Question

NAME: Carol Reece

AGE:     77 years old

DOB:     July 11, 1942

WEIGHT:   160 pounds (73kg)

HEIGHT: 61 inches (155cm)

Past Medical History: HTN, DM II, sore on the right heel that had progressed to a Grade 4 decubitus ulcer

She lives in a high rise public housing complex for elderly residents. The housing complex has a reputation for poor sanitation. Ms. Reece has a home health aide who visits once a week and a wound nurse who visits once weekly as well.

Home health aide called 9-1-1 when she arrived to find Ms. Reece in bed covered in vomit and a weak thready pulse.

She arrives via basic life support (emergency medical technician) ambulance with only oxygen in place.

1. From the provided information, what are your concerns?

2. What orders do you anticipate for this client?

3. What supplies do you anticipate you will need to care for this client?

Carol Reece

DOB: July 11, 1942

MR: 45928412 - CR

• Aspirin 81mg PO per day
• Metformin XR 2000mg PO once per day in morning
• Metoprolol 20mg PO per day
• HCTZ 25 mg PO per day in the morning
• Lisinopril 20 mg PO once per day in the evening
• Normal Saline 1000ml IV bolus now
• Normal Saline 250ml/hr IV after bolus

Order Set

• 2 Large bore peripheral IVs (Both already started)
• Assess breath sounds every 10 minutes
• Vital signs every 5 minutes
• 12 Lead EKG STAT
• Continuous EKG monitoring
• Oxygen at level to maintain SpO2 of >95%
• LABS: CBC with diff, CMP, lactic acid, Blood Culture x2, troponin, CRP (Already drawn and sent to lab)

Simulation #1 Information and Questions:

The client is severely confused and does not answer questions appropriately.

1. What ESI Level would you triage this patient as? Why?

2. What is your priority assessment?

3. What are your priority interventions?

4. What labs do you anticipate the physician will order?

Simulation #1   Post-Simulation Questions:

Lab Values: Lactic Acid 5.6, WBC 34

1. What are the phases of shock? What phase do you think this patient is in? Why?

2. What are the signs/symptoms of sepsis?

3. What does the elevated lactic acid level indicate?

4. You assess the patient’s urine output and measure 10ml/hr. How would you define this level of urine output? What would be your priority action?

5. During your assessment you also note that your patient is experiencing hypovolemic shock. What interventions would be appropriate?

NAME: Carol Reece

AGE:     77 years old

DOB:     July 11, 1942

WEIGHT:   160 pounds (73kg)

HEIGHT: 61 inches (155cm)

Past Medical History: HTN, DM II, sore on the right heel that had progressed to a Grade 4 decubitus ulcer

She lives in a high rise public housing complex for elderly residents. The housing complex has a reputation for poor sanitation. Ms. Reece has a home health aide who visits once a week and a wound nurse who visits once weekly as well.

Home health aide called 9-1-1 when she arrived to find Ms. Reece in bed covered in vomit and a weak thready pulse.

She arrives via basic life support (emergency medical technician) ambulance with only oxygen in place.

1. From the provided information, what are your concerns?

2. What orders do you anticipate for this client?

3. What supplies do you anticipate you will need to care for this client?

Carol Reece

DOB: July 11, 1942

MR: 45928412 - CR

• Aspirin 81mg PO per day
• Metformin XR 2000mg PO once per day in morning
• Metoprolol 20mg PO per day
• HCTZ 25 mg PO per day in the morning
• Lisinopril 20 mg PO once per day in the evening
• Normal Saline 1000ml IV bolus now
• Normal Saline 250ml/hr IV after bolus

Order Set

• 2 Large bore peripheral IVs (Both already started)
• Assess breath sounds every 10 minutes
• Vital signs every 5 minutes
• 12 Lead EKG STAT
• Continuous EKG monitoring
• Oxygen at level to maintain SpO2 of >95%
• LABS: CBC with diff, CMP, lactic acid, Blood Culture x2, troponin, CRP (Already drawn and sent to lab)

Simulation #1 Information and Questions:

The client is severely confused and does not answer questions appropriately.

1. What ESI Level would you triage this patient as? Why?

2. What is your priority assessment?

3. What are your priority interventions?

4. What labs do you anticipate the physician will order?

Simulation #1   Post-Simulation Questions:

Lab Values: Lactic Acid 5.6, WBC 34

1. What are the phases of shock? What phase do you think this patient is in? Why?

2. What are the signs/symptoms of sepsis?

3. What does the elevated lactic acid level indicate?

4. You assess the patient’s urine output and measure 10ml/hr. How would you define this level of urine output? What would be your priority action?

5. During your assessment you also note that your patient is experiencing hypovolemic shock. What interventions would be appropriate?

Answer 1

From the provided information, it is assessed that the patient is undergone cardiogenic shock. The patient is in ESI level 1, and need urgent care and attention. She was taken to the emergency room and the doctor would have to

* Administer oxygen as prescribed

* Prepare for intubation and mechanical ventilation

* Administer diuretics and nitrates as prescribed while monitoring BP constantly

* Monitor arterial blood gas level and prepare to treat imbalances

* Monitor urinary output

* Administer morphine sulfate intravenously as prescribed to decrease pulmonary congestion and relieve pain.

Phases of Shock

Shock is defined as failure of the circulatory system to maintain adequate perfusion of vital signs. Shock is commonly divided into three major classifications...

** Hypovolemic

** Cardiogenic

** Distributive is again divided into three

Anaphlyatic shock

Neurogenic shock

Septic shock

Hypovolemic shock is due to inadequate circulating blood volume resulting hemorrhage with actual blood loss, burns with loss of fluid volume.

Cardiogenic shock is due to inadequate pumping action of the heart because of primary cardiac muscles dysfunction.

Distributive shock also called vasogenic shock is due to changes in blood vessel tone that increase the size of the vascular space without as an increase in the circulating blood volume.

Signs and symptoms of Sepsis

* Fever

* Difficulty in breathing

* Low blood pressure

* Fast heart rate

* Mental confusion

* Chills

* Dizziness

* Fatigue

* Insufficient urine production

* Skin discoloration

Lactic acid value 5. 6 shows an elevated value. A level greater than 4mmol/l defines lactic acidosis,a level high enough to tip the acid base balance which may result in a Serum pH <7.35 in association with metabolic acidosis.

The given urine output level shows the patient is anuria, which occurs when the kidneys are not producing urine. A decrease of urination can complicate any underlying health problems. It may even become life threatening.

Anuria can be treated with dialysis, uretral stents or kidney transplant.