WESTERN MINDANAO STATE UNIVERSITY

COLLEGE OF NURSING
ZAMBOANGA CITY

EMERGENCY ROOM RELATED LEARNING EXPERIENCE

ALTERNATIVE LEARNING SCHEME

Saavedra, Chryst Louise M.

BSN 3C

ACTIVITY #1. CASE STUDY SCENARIO

Instruction: Given the following case study scenario, comply the following:

1. Answer the questions after each case study presented.

2. Conduct a comprehensive study of the illness condition; illustrate organ involved,

physiology and pathophysiology of the disease condition.
3. Formulate at least three (3) identified and prioritized nursing diagnoses.

4. Generate one (1) appropriate Nursing Care Plan from identified nursing
diagnosis of your choice (use prioritization).
5. Relate pharmacological interventions utilized in the treatment of disease
condition (Drug Study).

Case Study Analysis #1

A 11 month-old-female named Odette with no significant past medical history and

in her usual state of health presented to ED after a sudden event of unresponsiveness
(GCS 3). Reportedly, according to the mother, the patient was eating when she threw
her head back and became unresponsive. She also stated that her daughter was barely
breathing. On the arrival of emergency medical services (EMS) the patient had a
respiratory rate of 4 with weak pulses and bag valve mask ventilation was initiated for
apnea. The patient was transported to the nearest hospital. On arrival, the patient was
bradycardic (65Bpm) and hypotensive (60/40mmHg), with a rectal temperature of
35.1°C, 02sat at 53%. In response, endotracheal intubation was done for acute
respiratory failure as well as dopamine drip IV at 5cc/hr was given to increase the blood
pressure and heart rate. Imaging obtained including a CT scan of the head which was
negative for any acute pathology and a chest X-ray with findings shown in figure 1.

Figure 1. Boot-shaped heart with unilateral atelectasis left

The patient’s lab work was significant for Arterial Blood Gas PH: 7.35; CO2:
51mmHg; HCo3: 31meq/L (Respiratory Acidosis), the patient’s heart rate was 187,
blood pressure was 120/72, oxygen saturation was 100% while being bagged through
the ET tube upon transport to the Respi-ICU and eventually hooked to a mechanical
ventilator. Sodium Bicarbonate IV 20meqs/ml was given to correct the acidosis. A
complete nurse to nurse endorsement was done to the RESPI-ICU nurse on duty
named Pharsa.

QUESTIONS:

1. Figure 1. Showed an xray with what seems to be a Boot-shaped heart with

unilateral atelectasis (Left). A “boot” shaped heart is a Hallmark sign of what
illness condition? _Tetralogy of Fallot_. (Use this answer to formulate your SIC).
2. What would be the most important nursing intervention for patients experiencing
“Tet spells”? (Clue: _Q_ A_T_ _G).
 Answer: Squatting
3. As stated, the patient’s lab work was significant for Arterial Blood Gas PH: 7.35;
CO2: 51mmHg; HCo3: 31meq/L which indicated respiratory acidosis. Does the
following results indicate:

A. Partial Compensation
B. Full Compensation
C. No Compensation

Answer: B Full compensation

4. Please indicate the normal values among blood gases (Arterial vs Venous)

Arterial Venous

A. PH 7.35 to 7.45 7.30 to 7.40

B. Pco2 35 to 45 mmHg 42 to 48 mmHg
C. HCO3 22 to 28 mEq/L 24 to 30 mEq/L
D. Po2 80 to 100 mmHg 35 to 45 mmHg
 ACTIVITY #2 BACK TO THE BASICS

I. Illustrate the normal cardiac cycle / circulation (10 pts)

II. Name 3 classifications of cardiac medications and give 2 examples each (6pts)

Anticoagulants
 Apixaban (Eliquis)
 Heparin (various)

Antiplatelet Agents and Dual Antiplatelet Therapy (DAPT)

 Aspirin
 Dipyridamole (Persantine)

Angiotensin-Converting Enzyme (ACE) Inhibitors

 Benazepril (Lotensin)
 Captopril (Capoten)
III. Identify and label the correct lead placement via cardiac monitor (Not ECG leads)
(6 pts)

