Lauren Hill

ANS II Spring 2016

NUR 3112 Multisystem Case Study 2.5%

Emergency Department: John Budd, a 72-year old male arrived in the ED unconscious with multiple stab
wounds to the upper-right abdomen and lower-right chest that were sustained in his home fighting off a burglar.
The paramedics inserted two large-bore IVs and an ETT.
Wounds to
Upper right abdomen
Lower right chest

Surgical Intervention: During surgery, a right thoracotomy and right abdominal laparotomy were performed.
The right chest wound was explored, and a lacerated intercostal artery was ligated. Exploration of his upper-
right abdominal wound revealed more extensive damage. The liver and the duodenum were lacerated. Extensive
hemorrhage and leaking of intestinal contents were apparent after opening the peritoneum. Mr. Budds injuries
were repaired, the peritoneal cavity was irrigated with antibiotic solution, and incisional hemovac drains.
During the 4-hour surgery, Mr. Budd received 6 units of blood and an additional 3L of LR. A PAC and
right radial A-line were inserted.
Right Thoracotomy to look at chest wound
Right abdominal laparotomy to look at abdominal wound
o Extensive hemorrhage/leakage
o Lacerated intercostal aa. (ligated)
o Gross contamination by intestinal contents
o Liver and duodenal laceration
Abdominal cavity irrigated w/antibiotics
Incisional hemovac drains
6 U RBCs
PAC
A-line

Stop and Think (10 points): Why do you think a PAC and A-line were placed in Mr. Budd? What about
his clinical presentation warranted this level of monitoring? What information will these catheters
provide?
A-lines and PACs are invasive lines. They carry the risk of infection, but can also provide important
information and detailed monitoring of patients. The severity of Mr. Budds condition warrants the close
monitoring these lines provide.

The patient most likely received the A-line because of the massive blood loss he has experienced. The
A-line would give the most accurate BP possible, and would do so continuously. This would be valuable data in
the case of Mr. Budd because his hemodynamic stability has been compromised. His blood loss could send him
into hypovolemic shock and ultimately result in his death. Hypovolemia would manifest as low blood pressure
and tachycardia. Additionally the A-line could be used to draw ABGs. In the case of Mr. Budd, ABGs should be
drawn soon.

The PAC was most likely placed for monitoring purposes. It would help determine if Mr. Budd was suffering
from a pump problem or a volume problem, and would offer insight toward:
Pulmonary artery pressure (PAP)
20130318
 Right ventricular pressure
Pulmonary capillary wedge pressure (PAWP)
Right atrial pressure (CVP) PRELOAD (can help determine if Lasix are needed etc.)
Temperature
CO
PA pressure monitoring allows for precise therapeutic manipulation of pre-load. Preload is affected by
venous blood pressure and rate of venous return, which are respectively affected by venous tone, or in the case
of Mr. Budd, volume of circulating blood. Management of preload allows for CO to be controlled and
maintained. It would be important to ensure Mr. Budds CO is adequate so that the rest of his body is being
perfused.

Intensive Care Unit - Immediately After Surgery: Mr. Budd arrived in the ICU intubated and sedated. Vent
settings: A/C, rate=12 FiO2=60%, Peep=5cm, Pressure Support=20cm, VT=500mL

His vital signs and hemodynamic monitoring parameters after surgery indicated that he was critically ill, but
relatively stable. His labs were WNL, except for WBC=13,600/mm3 and Hgb=10 g/dL
BP = 92/52 mmHg (Hypovolemia)

HR = 114 bpm (Elevated)

Respirations = 12/12 breaths/minute (The vent is giving 12 and Mr. Budd is breathing 12)

Temperature = 36.2C (Low)

PAP = 20/8 mmHg (Adequate)

PAWP = 6 mmHg (Measure of pulmonary capillary pressure/ left ventricular end diastolic pressure.

Normal is (6-12).

o PAD & PAWP are sensitive indicators of cardiac function and fluid volume status

o These levels increase in HF and fluid volume overload

Levels decrease with volume depletion

Fluid replacement therapy is often given based on PA pressure

CVP = 4 mmHg Direct measure of right ventricular preload. Normal is (2-8)

CO = 5 L/min adequate (4-8L is normal)

CI = 2.9 L/min/m2 Adequate. (2.5-4 l/min/m2)

SVR = 1040 dynes/sec/cm-5 Adequate. Normal (800-1200)

20130318
Intensive Care Unit - POD 1: Mr. Budd remained drowsy and received ventilator support for 24 hours. His
pain was controlled by IV morphine sulfate. The NGT continued to drain large amounts of green fluid, and an
incisional hemovac drain drained large amounts of greenish brown fluid. His right chest and abdominal
dressings remained dry. Breath sounds were diminished on the right side but clear on the left. His chest tubes
continue to drain small amounts of bloody fluid. Urine output was 40-60 mL/hr. His abdomen was slightly firm
and distended, but he had no bowel sounds.

