NUR 3112 Multisystem Case Study 2.

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Jeanne Indelicato, Stephanie Lester, Mary Patton
Emergency Department: John Budd, a 72-year old male arrived in the ED unconscious with multiple stab
wounds to the upper-right abdomen and lower-right chest that were sustained in his home fighting off a burglar.
The paramedics inserted two large-bore IVs and an ETT.
Surgical Intervention: During surgery, a right thoracotomy and right abdominal laparotomy were
performed. The right chest wound was explored, and a lacerated intercostal artery was ligated. Exploration of
his upper-right abdominal wound revealed more extensive damage. The liver and the duodenum were lacerated.
Extensive hemorrhage and leaking of intestinal contents were apparent after opening the peritoneum. Mr.
Budds injuries were repaired, the peritoneal cavity was irrigated with antibiotic solution, and incisional
hemovac drains.
During the 4-hour surgery, Mr. Budd received 6 units of blood and an additional 3L of LR. A PAC and
right radial A-line were inserted.
Stop and Think (10 points): Why do you think a PAC and A-line were placed in Mr. Budd?
What about his clinical presentation warranted this level of monitoring? What
information will these catheters provide?
A pulmonary artery flow-directed catheter (PAC) can be indicated for major trauma, which Mr. Budd
had. It can also be used for perioperative fluid imbalance in high-risk patients as well as severe shock states
which Mr. Budd could qualify as he had extensive hemorrhage and leaking of intestinal contents into the
peritoneum as well as fluid imbalance as he needed 6 units of blood and 3L of LR perioperatively. PAC
measures pulmonary artery pressure, which can indicate cardiac function and fluid volume status. Fluid
therapy based on PA pressure can restore fluid balance while avoiding overcorrection or undercorrection of the
problem, without placing the patient as risk for pulmonary edema. (Lewis, 2011. pg.1689-1690)
An arterial line (A-line) placement could be used to measure more accurate blood pressure for critically
ill patient as well as collecting ABGs. Continuous arterial BP monitoring is indicated for patients in many
situations, including shock such as Mr. Budd could potentially be suffering. With Mr. Budds deteriorating
condition frequent ABG checks will be needed in order to assess perfusion and oxygenation. (Lewis, 2011.
pg.1688)
Intensive Care Unit - Immediately After Surgery: Mr. Budd arrived in the ICU intubated and sedated.
Vent settings: A/C, rate=12 FiO2=60%, Peep=5cm, Pressure Support=20cm, VT=500mL
His vital signs and hemodynamic monitoring parameters after surgery indicated that he was critically ill, but
relatively stable. His labs were WNL, except for WBC=13,600/mm3 and Hgb=10 g/dL
BP = 92/52 mmHg
HR = 114 bpm
Respirations = 12/12 breaths/minute
Temperature = 36.2C
PAP = 20/8 mmHg
PAWP = 6 mmHg
CVP = 4 mmHg
CO = 5 L/min
CI = 2.9 L/min/m2
SVR = 1040 dynes/sec/cm-5

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Intensive Care Unit - POD 1: Mr. Budd remained drowsy and received ventilator support for 24 hours. His
pain was controlled by IV morphine sulfate. The NGT continued to drain large amounts of green fluid, and an
incisional hemovac drain drained large amounts of greenish brown fluid. His right chest and abdominal
dressings remained dry. Breath sounds were diminished on the right side but clear on the left. His chest tubes
continue to drain small amounts of bloody fluid. Urine output was 40-60 mL/hr. His abdomen was slightly firm
and distended, but he had no bowel sounds.
Stop and Think (10 points): What are the risk factors for infection and development of
septic shock? **Identify those that applied to Mr. Budd. (underlined)
Extremes of age
Immunosuppression
Prior antibiotic therapy
Severe burn, trauma, recent surgical procedure, invasive procedures
Malnutrition, TPN
Alcohol, other misused drugs
Prolonged ICU stay: ETT, VAP
Chronic illness- DM, CRF, hepatitis
(Lewis, 2011. pg. 1718)
Septic shock is the presence of sepsis with hypotension despite fluid resuscitation along with presence of
inadequate tissue perfusion. (Lewis, 2011. pg.1723) Mr. Budds BP is 92/52 he also lost a lot of blood through
the trauma and in surgery and needed 6 units of blood and 3 liters of fluid, he was and still could be
hypovolemic which can cause inadequate tissue perfusion.
Intensive Care Unit - POD 2: Mr. Budds condition remained stable until his second postoperative day. At
this time he became difficult to arouse, but did respond to commands. His respirations were 28 breaths/minute,
shallow, and labored. His urine output dropped to 20 mL/hr. His skin became warm, dry, and flushed.

