You are the 1900- 0700 charge nurse on the intermediate cardiac care unit in a large hospital. One of the patients, R.J., is being cared for by a new graduate nurse under your supervision. R.J. was admitted at 1300 after an auto accident in which he sustained a chest contusion and fractures of the fourth and fifth ribs on his left side. At about 2000 hours, his wife runs up to you at the nurses’ station and says, “I think my husband just had a heart attack. Come quick!” She follows you into his room, where you find him still in bed. He is breathing and is cyanotic from the neck up. His pulse is rapid but very weak.
1. What will your first action be?
2. What immediate care will you provide to R.J.?
3. Given R.J.’s admitting diagnosis, what differential diagnoses do you consider?
4. What immediate information do you need to obtain from the nurse who is caring for R.J.?
5. Suddenly you remember R.J.’s wife, who is anxiously hovering over you in the room. What are you going to do?
CASE STUDY PROGRESS
The code team arrives. R.J.’s trauma surgeon is making rounds on your unit when the code is called, and he runs into the room. R.J. is intubated, and the normal saline lock is changed to an IV of lactated Ringer’s solution at “wide open.” The trauma surgeon recognizes Beck’s triad associated with cardiac tamponade and calls for a cardiac needle and syringe. He inserts the needle below the xiphoid process and aspirates 75 mL of unclotted blood.
6. What is Beck’s triad?
7. Describe cardiac tamponade.
8. What is the most likely reason R.J. developed cardiac tamponade?
9. Explain why the surgeon performed a pericardiocentesis.
10. What is the significance of the surgeon aspirating unclotted blood?
11. The surgeon orders IV dopamine to “begin at 4 mcg/kg/min and titrate to maintain a systolic BP over 100 mm Hg.” What is the reason for this order?
12. The stock dopamine solution contains 320 mg dopamine in 100 mL of 5% dextrose. R.J. weighs 240 lb. How many micrograms should R.J. receive per minute? How many total milligrams of dopamine should R.J. initially receive per hour? (Round to the hundredth.) At how many milliliters per hour would you set the infusion pump? (Round to the tenth.)
13. Describe how you titrate a dopamine infusion.
14. Since R.J. underwent an emergency pericardiocentesis, which nursing interventions should you include in his immediate postprocedural care? (Select all that apply)
- Maintain continuous ECG monitoring
- Closely assess for further cardiac tamponade
- Obtain blood cultures at two sites and send to the laboratory
- Be prepared for an emergency thoracotomy if tamponade recurs
- Observe for complications such as bleeding and cardiac dysrhythmias
15. Name 4 assessment findings that would show R.J. is responding to the immediate actions.
CASE STUDY PROGRESS
R.J. is being transferred to the intensive care unit (ICU) for observation.
16. Using the SBAR framework, describe the report you will give the ICU nurse.
17. As the team prepares R.J.’s transfer, you go find R.J.’s wife to thank her for alerting you to the emergency so promptly and to tell her what has happened. Briefly, and in lay terms, how would you explain what happened to her husband?
18. As you both get up to leave, Mrs. J. suddenly turns pale and says she feels very dizzy. What should you do?
CASE STUDY OUTCOME
Once in the ICU, R.J. underwent placement of a central venous catheter and an emergency echocardiogram. After finding about 50 mL of additional fluid in the pericardial sac, the decision was made to take R.J. to the operating room. A thoracotomy was done with repair of a right atrium laceration. He made an uneventful recovery and was discharged home on postoperative day 5.