Stop and Think (10 points): What are the risk factors for infection and development of septic shock?
**Identify those that applied to Mr. Budd.
Patients at risk for septic shock include older adults, patients with chronic diseases or persons who have
experienced trauma, patients receiving immunosuppressive therapy, and patients who are malnourished or
debilitated. Mr. Budd is at risk because of his:
Age
A penetrating chest and abdominal wounds that he has suffered
o The resulting exposure of abdominal cavity and blood to fecal contents
His surgery
The presence of an A-line, PAC, foley, and EET
Antibiotic flushing
Blood administration, as blood products are immunosuppressants.

Intensive Care Unit - POD 2: Mr. Budds condition remained stable until his second postoperative day. At this
time he became difficult to arouse, but did respond to commands. His respirations were 28 breaths/minute,
shallow, and labored. His urine output dropped to 20 mL/hr. His skin became warm, dry, and flushed.

Change in LOC get a blood gas right away

BP = 80/50 mmHg shock

HR = 132 bpm shock

Respirations = 28 breaths/minute shock

Temperature = 38C fever

PAP = 14/7 mmHg low

PAWP = 4 mmHg low

CVP = 2 mmHg low

CO = 8 L/min adequate

CI = 4.7 L/min/m2 high

20130318
 SVR = 560 dynes/sec/cm-5 very low. The resistance offered by peripheral circulation. Low because of

fluid volume loss = floppy, loss of tone

WBCs = 22,000/mm3 Infection. Very high

Glucose = 270 mg/dL elevated from physiologic stress

Stop and Think (20 points): What is happening to Mr. Budd? How do you explain his laboratory values
and hemodynamic changes (be specific and address each parameter that is abnormal)?

Mr. Budd presentation is evocative of septic shock. His skin is warm, dry, and flushed, most likely due
to his hyperdynamic state. His urine output has decreased to and inadequate 20 mL/hr. Prolonged hypotension is
the most likely culprit. Inadequate blood pressure deprives the delicate kidneys of adequate blood flow. As
shock progresses, the brain suffers from the same problem.

Mr. Budd was difficult to arouse. This change in his level of consciousness is probably due to inadequate
perfusion to the brain, sepsis and elevated C02. His low BP of 80/50 is one of the classic signs of shock, and
occurs because of decreased CO and a narrowing pulse pressure. His increased HR of 132 bpm is likely a
compensatory mechanism by the SNS. The SNS raises heart rate in an attempt to perfuse the body and respond
to increase oxygen demand. Mr. Budds rapid respiratory rate is most likely the result of a similar compensatory
response. The body is trying to combat the loss of blood and resulting hypoxia to meet the increased need to
oxygen.

LOC changes: probably due to sepsis, and elevated C02 from hyperventilation
BP: Hypovolemia from blood loss. Hes going into shock as indicated by
HR 132
BP 80/50
RR 28
WBC: Mr. Budd has an infection as indicated by WBC count and elevated temperature
PAP& PAWP: volume depletion is causing a decrease in these levels. It is possible Mr. Budd is currently
bleeding and continuing to loose volume. These levels are sensitive indicators of cardiac function and fluid
volume status, both of which are declining.

CVP: CVP of 2 is low. Preload or right atrial pressure would be low with continued volume loss

SVR of 560: Systemic vascular resistance (offered by peripheral circulation). A low level is most likely the
result of continued volume loss and hypovolemia.
Persistently high CO and low SVR is not a good sign.

BG: likely elevated due to physiologic stress placed on the body by the assault

Culture and sensitivity reports form wound drainage indicated gram-negative bacilli. Appropriate IV
antibiotics were administered, as well as IV hydrocortisone and naloxone (Narcan). A pharmacy consultation to
formulate and calculate nutritional needs was done, and TPN was started. His LR IVF rate was increased to
150 mL/hr, and dopamine at 5 mcg/kg/min was started (concentration of 400mg/250mL of D5; dry weight =
85kg).
20130318
Stop and Think (20 points): What is the rationale for each of the following therapeutic modalities ordered
for Mr. Budd: Blood culture and sensitivity, IV rate increased, use of LR, ATB administration, dopamine,
steroids, naloxone (Narcan) administration, and TPN?

