Question

Brief Patient History

Mr. Z is a 38-year old Hispanic construction worker who sustained a liver laceration after falling from a roof. He acquired an exploratory laparotomy for splenectomy and repair of the liver laceration 4 days earlier. His medical history reveals no chronic health problems, although he smokes 20 packs of cigarettes per year.

Clinical Assessment

Mr. Z is admitted to the medical intensive care unit from the telemetry unit with acute respiratory insufficiency and hypotension. He is using his accessory muscles to breather. He is speaking Spanish. Mr. Z’s abdomen is distended, and there are no bowel sounds. Small amounts of dark green drainage are visible in the nasogastric tube. There is no sign of redness or drainage around his surgical wound.

Diagnostic Procedures

Vital signs were as follows: blood pressure of 78/55mmHg, heart rate of 142 beats/min (sinus tachycardia), respiratory rate of 35 breaths/min, temperature of 103.1°F, and urine output of 20mL over the past 8 hours. ABG values on a 100% non-breather mask were as follows: pH of 7.22, PaO2 of 54mmHg, PaCO2 of 69mmHg, HCO3 ¯level of 10mEq/L and O2 saturation of 88%. The chest radiograph revealed infiltrates in the right lower lobes. Laboratory data revealed a hemoglobin level of 9.8g/dL, hematocrit of 25%, and WBC count of 18,000/mm3.

Medical Diagnosis

Mr. Z is diagnosed with severe sepsis.

Questions

1. What major outcomes do you expect to achieve for this patient?
2. What problems or risks must be managed to achieve these outcomes?
3. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?
4. What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?
5. What possible learning needs do you anticipate for this patient?
6. What cultural and age-related factors may have a bearing on the patient’s plan of care?

Answer 1

1. What major outcomes do you expect to achieve for this patient?

Hemodynamic stability

          Vital signs within normal range

          Fluid balance

Elimination of infection

Wound healing

Improve urine output

Improve knowledge

2. What problems or risks must be managed to achieve these outcomes?

Liver laceration

Shock: hemodynamic instability- hypotension, fluid – electrolyte imbalance,

The absence of bowel sounds and abdominal distention

Surgical Wound

Unstable vital signs

3. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?

Monitor:

Patient assessment: frequent observation and monitoring

Effective assessment of the patient to identify the exact status

    CVP

    Vital Signs

    ABG analysis

    Pulse Oximetry

    Blood studies

Prevent

Fall prevention

Maintain aseptic technique

Judicial assessment of the patient

Manage :

Antibiotics

Fluid therapy: colloids and crystalloids

Oxygen therapy

CVP monitoring

Vasopressors to maintain MAP, if MAP less than 65 mm of HG

RBC transfusion to maintain hematocrit value above 30%

Dobutamine to maintain SvO2 above 70%

Mechanical ventilation and sedatives

Eliminate:

Careful assessment and management

4. What interventions should be initiated to promote optimal functioning, safety, and well-being of the patient?

Cautious monitoring

Effective management

Meet the needs: physical and psychosocial

5. What possible learning needs do you anticipate for this patient?

Fall prevention

Wound care

Infection control

Maintain nutrition

6. What cultural and age-related factors may have a bearing on the patient’s plan of care?

Consider the ethnicity as the patient is Spanish

Overcome the language barriers

Plan the acre based on patient’s ethnic preferences

As the patient is a young, maintain optimal activity