BP = 80/50 mmHg
HR = 132 bpm
Respirations = 28 breaths/minute
Temperature = 38C
PAP = 14/7 mmHg
PAWP = 4 mmHg
CVP = 2 mmHg
CO = 8 L/min
CI = 4.7 L/min/m2
SVR = 560 dynes/sec/cm-5
WBCs = 22,000/mm3
Glucose = 270 mg/dL

Stop and Think (20 points): What is happening to Mr. Budd? How do you explain his
laboratory values and hemodynamic changes (be specific and address each parameter
that is abnormal)?
Mr. Budd is developing early septic shock
He has an altered mental status, as he is now difficult to arouse.
He has become tachypenic with respirations at 28 breaths/minute, shallow and labored.
His urine output has decreased to 20 mL/hr, which is below adequate output.
His skin is now warm, dry and flushed, indicating a possible fever and/or infection due to hyperdynamic state.
His blood pressure is decreasing, from 92/52 POD 1 to 80/50 POD 2. One of the classic signs of shock is a drop
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in blood pressure, this occurs because the decrease in CO and narrowing of pulse pressure.
His heart rate is tachycardic, at 132 bpm. this is also one of the first signs of shock.
His temperature has elevated to 100.4, indicating a possible infection.
PAP (pulmonary artery pressure) is decreased at 14/7, indicating hypovolemia.
PAWP is decreased at 4, normal range is 6-12. PAWP reflects left ventricle end-diastolic pressure, which is the
volume of blood within the ventricle at the end of diastole.
CVP is right ventricular preload. Mr. Budds is WNL.
CO(cardiac output) is WNL.
CI (cardiac index) is elevated at 4.7 which is a better indicator of cardiac output, adjusted for patients
weight. This means that Mr. Budds heart is trying to pump more blood throughout the body, indicating
decreased contractility and tissue perfusion.
SVR is systemic vascular resistance. This measures afterload. Mr. Budds SVR is 560, and decreased. Therefore
there is a decreased amount of blood being pumped to the body.
His WBC is now 22,000, indicating an infection.
He is hyperglycemic without diabetes, with a glucose of 270.
All of the above are diagnostic criteria for sepsis.
(Lewis, 2011. pg.1685-1691)
Culture and sensitivity reports from wound drainage indicated gram-negative bacilli. Appropriate IV
antibiotics were administered, as well as IV hydrocortisone and naloxone (Narcan). A pharmacy consultation to
formulate and calculate nutritional needs was done, and TPN was started. His LR IVF rate was increased to
150 mL/hr, and dopamine at 5 mcg/kg/min was started (concentration of 400mg/250mL of D5; dry weight =
85kg).
Stop and Think (20 points): What is the rationale for each of the following therapeutic
modalities ordered for Mr. Budd:
Blood culture and sensitivity: Mr. Budd presented with a fever as well as lacerated
internal organs, intestinal content spill and major surgery. Blood cultures should be
drawn prior to the start of AB therapy in order to obtain an accurate sample and
identification of the organism (Lewis, 2011. pg.240)
IV rate increased: cornerstone of most shock therapy, will assist in increasing patients
volume (Lewis, 2011. pg. 1731).
use of LR: used cautiously in shock victims because liver cannot convert lactate to
bicarbonate. Fluid choice based on type and volume lost and patients clinical status
(Lewis, 2011. pg.1731).
ATB administration: broad spectrum AB should be started within the first hour of septic
shock, narrowing down the organism with a blood culture report (Lewis, 2011. pg.1733). The
C&S indicates Mr. Budd has a gram-negative bacilli infection.
dopamine: vasopressor, use with central line, may extravasate a peripheral line.
Increases peripheral vasoconstriction properties; increases HR, CO, BP, MAP MVO2. At
low dose will increase blood flow to renal, mesenteric and cerebral circulation (Lewis, 2011.
pg.1731).
steroids: decreases inflammation, reverses capillary permeability, further increases BP
and HR (Lewis, 2011. pg.1732).
naloxone (Narcan) administration: used to bring Mr. Budd out of opiod sedation or verify
unresponsiveness. Careful titration required, short half life. Side effects include severe
pain, profound withdrawal symptoms and seizures (Lewis, 2011. pg.141)
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TPN: nutritional therapy should be started to avoid malnutrition and to decrease

morbidity (Lewis, 2011. pg.1733). Mr. Budd requires the nutrition to assist in the healing process.
Calculate the rate and volume for the dopamine infusion please show your work (round
to the tenth).
5 mcg/kg/min x 85kg x 60min/hr
1600mcg/mL
Rate = 15.9mL/hr
Volume = 250mL
Intensive Care Unit - POD 6: By the sixth postoperative day, Mr. Budds condition has deteriorated
dramatically. His skin was cool, mottled, and moist. His sclera was yellow-tinged. He no longer responded to
stimuli and required re-intubation (A/C with previous ventilator settings). A norepinephrine (Levophed) drip
infused at 6 mcg/min (concentration 8mg/250mL of D5W).
Stop and Think (5 points): Calculate the rate and volume for the Levophed infusion
please show your work.
6mcg/min x 60 min/hr
32mcg/mL
Rate = 11.25mL/hr
Volume = 250mL
This was the 6-second/Lead II EKG tracing for Mr. Budd.

