NUR 3112 Multisystem Case Study 2.

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Mariah Blystone, Lacy Stephens, & Jade Blackburn
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 upperright 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?
An A-line will give continuous arterial blood pressure monitoring and frequent ABG sampling (Lewis,
pg. 1606). The information this catheter will provides includes systolic, diastolic, and mean blood pressures
(Lewis, pg. 1606). Clinical presentation that warrant this type of monitoring include acute hypertension and
hypotension, respiratory failure, shock, neurologic injury, coronary interventional procedures, continuous
infusion of vasoactive drugs and frequent arterial blood gas sampling (Lewis, pg. 1606). An A-line was placed
in Mr. Budd to monitor provide continuous monitoring of his blood pressure that is more than likely low related
to the amount of blood loss during surgery. He is also receiving 3L of LR which could affect his blood pressure
related to volume expansion and a risk for excess fluid volume.
A PAC line allows monitoring of acute-phase management of patients with complicated heart and lung
problems (Lewis, pg. 1607). The PAC line will provide information on Pulmonary artery (PA) diastolic (PAD)
pressure and Pulmonary artery wedge pressure (PAWP) or Left arterial pressure (LAP) which are indicators of
cardiac functioning and fluid status (Lewis, pg. 1607). Both of these values increase in heart failure and fluid
volume overload and decrease with fluid depletion (Lewis, pg. 1607). Fluid therapies are often based on PA
pressures in order to restore fluid balance while avoiding overcorrection or under correction of the problem
(Lewis, pg. 1607). The continuous monitoring of PA pressures allows for titration of therapies to ensure
appropriate preload which allows for adequate CO without putting the patient at risk for pulmonary edema
(Lewis, pg. 1607). Clinical presentations that warrant this level of monitoring include assessment of response to
therapy in patients with precapillary and mixed types of pulmonary hypertension, cardiogenic shock,
differential diagnosis of pulmonary hypertension, myocardial infarction with complications, potentially
reversible systolic heart failure, severe chronic heart failure requiring inotropic, vasopressor, and vasodilator
therapy, and transplantation work up (Lewis, pg. 1607 Table 66-3). A PAC line was placed in Mr. Budd because
risk for fluid deficits related to blood loss and for his risk for fluid overload related to fluid therapy with LR and
units of blood. Also, the continuous monitoring will allow for titration of the fluid therapy if needed.
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
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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

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.
Risk Factors for infection and development of septic shock:

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
(Roberson, slide 37).

Mr. Budds risk factors for developing infection and/or septic shock include his increased age, severe trauma,
recent surgical procedure, drain placements, and ETT. Mr. Budd possibly is malnourished related to his
increased age.