RA LA

LL

Activity #3 DRUGS AND IV FLUID CALCULATIONS (2PTS EACH) *Please include

your solution

1. A health care provider prescribes Gentamycin (Gentam) 7.5 mg/kg IM q 12 hr;

Available: kanamycin 0.35 Gm/mL. How many mL will you administer for each
dose to a 157 lb patient? (Use one decimal place).
1 kg
157 lbs x = 71.36kg
2.2lbs
7.5 mg
x 71.36kg = 535.2mg
kg
7.5535.2 mg
= 0.54gm
1000 gm
Desired dose
( x Volume)
Stock on hand

0.54 gm
x 1 ml = 1.5ml
0.35 gm
2. A patient is for discharge in the OPD and the nurse gives the discharge
instructions for a patient who must take Lactulose (Lilac) 30 mL PO. How will you
 instruct the patient to measure the dose using ordinary household measuring
devices?
A: Tsps.:_ 30ml x 0.20tsp/ml = 6tsps
B. Tbsp.:_ 30ml x 0.07tbsp/ml = 2.1 or 2 tbsps

3. Tranexamic Acid 500mg IV push now then 250mg IV push every 12hours
thereafter. Stock on hand is Tranexamic Acid 100mg/ml in a 5ml ampule.
a. How many ml will you give for the now dose? 500mg/100mg x 1ml = 5 ml
b. How many ml will you give every 12 hours? 250mg/100mg x 1ml = 2.5 ml

4. Start Nicardipine drip. Nicardipine 10mg + D5W 90ml to run at initially

20mcgtts/min with target SBP 130mmHg with increments of 5mcgtts/min q1*
(12:00). Stock on hand Nicardipine 1mg/ml in a 10ml ampule. How many ml/hr
will you run the drip at different times with different systolic blood pressure?
20 mcgtts 60 min 1ml
x x = 20 ml/hr for 12:00
min 1 hr 60 mcgtts

5 mcgtts 60 min 1ml

x x = 5ml/hr
1min 1 hr 60 mcgtts
a. At 13:00, SBP is at 140mmHg: 20ml/hr + 5 ml/hr = 25ml/hr
b. At 14:00, SBP is at 150mmHg: 25ml/hr + 5 ml/hr = 30 ml/hr

5. Start Dobutamine Double Concentration (2000mcg/ml) drip at 13mcg/kg/min.

Patient’s Weight is 80kg. Compute for flow rate (ml/hr).

80kg x 13mcg/kg/min = 1040 mcg/min

1040 mcg 60 min 1 ml 62400 ml
x x = = 31.2 ml/hr
1 min 1 hr 2000 mcg 2000 hr

BONUS QUESTION (6PTS):

 6. 12:00-Start down titrating Dopamine 200mg/250ml at 15mcg/kg/min by 4ml/2hrs
to titrate SBP greater or equal to 100mmHg. Patient weight is 60kgs. Compute
for the actual dose of the following time:
60 kgs x 15 mcg/kg/min = 900 mcg/min
900 mcg 60 min 1 mg 250 ml 13500000ml
x x x = = 67.5 ml/hr
1 min 1 hr 1000 mcg 200 mg 200000 hr

a. 14:00: 67.5 ml/hr – 4ml2hrs = 63.5ml/hr

b. 16:00: 63.5ml/hr – 4ml/2hrs = 59.5ml/hr
c. 18:00: 59.5ml/hr – 4ml/2hrs = 55.5ml/hr