The blood culture and sensitivity was ordered because the patients WBC and temperature are indicative of
infection. This test would determine if bacteria are present in the blood, and if so, the type of bacteria.
Identifying the bacteria as gram positive or gram-negative, would help health care providers to select the correct
and most effective medication to treat the patient.

Mr. Budds IV flow rate would have been increased because of his SVR, PAP, PAWP, and low BP. These levels
are low from fluid volume loss and the resulting shock. Increasing the patients volume could potentially
increase the patients preload, CO, SVR, BP and perfusion status. Patients in septic shock require large amounts
of fluid replacement. Replacement therapy or fluid resuscitation could restore the intravascular volume deficit
he has experienced and increase perfusion to his vital organs.

LR would be appropriate for the initial replacement because it is isotonic and would primarily remain in the
intravascular space, increasing Mr. Budds intravascular volume.

ATB administration should be started within the first hour; broad spectrum antibiotics can be given initially,
followed by antibiotics that are more specific once the organism has been identified.
IV antibiotics would be given to try to combat the infection that has set in as indicated by the patients WBC

Dopamine in a low dose might help improve Mr. Budds renal perfusion and urine output. Prolonged
hypotension would lead to renal insufficiency due to inadequate perfusion. I would question the use of
dopamine however because of the patients heart rate. I would consider asking the physician for Levophed
instead, another vasopressor. Dopamine or Levophed would increase the patients SVR and blood pressure.
The goal of either vasopressor is to achieve and maintain a MAP of greater than 65 mm Hg.

IV Hydrocortisone: the patient might be experiencing relative adrenal insufficiency from his ordeal. Giving a
steroid might increase cortisol levels in his blood and raise his blood pressure.

Naloxone: may have been given as a reversal agent for the morphine sulfate he received earlier. Giving
naloxone to reverse opioid administration might also raise the patients blood pressure, as opioids can lower
blood pressure.

TPN: TPN would be given vs. a feeding tube because Mr. Budd has laceration to his intestines and an
abdominal wound that might affect nutrient intake. His wounds would probably disqualify him from receiving
tube feedings. TPN would go directly into Mr. Budds blood stream to offer him the nutrients he needs.

Calculate the rate and volume for the dopamine infusion please show your work (round to the tenth).

(5(85)(60))/ ((400,000/250)) =25,500/1,600 =15.9 mL/hr

Volume: 250 mL

20130318
Intensive Care Unit - POD 6: By the sixth postoperative day, Mr. Budds condition has deteriorated
dramatically. His skin was cool, mottled, and moist. His sclera was yellow-tinged. He no longer responded to
stimuli and required re-intubation (A/C with previous ventilator settings). A norepinephrine (Levophed) drip
infused at 6 mcg/min (concentration 8mg/250mL of D5W).

Stop and Think (5 points): Calculate the rate and volume for the Levophed infusion please show your
work.

((6)(60)) / ((8,000)/(25)) = (360/32) =11.3 mL/hr

Volume: 250 mL

This was the 6-second/Lead II EKG tracing for Mr. Budd.

Stop and Think (5 points): Analyze this rhythm: Sinus Tachycardia

Regular/Irregular: Regular Rate: 140 bpm

P-Waves Present? Yes

Interpretation: Sinus Tachycardia

A 12-lead EKG shows significant ST elevation. What is the significance of this ST elevation?
ST elevation is typical the result of ischemia, injury, or infarction. Myocardial injury represents a
worsening stage of ischemia that may evolve to infarction. ST segment elevation is significant if it is greater
than or equal to 1mm above the isoelectric line. If addressed quickly, the injury and ischemia can be reversed.
The absence of serum cardiac markers confirms this. The presence of serum cardiac markers confirms an
infarction. Myocardial dysfunction is a clinical presentation of septic shock.

Mr. Budd received a 150 mg bolus of IV amiodarone over 20 minutes, followed by a continuous infusion of
amiodarone. His breath sounds revealed crackles throughout his chest. Urinary output was only 3-5 mL/hr and
was grossly bloody/tea-colored with sediment. His abdomen was enlarged and firm. His duodenal hemovac and
NGT began to drain bloody drainage. His IV sites all began to ooze blood.

Hemodynamics
BP = 70/52 mmHg (with Levophed and dopamine running)

o Cardiogenic Shock (low CO and high PAP)

o Heart Failure

o Troponin? BNP?

