• Case – Catherine’s Story
You are a graduate nurse and have just commenced your morning shift on the medical ward of a large tertiary hospital. You have been allocated the care of four patients, including Catherine Bexley, a 77 year old woman who was admitted last night via the Emergency Department with R) lower lobe pneumonia. Catherine has a past history of ischemic heart disease, hypertension, and hypercholesterolaemia. Her current medications are Aspirin 100mg mane, Ramipril 10mg mane, Spironolactone 50mg mane, Atorvastatin 80mg nocte.
In ED: The night shift staff hand over that Catherine was initially quite short of breath in the ED and so the team were wondering if she may need HDU, however post oxygen and antibiotics she improved in the ED and so was safe for the ward. Catherine received 1gm of Ceftriaxone in the ED at 0030. She was transferred to the ward at 0130. On arrival to the ward Catherine’s vital signs were RR 24 breaths/min, SpO2 98% on 2L via nasal prongs, HR 96 regular, BP 140/90mmHg, GCS 15/15, Temp 37.1oC, pain 3/10 in her R) lower chest with deep inspiration. Her ECG is NAD. The nursing staff state that Catherine has slept well since her arrival on the ward. They state that she has an IDC insitu that was emptied when she arrived at 0130.
In the Word: When you enter Catherine’s room at 0720 you find Catherine to appear short of breath, she has an increased work of breathing and is talking to you in short sentences. She appears confused and she has removed her IV line from her right cubital fossa and there is blood on the sheets. You don gloves and begin an assessment.
Observations:
Cardiovascular: BP 90/65mmHg, HR 120 bpm, weak, thready radial pulse, skin flushed and sweaty. Capillary refill is 3 seconds.?
Respiratory: RR 36 breaths/min; increased work of breathing, she is using her upper accessory muscles. She has decreased air entry to her R) lobe to midzone, pulse oximetry is 91% on 2L O2 via nasal prongs.?
Temperature: 38.9oC?
Neurological: 14/15, confused to day and place, PEARL 3mm, she is complaining of 5/10 pain in the lower part of R) chest with deep inspiration?
BSL: 14.4 mmol/L
Renal: 30mL in IDC drainage bag since 0130
You call the nurse in charge who agrees you need to call a MET call.
The Medical Emergency Team (MET) is called for Catherine, and they insert a triple lumen CVC into her R) subclavian vein, which is sutured so Catherine is unable to remove this. They
• Order 2L of Normal Saline 0.9% STAT and ask you to
• Administer 500mg of Azithromycin, which they have charted.
• They ask you to increase her oxygen.
• The ICU registrar asks you collect the pathology tests she has written on the pathology slip.
1. Provide an introduction to your essay. Outline what the context of the paper is, and the scope / structure of your essay. ?
Provide a succinct but detailed description of the structured primary assessment approach you would use when assessing Catherine. For each assessment step provide a rationale and example of what has been assessed. ?DRABCDE (• Danger?• Response?• Airway • Breathing • Circulation? • Disability?• Exposure)
2. Based on the assessment findings discuss ONE relevant focused assessment that you would perform on Catherine. Provide a succinct rationale for each step in the assessment process. ?(Respiratory system)
3. Provide a definition of the type of shock that Catherine is experiencing (Septic shock). Explain the pathophysiology of Septic shock. In your answer explain the pathophysiology of each clinical manifestation that Catherine is experiencing that directly relates to Septic shock. ?
4. When the MET team arrives they provided you with strategies to treat Catherine’s shocked state (Septic shock). Prioritise four (4) of the evidenced based nursing interventions the MET team has instructed you to implement (above) so you can care for Catherine. Describe each intervention and rationalise it. Your nursing interventions need to specifically relate to Catherine’s presentation and shock management. You need to discuss these interventions in order of priority ?
1- oxygen 2- normal saline 3- antibiotic 4- pathology test