Stop and Think (5 points): Analyze this rhythm

Regular/Irregular: Regular
P-Waves Present? Yes
Interpretation: Sinus Tachycardia

Rate: 140 bpm

A 12-lead EKG shows significant ST elevation. What is the significance of this ST

elevation?
Indicative of an MI
Mr. Budd received a 150 mg bolus of IV amiodarone over 20 minutes, followed by a continuous infusion of
amiodarone. His breath sounds revealed crackles throughout his chest. Urinary output was only 3-5 mL/hr and
was grossly bloody/tea-colored with sediment. His abdomen was enlarged and firm. His duodenal hemovac and
NGT began to drain bloody drainage. His IV sites all began to ooze blood.
Hemodynamics
BP = 70/52 mmHg (with Levophed and dopamine running)
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HR = 140 bpm
Respirations = 14/14 breaths/minute
Temperature = 35.8C
PAP = 44/26 mmHg
PAWP = 24 mmHg
CVP = 8 mmHg
CO = 2 L/min
CI = 1.1 L/min/m2
SVR = 2000 dynes/sec/cm-5
Other Laboratory
Values
ABG

Stop and Think (20 points): Interpretation

Metabolic acidosis

pH = 7.14
PaO2 = 68
PCO2 = 49
HCO3 = 12
SaO2 = 85%

Possible cause: renal failure with increased creatinine levels and decreased
urine levels.

Lactic Acid = 8 mmol/L

Lactic Acid= increased; tissues are hypoxemic d/t shock or localized

vascular occlusion

Na+ = 152 mmol/L

K+ = 5.9 mmol/L

Na= increased; kidneys are shutting down and not functioning in the way of
absorbing the Na as they normally should
K= increased; r/t the acidotic state of the pt

Creatinine = 3.4 mg/dL

Increased; shows impaired renal function; kidneys possible failing as

evidenced by lack of urine output

Platelets = 75,000/mm3
PT = 22 seconds
PTT = 98.5 seconds
Fibrinogen = 130 mg/dL

Platelets= decreased; possible hemorrhage since the patient is bleeding from

IV sites and now has an enlarged and firm abdomen; possible GI bleed.
PT= increased; takes the patient a critical amount of time to clot
PTT= increased; indicating the amount of time the patient will take to clot is
excessive. Possibly d/t liver disease or dysfunction
Fibrinogen= decreased; associated with spontaneous bleeding hence IV sites
oozing blood.

CK-MB = 640 U/L

Troponin I = >50

CK-MB= supports suspected MI and 12 lead EKG of MI

Troponin I= increased; indicative of a heart attack

ALT = 100 U/L

AST = 82 U/L
Amylase = 290 U/L
Lipase = 190 U/L

ALT= increased; liver dysfunction; possibly evidenced by enlarged and firm

abdomen.
AST= increased; possible acute pancreatitis, or hepatic dysfunction
Amylase= increased; used for detection and monitoring of pancreatitis; also
could be cause of enlarged and firm abdomen
Lipase= increased; indicates pancreatic disease or renal failure

(Pagana, 2010)

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Intensive Care Unit - POD 8: Mr. Budds condition continued to deteriorate and his EKG displayed the
following rhythm (6-second tracing/Lead II):

Stop and Think (5 points): Analyze this rhythm

Regular/Irregular: Irregular
P-Waves Present? No

Rate: Unable to determine

Interpretation: Ventricular Fibrillation

What would you expect to be the treatment for this rhythm?

Defibrillation
Final Developments: Resuscitation attempts were ultimately unsuccessful for Mr. Budd and he died on
POD 8. An autopsy revealed several small abscessed areas in the lung, acute hepatic failure, multiple
hemorrhagic areas, and an acute myocardial infarction.
Stop and Think (3 points): Please reflect on the case study thoughts, feelings, fears,
identify things that could have been done differentlyHow would you have practiced
loving kindness with Mr. Budd?
The staff could have done a few things differently: chest X-ray, MRI, CT, repeat blood
cultures, repeat CBC, BMP, more aggressive AB therapy, contact precautions.
Thoughts: On paper it is easy to say this should have been done and that should have
been done, in person its different. Vital signs and lab results come in separately,
communication issues may have been present within the department, the nurses caring
for Mr. Budd may have been inexperienced, there could have been a number of factors
contributing to what happened to Mr. Budd and why certain signs, symptoms and
deteriorating conditions were not noticed or addressed. The fact is, however, that key
signs of shock, deteriorating condition and risk factors for shock were overlooked, not
addressed and lead to the worsening of Mr. Budds condition and is ultimate passing.
Loving kindness: Greet and talk to Mr. Budd as if he were alert, orient him to the day,
year, place and time. Explain each procedure as it occurs as if he were alert. Ensure he
was presentable to the family at each visit and at the end.
Stop and Think (2 points): Please be sure each answer is cited and a separate reference
page is attached.

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References
Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. (2011) Medical-surgical nursing:
Assessment and management of clinical problems (8th ed.). St. Louis, MO: Elsevier, Mosby.
Pagana, K. D., & Pagana, T. J. (2010). Mosby's manual of diagnostic and laboratory tests (4th ed.). St. Louis,
Mo.: Mosby/Elsevier.

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