13

Mrs. L is a 72-year-old woman who was admitted to the emergency department after she fell down the stairs of her apartment. Upon assessment, she was diaphoretic and pale and has diminished pulses in her bilateral lower extremities. She complained of 8/10 pain in her pelvic region and upon palpation, her pelvic was found to be unstable. Her vital signs upon admission were: temperature of 97.8, RR of 26, HR of 148, and a BP of 74/40. Laboratory values were Hgb of 6.8, Hct of 22.6%, BUN of 28, creatinine of 1.4, and a serum lactate of 6.8 mmol/L. Her ABG’s showed metabolic acidosis. A pelvic CT scan revealed an open book fracture. She was admitted to the ICU with a diagnosis of pelvic fracture and hemorrhage where she received fluid resuscitation and multiple units of packed RBC’s. After surgical repair and stabilization of her pelvis she remained in the ICU on a ventilator and was hemodynamically stable. Her vital signs post-op day 1 were: temperature of 98.8, RR 12 (ventilated), HR 84 , and a BP of 108/64. Attempts at weaning Mrs. L off the ventilator have been unsuccessful and she remained in the ICU on the ventilator. By post-op day 3, Mrs. L is extubated successfully. The following morning, Mrs. L’s family reported that she is growing increasingly agitated and had been pulling at the IV lines. Her vital signs revealed that she was going into septic shock. Mrs. L was then reintubated and fluid resuscitation and broad-spectrum antibiotics were initiated. She was started on vasopressors because a satisfactory BP could not be achieved. Mrs. L is now unable to follow commands and unresponsive to painful stimuli. On post-op day 7, Mrs. L goes into acute respiratory distress syndrome (ARDS). The physician and family discuss options for her future care, and the option of DNR and withdrawal of life support is discussed with the family.

Questions

1. Mrs. L’s ARDS resulted from her Hypovolemic and septic shock. What are the nursing interventions and goals for managing hypovolemic and septic shock?
2. What are the nurse’s roles regarding the conversation the family had with the physician about DNR and withdrawal of life support?
3. If life support is removed and a DNR is put in place, what are the goals for care?