MHR 623 Chapter 1-9: hr planning document to check
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Case-3: Patient History
T.J. is a 46-year-old science professor brought to urgent care this afternoon by his wife. T.J. has been at home for 3 days with severe diarrhea and vomiting. His youngest daughter was hospitalized earlier in the week with similar symptoms. T.J. has no significant medical history and takes no medications. Examination reveals an ill-appearing, pale, diaphoretic man who is having difficulty concentrating and answering questions. He has diffuse abdominal pain. Vital signs are as follows: LyingâHR 100, BP 100/80, resp 26, temp 100. SittingâHR 136, BP 90/60. He has not urinated since yesterday morning.
Analyze this case study and answer the next three questions that follow.
Case-3: Question-1
What other laboratory or clinical data would be helpful in assessing T.J.âs fluid-electrolyte and acid-base status? (select all that apply)
| Blood test to assess the level of glucose. |
| A chemistry panel would be helpful in assessing for imbalances of serum sodium, potassium, and bicarbonate. |
| Further assessment could include inspection of mucous membranes for dryness, skin turgor, status of neck veins, and presence of dizziness with position change. |
| Assessment of body temperature. |
Case-3: Question-2
Which assessment data should be monitored during fluid replacement therapy to determine when adequate volume has been restored? (select all that apply)
| Mental status should be assessed and expected to improve with adequate fluid replacement. |
| Vital signs should be monitored for resolution of tachycardia and postural symptoms, as well as intake and output. |
| Skin turgor and mucous membranes should be monitored for improvement of dehydration. |
| Electrolytes should be monitored for resolution of any electrolyte imbalance. |
Case-3: Question-3
How might persistent vomiting and diarrhea alter acid-base balance? (select all that apply)
| Metabolic alkalosis may occur as a result of persistent diarrhea. |
| Vomiting may contribute to metabolic acidosis. |
| Metabolic acidosis may occur as a result of persistent diarrhea. |
| Vomiting may contribute to metabolic alkalosis. |
Shock Case Study (15 pts)
HPI. Mrs. K is a 22 y/o college student, rushed to the ED 35 minutes after sustaining multiple stab wounds to the chest and abdomen by an unidentified assailant. A witness called 911. Paramedics arriving at the scene found the victim to be in severe acute distress.
Vital signs were as follows: HR 128 (baseline 80), BP 80/55 (baseline 115/80), RR 37 and labored. Chest auscultation revealed decreased breath sounds in the R lung consistent with basilar atelectasis (ie. collapsed R lung). Pupils were equal, round, reactive to light, and accommodation. Her LOC was reported as âawake, slightly confused, and complaining of severe chest and abdominal pain.â Pedal pulses were absent, radial pulses were weak, and carotid pulses were palpable. The patient was immediately started on IV Lactated Ringerâs solution at a rate of 150 mL/hr.
An ECG monitor placed at the scene of the attack revealed that the patient has developed sinus tachycardia. She was tachypneic, became short of breath with conversation and reported her heart was pounding out of her chest. She appeared to be very anxious and continued to c/o pain. Her skin was cool and nail beds were pale but not cyanotic. Skin turgor was poor. Peripheral pulses were absent with the exception of a thread, brachial pulse. Capillary refill time was 7-8 seconds. Doppler ultrasound had been required to obtain an accurate BP reading. The patientâs skin was cool and clammy. There was a significant amount of blood on her dress and on the pavement where she was lying.
Question 2. What is the pathophysiologic sequence of events for shock? (2pts)
Question 3. What type of shock does this patient seem to have? What is your rationale? (2 pts)
Question 4. Does this patient need a blood transfusion? Provide rationale for your answer. (2pts)
During transport to the hospital, vital signs were reassessed: HR 138, BP 75/50, RR 38 with confusion. Patient was diagnosed with hypovolemic shock and IV fluids were doubled. Oxygen was started at 3L/min by nasal cannula. ER physicians chose not to start a central venous line. An indwelling foley catheter was inserted with return of 180mL of amber colored urine. Urine output measured over the next hour was 14mL. Patient was taken to the OR for surgical correction of lacerations to the right lung, liver and pancreas. In total, patient received 1L of Lactated Ringers.
Table 1.
| Class | ||||
|---|---|---|---|---|
| Parameter | I | II | III | IV |
| Blood loss (ml) | <750 | 750â1500 | 1500â2000 | >2000 |
| Blood loss (%) | <15% | 15â30% | 30â40% | >40% |
| Pulse rate (beats/min) | <100 | >100 | >120 | >140 |
| Blood pressure | Normal | Decreased | Decreased | Decreased |
| Respiratory rate (breaths/min) | 14â20 | 20â30 | 30â40 | >35 |
| Urine output (ml/hour) | >30 | 20â30 | 5â15 | Negligible |
| CNS symptoms | Normal | Anxious | Confused | Lethargic |