NRSG 2899 Name Alysia Garcia – 11/12/20 Sec T02

Please complete the following case study. This is an individual assignment and answer the questions in your own
words. Neatness counts, if it is illegible it will not be graded. If you have not put your name on this assignment, you
will receive no grade. GLO/SLO: Safety, Evidence based, Leadership, Interprofessional collaboration, Technologies

G.S., a 36-year-old secretary, was involved in a motor vehicle accident; a car drifted left of the center line and
struck G.S. head-on, pinning her behind the steering wheel. She was intubated immediately after extrication and
flown to your trauma center. Her injuries were found to be extensive: bilateral flail chest, torn innominate artery,
right hemothorax and pneumothorax, fractured spleen, multiple small liver lacerations, compound fractures of
both legs, and probable cardiac contusion. She was taken to the operating room for repair of her injuries. In OR,
she received 36 units of packed RBCs, 20 units of platelets, 20 units of cryoprecipitate, 12 units fresh frozen
plasma, and 18 L of lactated Ringer's solution. G.S. was admitted to the ICU postop, where she developed adult
respiratory distress syndrome (ARDS).

1. What is ARDS?

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ARDS (acute respiratory distress syndrome) is a progressive and sudden type of acute respiratory failure.

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Associated with lung inflammation which is typically caused by injury to the lung. ARDS results in damage done

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to the alveolar and capillary interfaces. This creates a permeable setting that allows intravascular fluid to cross
leading to alveolar edema. The edema will lead to decreased oxygen throughout the body. Additionally, there

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will be other changes including surfactant dysfunction (alveolar collapse), decreased elastin and collagen and
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vasoconstriction of the pulmonary artery.

2. What are the risk factors for developing ARDS? Which does G.S. have?
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Risk factors for developing ARDS includes any pulmonary infection, trauma, shock, sepsis and a history of
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multiple blood transfusions.

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G.S. suffered severe trauma and also had multiple blood transfusions due to her accident and injury.
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G.S. has been in ICU for 6 weeks, and her ARDS has almost resolved. She is transferred to your unit. You receive
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the following report: She is awake, alert, and oriented to person and place and can move both of her arms and
wiggle her toes on both feet. Heart tones are clear, vital signs are 138/90, 88, 26, 99.3 ° F (37.4 ° C); bilateral radial
pulse 3+, and foot pulses by Doppler only. All of her incisions and lacerations have healed. She has bilateral chest
tubes to water suction with closed drainage, both dressings are dry and intact. She has a duodenal feeding tube, a
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Foley catheter to down drain, and a double lumen PICC line.

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3. What additional information will you require during this report? (Think about body systems).

Motor or sensory deficits this patient may have.

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Is she able to communicate pain levels.

What has her cardiac rhythm been as well as if she has any noted edema.
Does she have any known skin breakdown? Any surgery complications. Any other tubes outside of chest tubes.
How many liters of O2 is she receiving? Description of breath sounds. Any positive cultures or diagnosed
infections. What respiratory treatments is she receiving? Characteristics of drainage from chest tubes.
Type of feeding she is receiving and at what rate. Recent stools and BM’s. Weight gain or loss. Urine output and
intake. Last Foley change as well as characteristics of urine. What are her allergies (food, medication, etc.) and
what medications is she taking/prescribed?
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 You complete your assessment of G.S. You note shortness of breath (SOB), fine crackles throughout all lung fields
posteriorly and in both lower lobes anteriorly, and coarse crackles over the large airways.

4. What is the significance of the fine and coarse crackles in G.S.'s case?

Fine crackles indicate fluid accumulation which can alter and impair gas exchange for G.S.
Coarse crackles indicated large airway secretions.

5. The nurse from the previous shift charted the following statement: “Fine and coarse crackles that clear with
vigorous coughing.” Based on your knowledge of pathophysiology, determine the accuracy of this statement.

Vigorous coughing will be able to clear the coarse crackles (secretions) but it will not clear fine crackles (fluid
accumulation). This statement is partially true.

6. It is time to administer furosemide (Lasix) 40 mg IV push (IVP). What effect, if any, will furosemide have on
G.S.'s breath sounds?

Giving G.S. furosemide may relieve the fine crackles she is experiencing by eliminating the excess fluid.
Furosemide is a diuretic that helps eliminate excess fluid.

