Case Studies Final Medsurge II PDF

**UNIT 2** **Application-Based Scenario for Different Types of Shock** **Scenario:** You are caring for a 65-year-old patient in the ICU who suddenly becomes hypotensive (BP **85/50** **mmHg**) with an elevated heart rate (**120 bpm**). The patient has **cool, clammy skin**, **altered mental stat...

**UNIT 2** **Application-Based Scenario for Different Types of Shock** **Scenario:** You are caring for a 65-year-old patient in the ICU who suddenly becomes hypotensive (BP **85/50** **mmHg**) with an elevated heart rate (**120 bpm**). The patient has **cool, clammy skin**, **altered mental status**, and a urine output of **15 mL/hour**. The provider diagnoses the patient with shock but requires further investigation to determine the type. - **Hypotension (BP 85/50 mmHg)** - **Tachycardia (HR 120 bpm)** - **Cool, clammy skin** - **Altered mental status** - **Low urine output (15 mL/hour)** The patient is likely experiencing **hypovolemic shock**. **Rationale:** 1. **Cool, clammy skin** and **low urine output** suggest poor perfusion due to decreased circulating blood volume. 2. **Hypotension** and **tachycardia** are compensatory mechanisms seen in hypovolemic shock as the body attempts to maintain cardiac output despite reduced blood volume. 3. No evidence of infection, anaphylaxis, or cardiac dysfunction was mentioned, making other types of shock less likely. If additional details (e.g., recent trauma, bleeding, or dehydration) confirm a fluid loss, this would further support the diagnosis of **hypovolemic shock**. If not, other types of shock like **cardiogenic** or **obstructive** might still need to be ruled out. **Types of Shock and Interventions:** **1. Hypovolemic Shock** **What would you do?** - Administer IV fluids (e.g., normal saline or lactated Ringer\'s) as ordered to restore intravascular volume. **Why are you doing this?** - To increase circulating blood volume and improve perfusion to organs. **What is causing the problem?** - Loss of fluid or blood due to trauma, dehydration, or hemorrhage. **How would you evaluate the intervention?** - Monitor blood pressure, heart rate, urine output (≥30 mL/hour), and mental status for improvement. **Critical Thinking Question:** - If blood loss is the cause, when would you consider administering packed red blood cells? **2. Cardiogenic Shock** **What would you do?** - Administer inotropic medications (e.g., dobutamine) to improve cardiac output. Provide oxygen as needed. **Why are you doing this?** - To enhance myocardial contractility and ensure adequate tissue perfusion. **What is causing the problem?** - The heart's inability to pump effectively, often due to an MI, heart failure, or arrhythmias. **How would you evaluate the intervention?** - Assess for increased blood pressure, improved heart rate, and reduced signs of pulmonary congestion (e.g., less dyspnea or crackles in lung sounds). **Critical Thinking Question:** - What diagnostic test could confirm that the shock is due to cardiac dysfunction (e.g., echocardiogram or EKG) **3. Distributive Shock (Septic, Neurogenic, or Anaphylactic)** **Septic Shock** **What would you do?** - Administer IV antibiotics and fluids. Begin vasopressors (e.g., norepinephrine) if hypotension persists. **Why are you doing this?** - To treat the underlying infection and restore blood pressure. **What is causing the problem?** - Systemic infection leading to vasodilation, capillary leakage, and reduced perfusion. **How would you evaluate the intervention?** - Monitor for stabilized BP, improved temperature, decreased WBC count, and better urine output. **Critical Thinking Question:** - What other labs (e.g., ABGs, Electrolytes, BUN/Creatinine, WBCs with\ differential, Blood cultures, central line culture,\ wound culture, and sputum culture) would help evaluate perfusion in septic shock? **Neurogenic Shock** **What would you do?** - Administer IV fluids and vasopressors to restore vascular tone. Stabilize the spine if trauma is involved. **Why are you doing this?** - To counteract massive vasodilation caused by loss of sympathetic tone. **What is causing the problem?** - Spinal cord injury or damage to the nervous system disrupting vascular regulation. **How would you evaluate the intervention?** - Look for stabilized BP, improved mental status, and restored peripheral perfusion (warm extremities). **Critical Thinking Question:** - Why is bradycardia, instead of tachycardia, a common sign in neurogenic shock? **Anaphylactic Shock** **What would you do?** - Administer IM epinephrine immediately, followed by antihistamines and corticosteroids. Provide oxygen and fluids as needed. **Why are you doing this?** - Epinephrine reverses bronchoconstriction, vasodilation, and swelling to restore perfusion and airway patency. **What is causing the problem?** - Severe allergic reaction causing systemic vasodilation and airway obstruction. **How would you evaluate the intervention?** - Monitor for improved airway patency, reduced swelling, normalized BP, and absence of wheezing. **Critical Thinking Question:** - Why is rapid identification of the allergen critical in preventing further anaphylaxis episodes? **4. Obstructive Shock** **What would you do?