Mr. Garcia has been transferred to ICU
Mr. Garcia has been transferred to ICU and his wife has been notified. She is on her way to the hospital. The following case scenario presents his condition after transfer to ICU. Review the information presented in the case scenario and answer the following reflection questions. You can work together to answer the questions. ICU Scenario: Physician Orders: Transfer to ICU Infuse 500 mL 0.9% Sodium Chloride bolus over 30 min. X 2 and maintain IV at 250 mL/hr. Have arterial and pulmonary artery (with ScVO2 capability) catheters inserted on arrival to ICU. Increase O2 to maintain SaO2 > 93%. Initiate Norepinephrine drip 4 mg/250 mL D5W begin at 4 mcg/min and titrate to keep MAP> 65 mm Hg. Administer Protonix 40 mg IVP QD. Administer Hydrocortisone 100 mg IVP q 12 hour. Sequential devices on both legs. Obtain stat ABGs. Repeat Stat lytes, Bun, Creatinine, Lactate, and Procalcitonin levels once fluid bolus is administered and Norepinephrine drip initiated. The HCP has inserted an arterial line and a pulmonary artery catheter with ScVO2 capability. A bolus of 500 mL 0.9% Sodium Chloride was infused over 30 min. /x 2. Maintenance IV 0.9% Sodium Chloride is infusing at 250 mL/hr. The ICU nurse assesses the patient with the following findings: VS: Temp 35.8 HR 122 BP 88/48 RR 26 Hemodynamics RAP 10 PAP 30/12 PCWP 12 CO 9.5 L/min SVR 500 ScVO2 65% Mr. Garcia moans only to painful stimuli. Cardiac monitor shows sinus tachycardia. S1 and S2 heart sounds auscultated. Bilateral crackles auscultated and breathing is labored. SaO2 88% on 6 L O2 simple mask. Hypoactive bowel sounds. A Foley catheter was inserted to measure I & O. UOP 20 mL since admission to ICU. Urine dark cloudy and foul-smelling. Stat lab and ABG results: WBC 30,000 Hgb 11.8 Hct 32% Na+ 145 K+ 5.5 Cl- 98 BUN 32 Creatinine 3.2 Lactate 5.0 mmol/L Procalcitonin 10 ABGs: pH 7.32, PaCO2 48, PaO2 75, SaO2 90% Reflection Questions: What is the clinical significance of the vital signs and hemodynamic parameters? a.)Calculate Mr. Garcia’s MAP? What is the clinical significance of MAP? 2.) Analyze and interpret the hemodynamic parameters. What is the clinical significance of these parameters? 3. What is the significance of the ScVO2? What three factors influence oxygen delivery? 4. Based on your analysis of the above data which variable is contributing to Mr. Garcia’s low ScVO2? What intervention is indicated? 5. Explain the ABG results. What problem may be contributing to the PaO2/SaO2 and the crackles that are now being auscultated? (Hint: it is not related to volume overload). 6. What is the clinical significance of the Lactate and Procalcitonin levels 7. Based on the current assessment findings, what are the problems the nurse needs to manage? 8. What interventions should the nurse initiate to manage the patient?
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