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7. What action should you take before giving the furosemide (Lasix)?

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Checking electrolyte values (Na and K) would be beneficial before administering furosemide. We would also
want to check Mg and Calcium also.

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Laboratory Test Results at 0500 rs e
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Sodium 129 mmol/L
Potassium 3.0 mmol/L
Chloride 92 mmol/L
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HCO 3 26 mmol/L
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BUN 37 mg/dL
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Creatinine 2 mg/dL
Glucose 128 mg/dL
Calcium 7.1 mg/dL
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8. Keeping in mind that you are about to administer furosemide (Lasix), which laboratory values concern you,
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and why?

Sodium, potassium and calcium are all low and concerning. Administering furosemide will likely decrease the
amount further causing additional complications to this patient. Complications can include neuromuscular
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reactions (sodium), electrical impulses in cardiac and skeletal (potassium) as well as altered muscle contractions
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(calcium).
BUN and creatinine levels are elevated and can indicate renal impairment which needs to be determined in
order to appropriately administer furosemide.
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9. Given the laboratory values listed, what action would you take before administering the furosemide (Lasix),
and why?

I would want to call and inform the physician that Na, K, and Ca levels were decreased significantly. As well as
BUN and creatinine were elevated. The reasoning behind informing the physician would be to obtain an
alternate medication to use for G.S. and avoid addition complications.

Physician's Orders

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 STAT magnesium (Mg) level
KCl 40 mEq IVPB over 4 hours now
Calcium gluconate 2 g in 100 mL NS intravenous piggyback (IVPB) over 3 hours

10. G.S. has one available port to use on the PICC line. Describe your plan for administering the potassium
chloride and the calcium gluconate.

These medications are compatible which means I will be able to administer both of these through individual Y
connectors leading into the PICC line. Each line would also be regulated by its one controller or pump.
Administering 4 bags of KCl 10 mEq because it is not appropriate to mix more than 10 mEq with 100 mL of NS.
While administering the KCL I would want to be sure that G.S. is on a cardiac monitor. Additionally, I would
monitor the infusion itself to confirm that the infusion is not running to quickly or slowly.

11. You open G.S.'s medication drawer, prepare the furosemide (Lasix) for administration, and find one 20-mg
ampule. The pharmacist tells you that it will be at least an hour before he can send the drug to you. You realize
it is illegal to take medication dispensed by a pharmacist for one patient and use it for another patient. What
should you do?

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Double check that I cannot find the second ampule needed. Ask if there is someone who can run and get the

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needed 20 mg ampule for me. If I still cannot find the missing ampule and cannot find someone who is able to

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run and pick up the ampule from pharmacy, I would give the first 20 mg IVP and then give the second 20 mg

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when available. I understand that two doses of 20 mg will not have the same effect as one does of 40 mg. I

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would want to monitor effects that these two doses did have. I would document my actions and include
reasoning for those actions. rs e
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12. While you administer the furosemide (Lasix) and hang the IVPB medication, G.S. says, “This is so weird. A
couple times this morning, I felt like my heart flipped upside down in my chest, but now I feel like there's a
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bird flopping around in there.” What are the first two actions you should take next? Give your rationale.
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Connect G.S. to a cardiac monitor and check pulses.

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Checking the cardiac monitor will help me determine if G.S. is experiencing any dysrhythmias and checking the
pulse will help me understand how fast or slow her heart is working. Both actions will help me anticipate my
next action.
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13. G.S.'s pulse is 66 beats/min and irregular. Her BP is 92/70 and respirations are 26. She admits to being “a little
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lightheaded” but denies having pain or nausea. Your co-worker connects G.S. to the code cart monitor for a
“quick look.” This is what you see. What do you think is happening with G.S.?
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It seems that G.S is experiencing runs of VTach.

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 14. What will your next actions be?

Increase O2 concentration, Hang KCl and Calcium gluconate ASAP and begin infusion. Page the physician STAT.
Assure IV access and get crash cart ready. Obtain a 12 lead EKG.

15. What are the most likely causes of G.S. having abnormal beats?

The most likely causes would be the decreased levels of NA, K, and Calcium. And also, the Mg levels.
Decreased O2 would also play a significant role in abnormal beats.

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