STUDY OF ILLNESS CONDITION

Systems/ Organs Normal Pathophysiolog Assessment Cluster of Cues Analysis

Involved Function y Parameter
The normal Tetralogy of Patient is
heart has four Fallot involves experiencing
Systems/ Organs chambers. The four defects that Probable: Probable: Acute
Involved two upper include pulmonic Assess heart rate  A bluish Respiratory
chambers stenosis, and blood coloration of Failure
known as atria ventricular septal pressure the skin secondary to
are separated defect, right Note skin color, caused by Tetralogy.
from each ventricular temperature, and blood low in Patient may
other by a hypertrophy, and moisture. oxygen experience A
fibrous an aorta that Check for (cyanosis) higher risk of
partition overrides the peripheral pulses,  Shortness of getting an
known as the ventricular septal including breath and infection of
atrial septum. defect. capillary refill. rapid the layers of
The two lower Transposition of Assess heart breathing, the heart,
chambers are the great vessels sounds for gallops especially called
known as is a condition in Monitor during endocarditis
ventricles and which the aorta electrocardiogra feeding or and delayed
are separated arises from the m (ECG) for rate, exercise growth and
from each right ventricle rhythm, and  Loss of development.
Circulatory system/ other by the instead of the left ectopy. consciousness All babies
Heart ventricular ventricle, and the (fainting) who have
septum. Valves pulmonary artery  Irritability tetralogy of
connect the arises from Actual:  Tet spells Fallot need
atria (left and the left ventricle Assessed the corrective
 right) to their instead of the patient’s vital Actual: surgery.
respective right ventricle, signs. The patient was Without
ventricles. The thereby causing a Imaging obtained unresponsive treatment,
valves allow reversal of the including a CT (GCS 3), barely the baby
for blood to be normal position scan and a chest breathing, might not
pumped of these arteries. X-ray. bradycardic, grow and
through the Transposition of Lab work was hypotensive, develop
chambers. the great vessels done for Arterial 02sat at 53%, has properly.
Blood travels is incompatible Blood Gas to a low heart rate
Respiratory system / from the right with life unless determine the of 187, blood
Lungs ventricle septal defects are acidosis pressure was
through the also present to oxygen saturation 120/72.
pulmonary allow mixing of was also assessed
artery to the blood from the
lungs where it two circulations.
receives
Medical Diagnosis: oxygen. The
Acute Respiratory Failure blood returns
secondary to Tetralogy of to the heart
Fallot through
pulmonary
veins and
enters the left
ventricle. The
left ventricle
sends the now
oxygen-filled
blood into the
main artery of
the body
(aorta). The
aorta sends
the blood
throughout the
body.
In a normal
heart, the
aorta is
attached to the
left ventricle
and allows
oxygen-rich
blood to flow
throughout the
body.

Nursing Diagnoses
 1. Ineffective Breathing Pattern
2. Decreased Cardiac Output due to boot-shaped heart
3. Compromised Family Coping due to family’s concern fear about infant/child’s
disease and condition

Nursing Care Plan

Assessment Diagnosi Planning Intervention Rationale Evaluation

s
Subjective cues: Ineffective After 8 Monitor for Paradoxical movement Monitored for
diaphragmatic of the abdomen (an diaphragmatic muscle
 According to Breathing hours of
muscle fatigue or inward versus outward fatigue or weakness
the mother, Pattern nursing weakness movement during (paradoxical motion).
(paradoxical inspiration) is indicative
the patient intervention,
motion). of respiratory muscle
was eating the patient fatigue and weakness.
when she will be able
threw her to breathe.
head back
and became
unresponsive
.
 She also
stated that
her daughter
 was barely
breathing

Objective Cues:
 HR: 65Bpm
 Temp: 35.1°C
 BP:
60/40mmHg
 02sat: 53%
Evaluate skin Lack of oxygen will Evaluated skin color,
color, cause blue/cyanosis temperature, capillary
temperature, coloring to the lips, refill; observe central
capillary refill; tongue, and fingers. versus peripheral
observe central Cyanosis to the inside cyanosis.
versus peripheral of the mouth is a
cyanosis. medical emergency!
Provide Beta-adrenergic Provided respiratory
respiratory agonist medications medications and
medications and relax airway smooth oxygen, per doctor’s
oxygen, per muscles and cause orders.
doctor’s orders. bronchodilation to open
air passages.
Position child in Upright position is Positioned child in
semi-Fowler’s recommended to semi-Fowler’s
position. (or reduce preload and position. (or squatting)
squatting) ventricular filling when
fluid overload is the
cause; Facilitates lung
expansion.
Administer The failing heart may Administered oxygen
oxygen therapy not be able to respond therapy as prescribed.
as prescribed. to increased oxygen
demands. Oxygen
saturation need to be
greater than 90%.
Administer Administered
medications as medications as
prescribed: prescribed
Digoxin (Lanoxin) Increases contractility
of the heart and force
of contraction.
Alprostadil (Prosti Maintain open PDA
n VR Pediatric) when needed for blood
flow.
Furosemide (Lasix Decreases edema
); spironolactone formation and diminish
 (Aldactone) afterload.

