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CT Week7
CT Week7
BSN 3Y2-2
QUESTION:
1. HYPERVOLEMIA
A patient was admitted in the medical ward with chief complaints of shortness of breath. Further
assessment reveals the following findings:
BP –140/90 mm Hg
HR –111 bpm
RR –24 cpm
+2 bipedal edema
Bibasilar crackles upon auscultation
The doctor initially ordered furosemide 20 mg ampule TIV every 8 hours and the following
laboratory tests: Complete Blood Count (CBC), Serum Sodium, Serum Potassium, Blood Urea
Nitrogen, Serum Creatinine, Total Protein, and Chest X-ray.
1. Write down three (3) priority nursing diagnoses for the patient and create a hypothetical
FDAR.
2. What laboratory test may give the hint to the doctor about the oncotic pressure of the
patient?
3. Create a drug study for FUROSEMIDE specifying the following:
1. Drug classification
2. Mechanism of action
3. Indication (*for the case of the patient mentioned above)
4. Contraindication
5. Side effects
6. Nursing Considerations
ANSWER:
Action:
Administered furosemide 20mg
ampule TIV every 8 hours as per
doctor’s order
Encourage restriction of sodium
and fat
Support active patient control of
condition
Response:
Blood Pressure is at less than
140/90 mmHg
No complications
Has palpable peripheral pulses
Action:
Teach the patient the proper
ways of coughing and breathing
(e.g. take a deep breath, hold for
2 seconds, and cough 2 or 3
times in succession)
Encourage patient to increase
fluid intake to 3 liters per day
within the limits of cardiac
reserve and renal function
Give medication as prescribed,
such as antibiotic, mucolytic
agents, bronchodilators,
expectorants, noting
effectiveness and effects.
Provide oral care every 4 hours
Educate patient coughing, deep
breathing, and splinting
techniques
Response:
The patient maintained airway
patency, clear breath sounds
The patient expectorated
retained secretions and
maintained normal breathing
pattern
Action
Limit sodium intake as
prescribed
Take diuretics as prescribed.
Elevate edematous extremities,
and handle with care.
Place the patient in a semi-
Fowler’s or high-Fowler’s
position.
Administer IV fluids through an
infusion pump, if possible.
Response:
Patient has balanced intake and
output and stable weight.
Patient maintains HR 60 to 100
beats/min
Patient has clear lung sounds as
manifested by absence of
pulmonary crackles.
Patient verbalizes awareness of
causative factors and behaviors
essential to correct fluid excess.
2. The serum creatinine provides a sufficient screen for advanced renal insufficiency, and
the serum albumin permits a useful approximation of the plasma oncotic pressure.
2. HYPOVOLEMIA
A teenage patient was rushed to the emergency department due to wrist laceration from a
suicide attempt. The patient is lethargic and has the following findings upon assessment:
BP –80/50 mm Hg
HR –110 bpm
RR –25 bpm
The doctor initially ordered fluid resuscitation with PNSS 1L, to fast-drip 200 cc then the
remaining fluid to run for 6 hours. Stat blood typing was ordered, and 3 units of whole blood was
ordered to be transfused immediately after proper cross-matching. The patient was hooked to
oxygen 8 liters per minute via face mask.
1. What parameters will the nurse check while the patient is undergoing rapid fluid
resuscitation?
2. For a patient who will undergo blood transfusion, enumerate the steps that the nurse
should prudently undertake while performing the procedure.
3. List down three (3) priority nursing diagnoses for the patient and create a hypothetical
FDAR.
ANSWER:
1. Fluid administration is beneficial only if it increases the stroke volume (SV) and thereby, the
cardiac output. Patients are considered fluid responsive if SV increases by at least 10% after a
fluid challenge of 500 mL of crystalloid. Pulse pressure variation, passive leg raising test, and
SV variation are some reliable markers for fluid responsiveness. In patients with massive blood
loss, permissive hypotension prevents progression to dilutional coagulopathy of trauma . In
severe and uncontrolled hemorrhagic shock, controlled resuscitation (MAP of 40 mmHg) is
preferred. Two strategies were proposed to avoid clot disruption and dilutional coagulopathy:
delayed resuscitation strategy where fluid is given after bleeding is controlled and permissive
hypotension strategy, where fluid is given to increase SBP without reaching normotension. In
penetrating trauma patients with hypotension (prehospital SBP < 90 mmHg), delayed
resuscitation shows better survival rates compared to immediate resuscitation. Increased
mortality is seen with increased in-field procedures, supporting “scoop and run” and delayed
fluid resuscitation techniques. However, when PTT is long, simple life support measures reduce
mortality in severely injured patients even when conducted in suburban and remote locations
with long PTT.
2.
Requesting blood, clearly indicating the reason for transfusion and communicating the
degree of urgency to the Blood Transfusion Laboratory.
Providing full information on transfusion requests
Explaining to patients the risks, benefits and possible alternatives to blood transfusion
and providing written information where appropriate
Requesting collection of blood including arranging urgent transportation if required
Obtaining red cells for transfusion via the electronic remote issue system, ensuring that
the right blood unit is correctly labeled for the intended patient and that blood for only
one patient is collected at each visit
Carrying out pre transfusion checks to ensure the right blood is transfused
Monitoring the patient during transfusion
Inclusion of medical staff in the management of the patient if a transfusion reaction
should occur
Reporting of transfusion reactions or other incidents to the Blood Transfusion Laboratory
Documentation of indications for transfusion, number of units administered and
observations recorded in patients’ medical records
3.
Acute Pain
Decrease Cardiac Output
Hypovolemic Shock
Action:
Foresee the need for pain relief.
Get rid of additional stressors or
sources of discomfort whenever
possible.
Determine the appropriate pain relief
method.
Provide analgesics as ordered,
evaluating the effectiveness and
inspecting for any signs and symptoms
of adverse effects.
Response:
Patient displays improved well-being
such as baseline levels for pulse, BP,
respirations, and relaxed muscle tone or
body posture.
Patient uses pharmacological and
nonpharmacological pain-relief
strategies.
Patient displays improvement in mood,
coping.
Response:
Patient maintain maximum tissue
perfusion to vital organs, as evidenced
by warm and dry skin, present and
strong peripheral pulses, vitals within
patient’s normal range, balanced I&O,
absence edema, normal ABGs, alert
LOC, and absence of chest pain.
Action:
Assess the client’s HR and BP,
including peripheral pulses. Use direct
intra-arterial monitoring as ordered.
Monitor oxygen saturation and arterial
blood gasses.
Monitor the client’s central venous
pressure (CVP), pulmonary artery
diastolic pressure (PADP), pulmonary
capillary wedge pressure, and cardiac
output/cardiac index.
Assess for any changes in the level of
consciousness.
Administer fluid and blood replacement
therapy as prescribed.
Use a fluid warmer or rapid fluid infuser.
Response:
Patient is normovolemic as evidenced
by HR 60 to 100 beats per minute,
systolic BP greater than or equal to 90
mm Hg, absence of orthostasis, urinary
output greater than 30ml/hr, and normal
skin turgor.