** - Treat the underlying obstruction (e.g., pericardiocentesis for cardiac tamponade or thrombolytics for a pulmonary embolism). **Why are you doing this?** - To remove the mechanical barrier preventing adequate cardiac output. **What is causing the problem?** - Physical obstruction of blood flow, such as a PE, tension pneumothorax, or cardiac tamponade. **How would you evaluate the intervention?** - Monitor BP, heart rate, respiratory status, and echocardiogram findings for improvement. **Critical Thinking Question:** - How would you recognize tension pneumothorax as a cause of obstructive shock (e.g., tracheal deviation or absent breath sounds)? **General Nursing Interventions for All Types of Shock:** - **Positioning:** Place the patient in a modified Trendelenburg position (flat with legs elevated) to promote venous return, unless contraindicated. - **Frequent Monitoring:** Check vitals, mental status, urine output, and perfusion status regularly. - **Education:** Teach patients and families about early warning signs of shock (e.g., confusion, dizziness, hypotension). **Critical Thinking Challenge: SHOCK** 1. A patient in shock does not respond to fluid resuscitation. What is your next step? 2. Why is identifying the type of shock crucial before initiating treatment? 3. How would you prioritize interventions if the patient presents with signs of both hypovolemic and septic shock? **1. A patient in shock does not respond to fluid resuscitation. What is your next step?** If the patient does not respond to fluids, consider the following: 1. **Reassess the type of shock:** - **Cardiogenic shock:** Fluid resuscitation could worsen pulmonary congestion. Evaluate cardiac function with an echocardiogram or EKG. Inotropic support (e.g., dobutamine) may be required. - **Septic shock:** Vasopressors (e.g., norepinephrine) may be needed to counteract vasodilation if fluids alone are insufficient. - **Obstructive shock:** Identify and address the obstruction (e.g., tension pneumothorax, cardiac tamponade, or pulmonary embolism) with specific interventions like chest tube placement or thrombolytics. 2. **Monitor closely for fluid overload:** - Signs include crackles, increased respiratory rate, or jugular vein distension. 3. **Add adjunct treatments:** - Provide oxygen therapy, monitor for acidosis, and correct any electrolyte imbalances (e.g., potassium or calcium). **2. Why is identifying the type of shock crucial before initiating treatment?** Each type of shock requires a different approach to treatment. Administering inappropriate therapy can worsen the patient's condition: - **Hypovolemic shock:** Fluids are the mainstay of treatment. Inotropic or vasopressor medications are typically not helpful unless fluid loss is corrected. - **Cardiogenic shock:** Fluids can exacerbate pulmonary edema, so inotropes are prioritized instead. - **Septic shock:** Antibiotics and vasopressors are critical to treat infection and maintain perfusion. - **Obstructive shock:** Treating the cause of the obstruction (e.g., draining fluid, removing a clot) is the only way to resolve the shock. Failing to identify the underlying cause delays proper intervention and worsens mortality risk. **3. How would you prioritize interventions if the patient presents with signs of both hypovolemic and septic shock?** In a case where both types of shock might coexist, prioritize interventions as follows: 1. **Stabilize circulation (ABC approach):** - Begin fluid resuscitation immediately to improve perfusion, as both types of shock involve intravascular depletion or maldistribution. 2. **Treat the infection:** - Administer broad-spectrum antibiotics as soon as possible to address sepsis, as delayed treatment increases mortality risk. 3. **Support blood pressure if fluids are insufficient:** - Start vasopressors (e.g., norepinephrine) to maintain MAP \>65 mmHg, particularly if septic shock is contributing to hypotension. 4. **Monitor carefully:** - Regularly assess for fluid overload (to avoid complications from excessive fluid resuscitation) and response to antibiotics. 5. **Further diagnostics:** - Evaluate for sources of bleeding or infection using labs (e.g., lactate, hemoglobin, WBC count) and imaging (e.g., CT scan or X-ray). **Key:** Fluid resuscitation is the initial priority, but treatment must address both conditions simultaneously to optimize outcomes. **Application-Based Scenario for Burns** **Scenario:** You are caring for a 45-year-old male patient who was rescued from a house fire. The patient sustained partial-thickness burns on 30% of his body, including the chest, arms, and face. He has singed nasal hairs, is complaining of severe pain (8/10), and has a hoarse voice. His vital signs are: BP 95/60 mmHg, HR 120 bpm, RR 24, and SpO₂ 91% on room air. **Key Burn Considerations:** Burn management focuses on airway, breathing, circulation, and preventing complications like infection and hypovolemia. Apply knowledge to this scenario using the following steps: **1. Airway and Breathing** **What would you do first?** - Administer 100% oxygen via non-rebreather mask and prepare for potential intubation. **Why are you doing this?** - The patient has signs of inhalation injury (hoarse voice, singed nasal hairs), which can lead to airway swelling and obstruction. Early intubation prevents respiratory distress. **What is causing the problem?