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Attached are 2 case studies that i need answers for them on separate sheet. Please no plagiarism. Please read the following attached case studies and give accurate answers to them. Number each question as they are being asked and chronologically. References are important please. Accurate answers are what i need. No plagiarism please

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SepsislSeptic M, LWrc Rodgers; &MC; ,k*S,N, CCRN, C.', ACNV.BC Emergency Department JohnBudd, a 7Z-year-old, arrived in the emergency department unconscious, with stab wourids to the upper-right abdomen and lower-right chest that were sustained in his home while fighting off a burglar. The paramedics secured two large-bore intravenous (IV) catheters in his right and left antecubital spaces and infused lactated Ringer,s solution wide open in both sites. An endotracheal tube was inserted, and ventilation w-ith a resuscitation bag at 1000/o oxygen was begun. Medical antishock trousers (MAST) were in place. pressure dressings to both wounds were secured. A S-cm (Z-inch) stab wound to his right lower chest and a 7.5-cm (3-inch) stab wound to his upper-right abdomen were inspected. Chest tubes were inserted into the upper-right and lower-right midaxillary regions. Immediatety, 500 ml of red drainage returned via the lower chest tube. His heart rate (HR) was 125 bpm, and the monitor showed sinus tachycardia without ectopy. His blood pressure (BP) was TOIS0 mm Hg. Inserting a Fo1ey catheter resuited in drainage of 400 ml clear, dark yellow urine. After infusion of more than 2000 mi of lactated Ringer's solution, Mr. Budd was sent to surger)4, still in a hypotensive state. Preoperative body weight was 74 kg (1651b). Surgical lntervention During surgery/ a right thoracotomy and dght 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 damag". the livei and the duodenum were lacerated. Extensive hemorrhage and leaking of intestinal contents were apparent after opening the peritoneum. Mr. Budd's injuries were repaired, the peritoneal cavity was irrigated with antibiotic solution, and incisional sump drains were plaied in the duodenum. During the 4-hour surgery, Mr. Budd received 6 U of biood and an additional 3 L of lactated Ringer's solution. A pulmonary artery catheter (PAC) and right radiai arterial line were inserted. lntensive Care Unit: Immediately after Surgery When Mr. Budd arrived in the surgical intensive care unit (ICU), he was receiving ventilatory support. Ventilator settings were as follows: 370 377 ChaPter 26 Sepsis/SePtic Shock Assist Rate mode Fio, Vr 600/o 72 800 ml were the immediately after surgery parameters hemodynamic Vital signs and 92l52mm Hg BP 114 bPm 12 breaths/min HR Respirations TemPerature 36.2' 2018 PAP c (97.2 F) mm Hg 6mmHg 4mmHg PCWP CVP 5 L/min co 2.9 Llminlmz 1040 dYnes/sec/cm- cl SVR cetl (WBC) count normal. Except for a white blood Arterial blood gas values were ^i."Li rr ro g7at, Mr' Budd's other laboratory values of 13.6 x 103/mm3 and a hemoglobin were within normal limits' ICU: PostoPerative DaY 1 t#: ;Hffi ;;J;drows,vandreceivedventilato?*Ytp,:,':l?'.11',1?SirTHi;" ?iil.?,#:fr iffi::il;l;':qTr*#S:*":.",il:Ti*"?"*:TJ,T:; f;'?x,1S.Tf :ril"jfiil::ff'Jfi:1,.i']xi;.'$d;!i*!*::"ry:*3Tlt"g,:T,*""*Tff l*# ;il#ffi fi *T"ilil,['*,T""1iie"iyq:4**"}iffi ,::,11i#*3i;Il?Ti"'::l;'#"i; 51trilT[H'#,iil11;fii,#'il1':i.ffi ;fi nrm ii"'f# +HI5jl""l]o','^','*:J*:"*ff :fr oo -rir,,. His abdomen was slightrv :ffi'll'l""l??"ff 'h*.