Discussion Reply
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Details: Please reply to these 2 discussions and provide 2 reference and in-text citation that is from years (2016-2021) for each post reply.
For post 1, reply to the case study questions and support them with 2 current references.
For post 2, including information you thought the first person left out when they replied to the initial post, critiquing their response, or asking additional questions. This second post should be well thought out and bring new information/ or critical thinking to the discussion and support it with 2 current references.
Post 1 (Vera):
Mr. S is a 64-year-old Caucasian male, that was admitted to the critical care unit after emergency surgery for treatment of a perforated bowel. Intraoperatively, he had an estimated blood loss of 300 mL, and he received 2.5 L of crystalloid solution. An arterial line, a central line, and an indwelling urinary catheter were placed while in the surgical unit. Upon admission to the critical care unit, Mr. S is intubated and sedated.
His initial postoperative vital signs and laboratory findings are:
Heart rate: 142 beats/min
Blood pressure: 86/48 mm Hg
Mean arterial pressure: 62 mm Hg.
Respiratory rate: 12 breaths/min
Right atrial pressure: 4 mm Hg
Cardiac Index (CI): 2.5L/min/m2
Temperature: 39.2° C (102.6° F)
Peak inspiratory pressure (PIP): 27 cm H2O
Lactate 1.1 mEq/L
The physician orders a 500-mL infusion of normal saline (NS) 0.9%, repeat of serum lactate level, and replacement of the triple-lumen catheter with a catheter that measures central venous oxygen saturation (SvO2). His nurse administers the fluids and assists with the placement of the SvO2 catheter.
After these interventions, the nurse reassesses vital signs and hemodynamic values, which are noted below:
Heart rate: 116 beats/min
Blood pressure: 98/54 mm Hg
Mean arterial pressure: 66 mm Hg.
Right atrial pressure: 8 mm Hg
Cardiac index (CI): 2.8 L/min/m2
Stroke volume variation (SVV): 12%
SvO2: 59%
Lactate: 3.6 mEq/L
Questions:
1. Discuss the rationale for placing the SvO2 catheter.
2. The patient’s lactate level has increased from 1.1 mEq/L to 3.6 mEq/L. What is the clinical significance of this increase?
3. What is the reasoning for the 500 ml bolus? List the assessment values that prompted the physician to order it?
References
Sole, M. L., Klein, D. G., & Moseley, M. J. (2021). Introduction to critical care nursing (8th edition). St. Louis, MO, MO: Elsevier.
Post 2 (Tabitha):
Excellent creation of own case scenario! it is an interesting patient to develop critical thinking.
To answer your three questions:
1: What is your preliminary diagnosis? Based on your clinical scenario, I would say that the diagnosis would be: ACUTE VIRAL HEPATITIS as evidenced by “distended and there is a diffuse tenderness to palpation with guarding with absent bowel sound, related to alcohol consumption.”
2: What tests should you do perform? The blood cultures that I would perform would include the following: Blood draw showing virus antibodies for hepatitis, prolonged prothrombin time, hyperglobulinemia, elevated alkaline phosphatase, complete CBC with Differential to detect Anemia.
A CT ABD/Pelvis to R/O bile obstruction, EKG to R/O abnormal acute ST or T wave changes, PT/INR, and APTT to R/O prolonged prothrombin time. Alcohol Ethyl: To R/O Hepatic damage secondary to the patient’s history of alcoholism.
3: How should this case be treated? In my opinion, treatment therapy is approached with IV antibiotic therapy, IV fluids such as Sodium Chloride 0.9% for hydration, medication such as Lactulose administered for ammonia detoxicant, Folic acid tablets administered for erythropoiesis increase.
Thiamine tablets administered for pyruvate metabolism. Adequate rest and a balanced low sodium nutritional diet.
Reference
Doenges, M. E., & Moorhouse, M. F. (1992). Application of nursing process and nursing diagnosis: An interactive text. Philadelphia: F.A. Davis
Robbins, S. L., Cotran, R. S., Kumar, V., Abbas, A. K., & Aster, J. C. (2015). Pathologic basis of disease. Philadelphia, PA: Saunders Elsevier.
The original case study that post 2 replied to:
A 48-year-old male presented to the emergency department. with severe abdominal pain and constant vomiting. He has nausea and a dull abdominal ache that turns into severe abdominal pain, which is worsened by any movement. He has been experiencing recurrent burning epigastric pain for the last 3 weeks. The pain lessens after meals but worsens 2-4 hours after each meal. He has a moderate fever. He denied any constipation, chill, urinary symptoms. He has no allergy. He didn’t smoke but reported alcohol consumption occasionally and denied recreational drug use. He has not taken any medication for his symptoms. He rates his pain at 9 out of 10 on the pain scale throughout his abdomen. lung sounds are clear to auscultation with a poor respiratory noted. His vital signs are: T = 38.3 C, P = 118, R = 25, BP = 118/76 mm Hg. The chest and heart examinations are normal. The abdomen is somewhat distended and there is a diffuse tenderness to palpation with guarding. There was no palpable mass and bowel sounds are absent. No herniations are noted. He has had no prior surgeries.
What is your preliminary diagnosis?
What tests should you do perform?
how should this case be treated?
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