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

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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 experiencing Septic Shock (Lewis, Table 67-3 & 67-4, P 1635-1637).
LOC- Alterations in mental status are a sign of septic shock (Lewis, P 1635). Post op day 1 Mr. Budd was able
to arouse; now he is not.
Skin- Mr. Budds skin is now warm and flushed which is a sign of septic shock (Lewis, P 1635).
BP- Hypotension, Low blood pressure along with increased heart rate indicates shock (Lewis, P 1635)
HR Tachycardia, Increased heart rate along with low blood pressure indicates shock (Lewis, P 1635)
Respirations- Tachypnea, increased respirations or hyperventilation can be an indicator of septic shock (Lewis,
P 1635)
Temperature- Hyperthermia, this can indicate infection (Lewis, P 1635)
PAP- This value is normal (Lewis, p 1603)
PAWP- This level is low; this can indicate left ventricle failure (Lewis, p 1603)
CVP- This is normal but very close to being low (Lewis, p 1603)
CO- This is within the normal range but it is on the high end (Lewis, p 1603)
CI- This level is elevated; this can mean the heart is overworking (Lewis, p 1603)
SVR- This level is low, this reflects afterload (Lewis, p 1604)
WBCS- Elevated (Pagana, p 548), Elevated white blood cells indicates infection and in this case can indicate
septic shock (Lewis P. 1635)
Glucose- Hyperglycemia (Pagana, P 267), Elevated blood glucose is an indication of septic shock (Lewis, P
1635)
GU- Decreased urine output indicates septic shock (Lewis, P 1635).
Culture and sensitivity reports form 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, IV rate increased, use of LR, ATB administration, dopamine,
steroids, naloxone (Narcan) administration, and TPN?
The greenish brown fluid draining from Mr. Budds Hemovac is abnormal and could indicate infection
this is why a culture and sensitivity was ordered; to determine the type of bacteria and also the type of antibiotic
needed to fight it (Lewis, p 361). LR, an isotonic solution, was used and increased to increase intravascular
volume and volume replacement in the initial stages of shock (Lewis, p 1642). Antibiotics were administered to
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fight the bacteria that are in the body (Lewis, p1644). Dopamine was given to increase blood pressure (Lewis, p
1643). Hydrocortisone was given to decrease inflammation and also to help increase blood pressure (Lewis, p
1643). Narcan was started to reverse the effects of the morphine so Mr. Budd will become more alert (increase
his level of consciousness) (Lewis, p 127). TPN was started because nutrition is vital to reduce mortality
(Lewis, p 1644).
Calculate the rate and volume for the dopamine infusion please show your work (round to the tenth).
(Henke, pg. 249-250)
5mcg/kg/min dry weight 85kg concentration 400mg/250ml
5mcg \ 1000 = .005 mg/kg/min
.005mg X 85 kg = 0.425 mg/min
0.425 mg \ 400mg X 250 ml = 0.265625 ml
0.265625 ml x 60 mins = 15.9 ml/ hr
VTBI: 250 ML
Rate: 15.9 ml/hr
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. (Henke, pg. 249-250)
Levophed 6mcg/min (ordered) and concentration= 8mg/250mL of D5W
8mg/250mL= 0.032mg/mL
0.032mgx1000= 32mcg
32mcg/60= 0.5333mcg/min
6mcg/min/0.5333mcg/minx1mL= 11.3mL/hr
VTBI= 250 mL
Rate= 11.3mL/hr
This was the 6-second/Lead II EKG tracing for Mr. Budd.

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Stop and Think (5 points): Analyze this rhythm

Regular/Irregular: Regular
Rate: 140 bpm
P-Waves Present? Yes
Interpretation: Sinus Tachycardia with ST elevation
A 12-lead EKG shows significant ST elevation. What is the significance of this ST elevation?
ST elevation (STEMI) implies myocardial infarction. Patients with a STEMI have a more extensive MI that is
accompanied by prolonged and complete coronary blockage. For diagnostic and treatment, it is important to
distinguish between ST depression (NSTEMI- ischemia) and STEMI (Lewis, pg. 749) & (Comp II Basic EKG
Interpretation Handout)
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)

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

Stop and Think (20 points): Interpretation

Partially Compensated Respiratory Acidosis
pH 7.14= Acidic Respiratory failure causing acidosis from a buildup of
PCO2
Pa02 68= Low & SaO2 85%= Low Anemic from blood loss, possible
atelectasis, possible pulmonary edema, possible emboli (the un-oxygenated
blood gains access to the oxygenated blood by direct shunting. By dilution,
the O2 content of the mixed blood returning to the heart is lowered. The
arterial blood is therefore lowered)
PCO2 49= Acidic Build up from not blowing off, hypoxemia, anxiety
HCO3 12= Acidic Acute renal failure r/t decreased renal perfusion
(Pagana, pg. 114-124)

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Other Laboratory Values

Lactic Acid = 8 mmol/L
Na+ = 152 mmol/L
K+ = 5.9 mmol/L

Creatinine = 3.4 mg/dL

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

Stop and Think (20 points): Interpretation

High possible shock in progress, tissue ischemia (anaerobic metabolism
occurs in hypoxemic states which produces lactic acid as a byproduct),
&severe liver disease (Pagana, pg. 341-343).
Na 152= High possible kidney failure, excessive sodium in IV fluids
w/decreased loss of Na from decreased urine output, and possible GI losses
(Pagans, pg. 479-482).
K 5.9= High Acute renal failure (decreased urine output w/ decreased
excretion of K), Infection (K exits in high levels in the cell. With cellular
injury and lysis, K within the call is released into the blood stream), Acidosis
(To maintain pH during acidosis, hydrogen ions are driven from the blood
and into the cell. To maintain electrical neutrality, K is expelled from the cell
causing an increase in the blood) (Pagans, pg. 421-424)
High disease affecting the renal function (acute renal failure r/t decreased
renal perfusion) (Pagana, pg. 204-206)
Platelets 75000= Low Hemorrhage (platelets are lost in the bleeding
process which will take hours to days for the bone marrow to produce an
adequate amount to replace. The problem is exacerbated when treatment is
done to replenish RBC count and blood volume because it dilutes the
remaining platelets to further decrease the platelet count) and Infection
(infections can cause thrombocytopenia, especially when the pt. is already
immunocompromised) (Pagana, pg. 416-419)
PT 22= Prolonged liver disease (coagulation factors are made in the liver
and with liver disease synthesis is inadequate and the PT is increased)
(Pagana, pg. 448-452).
PTT 98.5= High inadequate clotting factors, possible cirrhosis of the liver
(Pagana, pg. 396-399)