-1::ffi;'.,:"*r"*",'n,rl' no bowel sounds' u.rJ aitt""aed, and he had Postoperative DaY 2 he his second postoperative day' At this time Mr. Budd's condition remained stable until to commanai' Hls respirations were 28 became difficult to arouse but did respond output dropped to 20 ml/hr' His skin became breaths/min, shallow, and labored' His urine included the following: warm, dry, and flushed' Other clinical data 80/50 mm Hg BP 132 bpm HR 36.2' C (97.2 T) Temperature 7417 mm Hg PAP PCWP CVP co CI SVR WBCs Glucose 4mmHg 2mm Hg 8 L/min 4.7 Llminlmz 560 dynes/sec/cm s Z2,OOOlmm3 270 mgldl indicated gram-negative bacilli' Culture and sensitivity repolts from wound drainage naloxone we11 as"IV hvdrocortisone and Appropriate IV antibiotics were iA*f,iri.t.d, ;; done' was nutritional needs (Narcan). A pharmaciconsuitation to formulate and calculate phase i; prepareto' the suspected hvperdvnamic and total parenteral tl"Hl#fi;;;,;;' was inicreased to 150 ml/hr' and of septic shock, infusion of lactated Ringer;s ,ol.,tion of ZOOmglZSO ml of 5olo dopamine at 5 pg/kg/min was started *itf. u concentration dextrose in water (DSW)' Inc All rights reserved O 2004, 2001,1996 Elsevier' - 372 UNIT VII MULTISYSTEM ALTERATIONS ICU: Postoperative DaY 6 dramatically. His skin B_v-- the sixth postoperative day, Mr. Budd's condition had deteriorated r,r;as cool, ,rrotttea, and moist. His sclerae were yellow tinged. He no longer responded to stimuli. A norepinephrine (Levophed) drip infused at 6 Fg/min with a concentration of lmglZlO ml of D5W, along with a dopamine drip at 2 ptgikg/min was begun. His monitor showed sinus tachycardia with short runs of ventricular tachycardia. ST-segment elevation, T-wave inversion, and the development of Q waves over most of the anterior V leads on his electrocardiogram (ECG). A 75 mg bolus of lidocaine was given followed by a continuous intusion atimglmin with a concentration of 2 gl5OO ml of D5W. His breath sounds revealed crackles throughout his chest. Urinary output was only 3 to 5 ml/hr and was grossly bloody. His abdomen was enlarged and flrm. His abdominal suture lines had dehisced, and the peritoneum could be seen. The duodenal sump and NGT drainage started to turn red. AII irterial and venous puncture sites began oozing blood. Further clinical data included the following: 70152 mm Hg 140 bpm BP HR Respirations Temperature PAP PCWP CVP 14 breaths/min 35.8' C (96.4'F) 44126 mm Hg 24 mm Hg 8mmHg Z Llmin co 1.1 Liminlm2 2000 dynes/sec/cm cr SVR s Other abnormal laboratory results included the following: 7.74 49 mm Hg 46 mm Hg pH Pco2 Po, Sao, B5% HCO3- 72 mmoUL Lactic Acid 3.0 mEq/L Na* 152 mmol/L 5.9 mmol/L 3.4 mg/dl K* Creatinine Amylase Lipase ALT (SGOT) AST (SGPT) 290UlL FDP 39 3.9 TJ IL u/L 100 BZIJIL Platelets 75,000/mm3 PT 22 PTT 98.5 Fibrinogen 130 mg/dl sec 640UlL CK TroPonin sec I >50 Final Developments Despite attempts to reduce afterload with sodium nitroprusside (Nipride) and increase contraciility with dobutamine (Dobutrex), Mr. Budd's hemodynamic status failed even further. When his cardiac rhythm deteriorated into ventricular fibrillation, resuscitation efforts were unsuccessful. An autopsy revealed several small abscessed areas in the lung, acute hepatic failure, multiple hemorrhagic ateas, and an acute myocardial infarction (MI). O 2004, 2001, 1996 Elsevier, lnc. All rights reserved. t73 26 Chapter SePsis/SePtic Shock SEPSIS/SEPTIC SHOCK and the rerationship in hospirarized patienrs sepsis and bacteremia the masnitude of between these two diagnoses' "fT:::: those that of septic shock? Identify development and infection for what are the risk factors z. aPPlied to Mr' Budd' 3. Discuss the rationale septic shock' for use of a PAC in monitoring 4.Whatorganismsmostcommonlycausesepticshock?lnwhichsitesisinfectionmostoften seen? 5.Whatpathophysiologicprocessesoccurwithsepticshock?Whataretheeffectsofthese volume' and pump? processes on the ilffifi""'ililii'"t' 6.Discussclinical,laboratory'andtherapychangesthatoccurredonMr'Budd'ssecond postoPerative daY' lnc' All rights reserved' O 2004, 2001,1996 Elsevier' 374 UNIT VII MULTISYSTEM ALTERATIONS 7' what is the rationale for each of the following therapeutic modalities ordered for Mr. Budd on the second postoperative day? lV rate