20130318
 HR = 140 bpm Very tachycardic

Respirations = 14/14 breaths/minute vent is giving 14 and patient is breathing 14

Temperature = 35.8C cold. Septic shock

PAP = 44/26 mmHg HF

PAWP = 24 mmHg

CVP = 8 mmHg

CO = 2 L/min VERY insufficient

CI = 1.1 L/min/m2

SVR = 2000 dynes/sec/cm-5 High

20130318
 Other Laboratory Values Stop and Think (20 points): Interpretation
ABG The patient is currently experiencing hypoxemia as indicated by his Pa02
pH = 7.14 level. His blood gases indicate both respiratory and metabolic acidosis, and a
PaO2 = 68 complete lack of compensation on the part of the body. The acidic state his
PCO2 = 49 metabolic and respiratory systems have reached are too much for
compensatory mechanisms that exist.
HCO3 = 12
SaO2 = 85%
Lactic Acid = 8 mmol/L This level is high indicating poor perfusion. High lactic acid levels are seen
in septic shock and prolonged periods of hypoxia. Elevated lactic acid levels
are also indicative on impending death if not corrected.
Na+ = 152 mmol/L Elevated sodium levels often occur during the initial onset of shock as the
K+ = 5.9 mmol/L bodys RAAS system is initiated in an attempt to raise blood pressure.
Mr. Budds potassium level is likely elevated because of his acidotic state.
Extreme acidosis can initiate acute renal injury and failure. The acidosis and
hypoxemia over time would lyse his cells. Intracellular material, which
includes potassium would pollute the blood and elevate serum potassium.
Creatinine = 3.4 mg/dL Creatinine is the most sensitive indicator of kidney injury or some sort. The
patients prolonged hypotension would have damaged the delicate
microcirculation of his kidneys causing insufficient blood flow and damage.

Platelets = 75,000/mm3
PT = 22 seconds
PTT = 98.5 seconds
Fibrinogen = 130 mg/dL
The patients platelets are low and his PT and PTT are elevated.
Increased clotting time indicates liver failure. It is possible that Mr. Budd
developed DIC from his massive blood loss and state of shock. His massive
blood loss may depleted his platelets and he may have exhausted his clotting
factors in a desperate effort by his body to control bleeding after his attack.

CK-MB = 640 U/L Cardiac markers indicate cardiac injury from and MI or extreme stress on the
Troponin I = >50 heart.

ALT = 100 U/L Hepatic, colon, and pancreatic injury are indicated by these levels.
AST = 82 U/L ALT and AST levels probably indicate liver failure or at the least, injury. His
Amylase = 290 U/L elevated amylase and lipase levels are release by the pancreas and colon.
Lipase = 190 U/L

Intensive Care Unit - POD 8: Mr. Budds condition continued to deteriorate and his EKG displayed the
following rhythm (6-second tracing/Lead II):

Stop and Think (5 points): Analyze this rhythm

Regular/Irregular: Irregular

20130318
Rate: By nature, Ventricular Fibrilation is disorganized to the point that rate can not be determined

P-Waves Present? No Interpretation: VFIB

What would you expect to be the treatment for this rhythm?

Immediate defibrillation and administer Amiodarone.

Final Developments: Resuscitation attempts were ultimately unsuccessful for Mr. Budd and he died on POD 8.
An autopsy revealed several small abscessed areas in the lung, acute hepatic failure, multiple hemorrhagic
areas, and an acute myocardial infarction.

Stop and Think (3 points): Please reflect on the case study thoughts, feelings, fears, identify things that
could have been done differentlyHow would you have practiced loving kindness with Mr. Budd?

There were a plethora of warning signs showing the progression of infection and shock in Mr. Budd.
According to Lewis, the successful management of shock is dependent on early recognition and treatment of
signs and symptoms. Prompt intervention in the early stages of shock could have prevented Mr. Budds decline
and ultimate demise. I found this case study very challenging, but working out the situation helped me
understand the progression of shock symptoms and the immense responsibility that nurses have. As nurses we
must remain hyper vigilant and also apply critical thinking when working with acutely ill patients. It is truly a
matter of life and death for the patient.

References

Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. (2011). Medical-surgical nursing:

Assessment and management of clinical problems (8th ed.). St. Louis, MO: Elsevier, Mosby.

Nursing 2016 drug handbook (36th ed.). (2016). Philadelphia, PA: Wolters Kluwer.

Pagana, K. D. & Pagana, T. J. (2014). Mosbys manual of diagnostic and laboratory tests (5th ed.). St. Louis,

MO: Mosby.
20130318
20130318