CK-MB = 640 U/L

Troponin I = >50

Fibrinogen 130= High acute inflammatory reactions and trauma (Pagans,

pg. 176-182).
CK-MB 640= High cardiac ischemia r/t ST elevation signifying cardiac
infarction (any disease or injury to the myocardium causes CK-MB to spill
out of the damaged cells and into the bloodstream, producing elevated CKMB levels) (Pagana, pg. 199-204)
Troponin >50= High myocardial injury and myocardial infarction (this
myocardial intracellular protein becomes available in the bloodstream after
myocardial cell death because of ischemia. Normally no troponin is detected
in the blood) (Pagana, pg. 530-532).

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Other Laboratory Values

ALT = 100 U/L
AST = 82 U/L
Amylase = 290 U/L
Lipase = 190 U/L

Stop and Think (20 points): Interpretation

ALT 100= High possible hepatitis hepatic necrosis and hepatic ischemia
(liver damage) (Pagana, pa. 38-40).
AST 82= High possible liver disease (hepatitis, hepatic cirrhosis, druginduced liver injury, hepatic metastasis, hepatic necrosis, hepatic infiltrative
process), possible acute pancreatitis (Pagana, pg. 125- 127).
Amylase 82= WNL (Pagana, pg. 60)
Lipase 190= High possible pancreatic disease (lipase exits the pancreatic
cells into the bloodstream when disease or injury affect the pancreas) and
possible renal failure r/t decreased urine output from decreased renal
perfusion (lipase is excreted by the kidney) (Pagana, pg. 354-356).

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: Not Measurable

Interpretation: VFIB (Ventricular Fibrillation)

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

CPR and defibrillation will be started immediately; epinephrine and vasopressin will also be given to the patient
(Lewis, Dirksen, Heitkemper, & Bucher, P 801).
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?
We felt like this case study was a good in depth look of exactly how a patient can unravel in an ICU setting. It
really showed how when one thing goes wrong, everything can follow. It was helpful to have an in-depth
description from what brought him into the ER to the autopsy results. As a critical care nurse, this rapid decline
could be a fear on his or her mind due to the nature of the unit. Interventions sooner could have made a
difference in Mr. Budds life. On POD 2 was when things started to stray from his baseline. Some interventions
were done (dopamine for example), but more could have been done at that point in time involving his
respiratory status.
Nurses have patients like Mr. Budd often and can use many techniques to practice loving kindness. The biggest
one would be therapeutic touch. He could have used that person to not have to say anything, but just provide a
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presence with a healing touch. Also, since he was intubated, nurses could have positioned him comfortably,
performed mouth care, given him a warm bath, and spoken to him when they entered the room and when
something was going to happen. Even though he was vented and had a decreased level of consciousness, he
could still possibly hear everything going on. Although Mr. Budd did not live, it was the nurses responsibility
to practice loving kindness in those ways to make him as comfortable as possible.
Stop and Think (2 points): Please be sure each answer is cited and a separate reference page is attached.

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References
Buchholz, S. (2012). Henkes Med-Math Dosage Calculation, Preparation & Administration (7th ed.).
Philadelphia, PA: Wolters Kluwer Health
Lewis, S.M., Dirksen, S.R., Heitkemper, M.M., & Bucher, L. (2014). Medical-Surgical Nursing:
Assessment and Management of Clinical Problems (9th ed.). St. Louis: Mosby.
Pagana, K.D. & Pagana, T.J. (2010). Mosbys manual of diagnostic and laboratory tests (4th ed.). St.
Louis, MO: Mosby.
Roberson, M. (2015). Introduction to Shock PowerPoint

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