** - Heat and smoke inhalation damage the airway, causing inflammation and potential obstruction. **How would you evaluate the intervention?** - Monitor oxygen saturation (goal: \>95%), observe for improved respiratory effort, and reassess for stridor or worsening hoarseness. **2. Fluid Resuscitation** **What intervention is needed to maintain circulation?** - Initiate fluid resuscitation using the Parkland formula: - **4 mL x body weight (kg) x % TBSA burned.** - Administer half of this volume in the first 8 hours. **Why are you doing this?** - To prevent hypovolemic shock caused by fluid loss from capillary leakage in burns. **What is causing the problem?** - Burn injuries increase capillary permeability, leading to significant fluid loss into surrounding tissues. **How would you evaluate the intervention?** - Monitor urine output (goal: 30-50 mL/hour), blood pressure, heart rate, and mental status. **Critical Thinking Challenge:** - What signs indicate over-resuscitation (e.g., pulmonary edema)? **3. Pain Management** **What would you do for the patient's pain?** - Administer IV opioids (e.g., morphine or fentanyl) as prescribed. **Why are you doing this?** - Partial-thickness burns damage nerve endings, causing severe pain that interferes with recovery. **What is causing the pain?** - Exposed dermal layers are highly sensitive to air and touch due to nerve irritation. **How would you evaluate the intervention?** - Reassess pain levels within 15-30 minutes after administration and monitor for signs of relief (e.g., reduced restlessness, patient verbalizing improvement). **4. Wound Care and Infection Prevention** **What wound care intervention is needed?** - Apply sterile dressings and topical antimicrobial agents (e.g., silver sulfadiazine). **Why are you doing this?** - To prevent infection, which is a leading cause of mortality in burn patients. **What is causing the problem?** - Loss of skin integrity exposes the body to pathogens and impairs the natural barrier against infection. **How would you evaluate the intervention?** - Monitor for signs of wound infection (e.g., purulent drainage, redness, swelling) and check for fever or elevated WBC count. **Critical Thinking Challenge:** - When would you consider surgical intervention like debridement or grafting? **5. Nutritional Support** **Why would you prioritize early nutrition?** - Start enteral feeding as soon as the patient is stable. **Why are you doing this?** - Burn patients have high metabolic needs due to the body's effort to heal the wounds. **What is causing the increased metabolic demand?** - The stress response increases energy and protein requirements for tissue repair. **How would you evaluate the intervention?** - Monitor weight, serum albumin/prealbumin levels, and signs of wound healing. **Critical Thinking Challenge:** - What complications can arise from delayed nutritional support (e.g., muscle wasting or impaired wound healing)? **6. Psychosocial Support** **What psychological needs might this patient have?** - Address anxiety and provide emotional support related to the trauma of the fire and injury. **Why are you doing this?** - Burn injuries can cause significant emotional distress, including PTSD and body image concerns. **How would you evaluate the intervention?** - Observe for reduced anxiety and improved communication about their feelings. **Critical Thinking Challenge Questions:** 1. Why is fluid resuscitation the priority over wound care in the initial phase? 2. What complications are you monitoring for in a patient with burns to the face and chest (e.g., respiratory distress or compartment syndrome)? 3. How would you adjust fluid resuscitation if urine output remains low after the calculated volume is given? **1. Why is fluid resuscitation the priority over wound care in the initial phase?** - **Fluid resuscitation** is prioritized because the first **24-48 hours** after a burn are the **emergent phase**, during which the greatest risk is **hypovolemic shock** due to **massive fluid loss**. Restoring circulating volume **ensures adequate perfusion to vital organs**. Without resuscitation, patients are at high risk of **multi-organ failure.** - Wound care is important but secondary during this phase, as it primarily **prevents infection**, which becomes more critical during the **acute phase** of burn management. **2. What complications are you monitoring for in a patient with burns to the face and chest?** - **Airway Compromise:** - Signs: **Stridor, hoarseness, singed nasal hairs, or blackened sputum**. These suggest inhalation injury, which can cause airway edema and obstruction. - Carbon Monoxide poisoning: **Cherry Red** Skin/**Lips** - **Respiratory Distress:** - Chest burns can restrict chest wall expansion, leading to impaired ventilation. Look for shallow breathing or decreased oxygen saturation. - **Compartment Syndrome:** - Circumferential burns to the chest can act like a tourniquet, causing decreased tissue perfusion and respiratory difficulty. Perform regular assessments for increased respiratory effort or tightness of the chest. **3. How would you adjust fluid resuscitation if urine output remains low after the calculated volume is given?** If urine output remains \