Mr J. is a 44 year-old man with no previous medical history
presents to the emergency department with a chief complaint of
severe abdominal pain, fever, and chills. He is subsequently
admitted to the critical care unit after an open exploratory
laparotomy where it was found that he had a perforated appendix and
diffuse peritonitis. Intraoperatively he had an estimated
blood loss of 350 mL and he received 1 Liter of crystalloid
solution in the OR. He arrives at the critical care unit
intubated and sedated with a right radial arterial line, a
five-lumen pulmonary artery catheter, and an indwelling urinary
catheter in place.
CASE SCENARIO QUESTIONS:
1.The charge nurse and CCU nurse
receiving the patient from the OR team had just finished getting
the patient settled. The CCU nurse performs her admission
assessment and documenting vital signs and pressure. Before she
records his arterial, pulmonary artery pressure and right atrial
pressure readings, what should she do first?
Why?
2.Right after recording the PAOP, what
is most important nursing action to prevent complications of an
indwelling PA line?
3.The cardiologist asks the CCU nurse
to obtain and give him current CVP reading for Mr. J. Which
port on the PA line will the nurse need to access in order to
obtain these readings? What does the CVP reading
measures?
4.The RAP is reading 1 mmHg. What
does this mean? What may have caused this? What nursing
interventions do you expect Mr. J needs?
5.The night CCU nurse is now performing
her beginning of the shift assessment. She zeroes her
arterial and PA line via the transducer to phlebostatic axis.
What level does the stopcock needs to be positioned in relation to
the patient in order for the pressure readings to be
accurate? What pressure reading on the monitor indicates
successful zeroing?
6.What is important for the CCU nurse
to include in the documentation of Mr. J’s pressure lines? What
nursing interventions should be included during routine assessment
of patient in regards to pressure lines? What are the
complications of PA and arterial lines?
7.Since Mr. J is being weaned off
mechanical ventilation, the cardiologist has ordered follow-up ABG
to evaluate his tolerance to the weaning parameters. What
line will the nurse need to access to obtain the ABG
readings?
8. It is 4 hours post-op and Mr.
J’s current BP is 82/53, and HR 119. The nurse noticed that
his blood pressure has dropped from earlier reading of 95/65 mmHg
and heart rate increased from 110 bpm. Mr. J’s urine output
for past 4 hours has been approximately 20mL/hr. The
intensivist orders for the nurse to administer a 1000mL NS bolus
and start Dopamine drip to keep BP WNL. Which pressure line
is required for patients on vasopressor drips?
9.One hour after IV NS bolus given and
Dopamine drip started, Mr. J’s BP is now 105/68 mmHg and HR is 108
bpm with urine output of 30mL/hr. However, nurse noticed on
reassessment that patient still requires high FiO2 concentration to
keep his SaO2 >95%. The nurse documents his SvO2 which is
57% and pale skin color. Is the SvO2 reading normal and what
does it measure compared to SaO2? What may be a contributing
factor to this reading? What should the nurse expect the
patient needs? What labs will need to be
obtained?
10.After the blood transfusion, the
nurse is documenting current vital signs and pressure
readings. She notices the PAP suddenly dropped and performed
a dynamic response test. What abnormal response could the
nurse expect to observe on the monitor? What nursing
interventions may be done to troubleshoot?
11.The CCU nurse found the tubing to be
kinked in multiple areas along the pressure tubing. After
straigtening the tubing, a dynamic response test was done and is
normal. The nurse then zeroes the transducer/stopcock to
phlebostatic axis. She inflated the balloon of the PA line to
obtain the PAOP but was met with resistance after 1 mL of air is
injected. Is this normal? What is the next nursing
action? What may have caused this?
.