Question

Carmen Costa is a 67-year-old female with Type I Diabetes admitted on Sunday for severe abdominal discomfort. On admission her vital signs were: BP 116/80, heart rate 86, respirations 20, temperature 98.4. Her blood sugar (BS) was 115 and her initial lab work was WNL. Carmen's x-rays revealed an abdominal mass and she was scheduled for an exploratory laparotomy on Monday. During surgery, Carmen was diagnosed with a cancerous tumor. The tumor was removed and Carmen was taken to a medical/surgical unit. Postoperatively Carmen had an IV of 1,000 mL D5W infusing at 50 mL/hr, an NG to intermittent suction, a Foley draining clear amber urine, and a midline abdominal dressing that was dry/intact (D/I). You are assigned to care for Carmen on her first Post-op (POD). Carmen is alert/oriented and her color is gray/pale. Her morning accucheck is 210 and she receives 8 units of regular insulin. Carmen's NG is draining brown/green mucous, her abdominal dressing is D/I, and she has an IV of D5W at 50 mL/hr. Carmen has very limited conversation this morning but states, "I'm very tired and sick to my stomach."

Later:

The physician ordered Carmen to be out of bed three times a day starting today. At 1000, you give Carmen a complete bed bath and then decide to ambulate her to the chair per order while you change her sheets. While sitting at the bedside Carmen states, "I don't feel very well." After waiting 30 seconds, you decide to get Carmen in the chair. While in the chair, her color becomes more pale and her skin is diaphoretic. Her BP is 88/64, and her abdominal dressing has a 3x3 area of sanguinous drainage.

New Data:

The second POD Carmen has ambulated to the chair 3 times, her BP remains approximately 94/56 all day, blood sugars in the 200's with each accucheck, and her abdominal dressing remains dry and intact (D/I). By 1630 that evening, Carmen complains of nausea. At 1700 her sensorium began changing and her pulse oximeter was 88% with O2 at 2L/nasal cannula. At 1830, the family found the patient dangling at the bedside, restless and trying to gag herself to vomit. Her NG was draining dark brown/black aspirate, her accucheck was 232, P 133 and irregular. At 1845, Carmen was found thrashing in her bed. Her daughter runs to find you. At 1850, you find Carmen unconscious with Cheyne Stokes respirations, P 67, BP 60 systolic. ABGs were drawn at 1908 with the results: pH 7.13, HCO3 19.8, O2 sat 18.4%, PaCO2, 59.5, PaO2 18.8. At 1910: P 107, BP 40 palpable.

Lab values from first POD: Lab values at 1908, second POD:

RBC: 4.3 RBC: 3.29

Hgb: 11.5 Hgb: 6.8

Hct: 28.8 Hct: 23.3

K: 4.35 K: 6.9

Na: 134 Na: 134.4

CO2: 26.1 CO2: 12.7

Glucose: 354 Glucose: 383

BUN: 5 BUN: 8

Cr: 0.8 Cr: 1.1

1. What collaborative management strategies need to be initiated to manage shock, respiratory and cardiac changes, and blood sugar? What other disciplines need to be involved?

Answer 1

Management by a rapid response team is needed for her to mmanage the emergency

ventillator support and fliud management should include in the treatment srategy.

Since her hempglobin is low blood transfusion is required.

Strategies to manage the hyperkalemia is important.

Administer the drug such as theophylline and acetazolamide to treat chyne stroke respiration carefully as per the doctors advice.

continous and close monitoring of vital signs

monitor the intake out put chart correctly

The other discipline need to be involved in her care are the critical care team,cardiologist,endocrinologist,pulmonologist,respiratory therapist,physiotherapist