increased to .l50 ml/hr Dopamine 5 pglkg/min Steroids Naloxone lV infusion Total parenteral nutrition 8' 9' Discuss the clinical changes that occurred during Mr. Budd's sixth postoperative day. what is the rationale for each of the following therapeutic modalities ordered on the sixth postoperative day? How many milliliters pur liou, should be infused for each drug listed? Norepinephrine 6 pglmin Dopamine 2 p"glkg/min Lidocaine 2 mglkg/min 10. What are the reasons for the changes in the following hemodynamic parameters noted on the sixth postoperative day? 5VR CO/CI PCWP : ll' Interpret Mr. Budd's blood gas levels on the sixth postoperative day. 12' why are the renal, liver, and pancreatic laboratory values reported on the sixth postoperative day abnormal? i l i @2004,2001,1996 Elsevier, lnc. AII rights reserved, >-. ;**&w&,:ra. i1 Chapter 26 I Sepsis/Septic Shock 375 13. what complications do the hematorogic raboratory varues suggest? 14. What would account for the ECC changes described? Mr. Budd's liver was lacer:ated during the stabbing. What effect, if any, did this have on his eventual outcome? I :a ,' .i:: '/,. 'r' 16' t. :; Describe the differences in the parameters below between hyperdynamic or warm septic shock and hypodynamic or cold septic shock. i: Hyperdynamic ':t, , Hypodynamic LOC BP HR Respirations , Pulse Pressure Skin ? ,,, t; , SVR ,,, , co/cr I Urine Output ,: 17. How do elderly patients manifest symptoms of sepsis? 18' What antimicrobial and antiendotoxin therapies should be instituted in 19. What does the future hold for therapy in septic shock? @ 2Oo4,2$8tr,lg€tr-. 14 Head Trauma and Subdural Hematoma Cinda Alexnnder, MSN, CCRN, CNRN, CNOR, CRN[{ Joyce, a 27-year-old right-handed patient, was involved in a motor vehicle accident. Jovcc was an unrestrained passenger in a car that swerved off the road and struck a tree. She u'as ejected from the car and was found unconscious by the emergency rnedical serl,ice personnel. After being placed on a spinal board and in a Philadelphia collar, Joyce was transto the nearest emergency department trauma center. Joyce u-a-s somewhat combative and unresponsive to commands at arrival. Her pupils were reactir-e bilaterally (left > right). Her respiratory rate was 40 breaths/rnin and labored. Subsequentlran endotracheal tube was placed, and mechanical ventilation was started. Additional treatment included placement of a subclavian intravenous (lV) line, arterial catheter, and Foler catheter. Initial evaluation of her cervical spine revealed no abnormal findings, and the IonS spine board and Philadelphia collar were removed. Joyce's diagnostic data were as follorrs: ported by helicopter 9Ol10 mm Hg BP HR 100 bpm Respirations Temperature Pupils Reactive Glasgow Coma Scale score 40 breaths/min 36.7'. C (98'F) left > right 9 Joyce's initial computed tomography (CT) scan of the head revealed a left temporai cerebral contusion with a midline shift of brain structures. The CT scan also revealed a left temporal parietal subdural hematoma (SDH). After surgical removal of the hematoma, Joyce was transferred to the critical care unit. Intubation and mechanical ventilation were continued. An intracranial pressure (ICP, monitoring device was placed. The following were her diagnostic data after surgery: tcP 25 mm Hg BP 130/88 mm Hg HR 100 bpm 12 breaths/min Respirations Temperature 37.8'C (100" F) pH 7.48 '194 l==-ot-"]- Chapter 14 ]f 195 Head Trauma and Subdural Hematoma Po, 40 mm Hg 434 mm Hg HCO3- 2O.4mmoUL Pco2 Ventilator settings were as follows: Vr Rate Fio2 ml 7Zlmin 700 TOOo/o from the general anesthesia, she opened her eyes to speech, verbalized incomprehensible sounds, and exhibited abnormal general flexion to obtain a Glasgow Coma Scale score of 8. Over the next 2 hours, Joyce's body temperature increased to 38.3" C (101'F). Despite hyperventilation, Joyce's ICP remained elevated. Her