
would indicate severe sepsis as two organs are involved. She does not have MODS at this
time as no other organs show signs of failure.
2. ABGs: pH 7.30, pCO 55, pO 55, HCO 15
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The pH is below 7.35 indicating an acidosis. Next we need to find the primary target
organ. Looking at the pCO we find the patient is retaining CO ,so she is in a respiratory
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acidosis. Next we look at HCO . Ms. Cranston is retaining acid because the HCO is less
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than 22. She is also in a metabolic acidosis. Careful correction of these needs to occur as
the combined acidosis and quick drops in the pH are not compatible with life. She is also
severely hypoxemic with a pO less than 80 mmHg.
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3. Two things: She is currently undergoing chemotherapy and that can cause immunosup-
pression; we will look at the ANC to confirm this. Also, the presence of foul-smelling urine
with white sediment suggests a urinary tract infection. The pending UTI will confirm this. Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
The white cell count does not help out as it is below the normal level. This is due to neu-
tropenia caused by chemotherapy. The crackles in lung fields and low SaO may indicate
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lower lobe pneumonia.
4. ANC is calculated by taking the percentage of segmented and banded neutrophils and
multiplying that percentage by the total WBCs.
WBCs 2,500, neutrophils (segs) 25%, (bands) 9%
25% + 9% = 39%, change to percentage = 0.39
0.39 × 2,000 = 975
This patient is neutropenic.
5. Prioritized collaborative care would include:
Intubation and mechanical ventilation due to acidosis/hypoxemia.
Be careful when administering fluids; she might go into fluid overload. She might need a
pulmonary artery catheter along with urinary output and watching SaO /breath sounds to
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prevent pulmonary edema. Her Hct and Hgb indicate she may need blood transfusions.
Confirming all cultures have been taken prior to starting antibiotics.
Antipyretics like Tylenol.
Neutropenic precautions.
6. The nurse might anticipate the following pulmonary artery pressures:
CVP (low) due to vasodilatation
PAP (high) due to pneumonia and possible left-sided failure
PAOP (high) due to pneumonia and possible left-sided failure
CO (high) due to compensation by catecholamine release confirmed by the hypertension
SVR (low) due to liberation of endotoxins creating fluid translocating from the vasculature