serum osmolality was 282 mOsm/L, K* level was 3.9 mmol/L, and Na* level was 139 mmol/L. Postoperative orders included the following: As Joyce recovered . r . r Fluid restriction to maintain patient's osmolality between 305 and 315 mOsm/L Furosemide (Lasix) 20 mg q6h, lV Mannitol (Osmitrol) 25 to 50 g periodic bolus Phenytoin (Dilantin) 100 mg lV q6h than72 hours, then gradually her pressure stabilized. After 2 weeks in the intensive care unit, Joyce was transferred to a neurologic step-down unit and then to a head iniury rehabilitation unit. Joyce's ICP remained elevated for more l^ @ 2004, 2001 , 1 996 Elsevier lnc. All rights reserved' 196 UNIT III NEUROLOGIC ALTERATIONS HE,AD TRAI]MA AND SUBDURAL HEMATOMA QUESTTONS l. Where does head trauma rank as a cause of death in the United States? What are the statistics associated with head trauma? lnclude morbidity and mortality information. 2. ldentify the leading causes of head injury. 3. What is the rationale for Joyce being placed on a long spine board with a Philadelphia collar? 4. What is the Clasgow Coma Scale? How is this scale helpful? 5. Differentiate the types of skull fractures associated with head trauma. What clinical presentations and pathophysiology are pertinent in these types of trauma? 6. ldentify special considerations that are necessary for patients with basilar skull fractures for placement of an endotracheal or nasogastric tube. 7. List and describe the focal injuries associated with traumatic head injury. lnclude the mechanism of injury and clinical presentation associated with each. O 2004, 2001 , 1996 Elsevier, lnc. All rights reserved Chapter 14 197 Head Trauma and Subdural Hematoma 8. List and describe the diffuse injuries associated 9, Discuss the significance of a midline shift. with traumatic head injury. 1O. ldentify the types of SDHs. lnclude the pathology and clinical presentation of SDH. 11. What surgical intervention is indicated for patients with SDH? 12, Define lCP. What methods are available for monitoring ICP? Describe the potential complications of ICP monitoring. 13. What factors determine when an ICP monitoring device is placed? 14. List and describe 15. 6" possible secondary injuries with head injury. Based on Joyce's arterial blood gas results, whatventilator changes should be anticipated? What is the desirable arterial carbon dioxide pressure (Paco) range in the presence of increased / ICP? ,l 7 O 2004, 2001, 1996 Elsevier, lnc. All rights reserved. 198 UNIT III NEUROLOGIC ALTERATIONS 16" Discuss the effect hyperventilation has on cerebral blood flow and increased ICp. l7' Describe the pathophysiology of intracranial hypertension. what is the general cause of increased lCp in patients with acute head iiluryl l8' What is autoregulation and how does it affect cerebral blood flow and lCp? 19' civen an ICP of 25 mm Hg and blood pressure of 'l 2o/72mm Hg, calculate Joyce,s cerebral pressure (cPP)' ls the CPP an acceptable value? Discusithe arawbacts of using Cpp ffiTH:"' 20' Discuss the medical management that should be anticipated for patients with head injuries. lnclude the rationale and identify at least one potential complication associated with each. 21' Define and discuss the clinical significance of posturing such as abnormal flexion and abnormal extension 22' Describe the relevance of controlling hyperthermia in the management of patients with head injuries. @ 2004, 2001 ,1 996 Elsevier, lnc. AII rights reserved. Chapter '14 Head Trauma and Subdural Hematoma 199 23. What nursing management actions are essential to prevent or minimize the effects of secondary injury in patients with head injuries? 24. what are the potential extracranial effects of increased 25' which craniar nerves must be intact before the patient eats or drinks? rCp? @ 2004, 2001 . i 996 Elsevier. lnc. All rights reserved ...
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