Drug Study

Dopamine
Generic Name: Mechanism of Side Effect: Nursing
Dopamine Action:  Irregular Responsibilities:
heartbeats.
Brand Name: Dopamine is a  Instruct patient to
 Nausea.
Intropin, precursor to inform nurse immed
 Vomiting.
Dopamax, norepinephrine in  Anxiety. iately of pain or
Dopazef, Hospira noradrenergic  Headache. discomfort at the
Dopamine HCl, nerves and is  Chills. site of ad-
Hospira Dopamine also a  Goosebumps. ministration.
 Shortness of
HCl in 5% neurotransmitter Increase in BP.
breath.
dextrose solution in certain areas of Increase in
(Premixed) the central Adverse Effect: peripheral
Classification: nervous system. Significant: Arrythm circulation. Increase
Inotropic Agents, Dopamine ia, extravasation. in urine output.
vasopressors produces positive Blood and lymphatic  Monitor BP, heart
Dosage/Frequen chronotropic and system rate, pulse
cy: inotropic effects disorders: Azotaemia pressure, ECG,
For infants: 2-20 on the . pulmonary capillary
micrograms/kg/mi myocardium, Cardiac wedge pressure
nute by resulting in disorders: Anginal (PCWP), cardiac
continuous IV increased heart pain, atrial output, CVP, and
infusion rate and cardiac fibrillation, urinary output
Adult: For contractility. bradycardia, continuously during
correction of Indication: palpitation, ectopic administration.
haemodynamic Acute heart beats, tachycardia,  Monitor urine output
imbalance as failure, and ventricular frequently
present in shock, stimulation of conduction, widened throughout
MI, open heart alpha1-receptors: QRS complex. administration.
surgery, renal Induce Gastrointestinal Report decreases
failure, or cardiac vasoconstriction disorders: Nausea, in urine output
decompensation: primarily in skin promptly
vomiting.
Initially, 2-5 and mucous  If excessive
Nervous system
mcg/kg/minute, membranes, hypertension
disorders: Headache.
increased nasal occurs, rate of
Psychiatric
gradually by up to decongestion infusion should be
disorders: Anxiety.
5-10 Contraindication decreased or
Respiratory, thoracic
mcg/kg/minute : temporarily
and mediastinal
according to Phaeochromocyt discontinued until
disorders: Dyspnoea.
patient's blood oma, BP is decreased.
Skin and
pressure, cardiac hyperthyroidism,  If hypotension
subcutaneous tissue
and urine output. uncorrected occurs,
disorders: Piloerecti
For severe cases, tachyarrhythmias administration rate
on.
up to 20-50 or ventricular should be
Vascular
mcg/kg/minute fibrillation. increased. If
disorders: Hypertens
may be required. Concurrent use ion, hypotension. hypotension
Route: with Potentially continues, more
Intra Venous (IV) cyclopropane and Fatal: Rarely, potent
halogenated ventricular vasoconstrictors
hydrocarbon arrythmia, gangrene (norepinephrine)
anaesthetics. (high dose) may be
administered.

Sodium
Bicarbonate
Generic Name: Mechanism of Side Effect: Nursing
Sodium Bicarbonate Action: Responsibilities
 Aggravated conges
Brand Name: Acts as an
tive heart :
Hospira Sodium alkalinizing agent failure (CHF)  IV: Assess fluid
 Cerebral hemorrha
Bicarbonate, Rhea by releasing balance (intake
ge
bicarbonate ions.  Swelling (edema)
Sodium and output,
 High blood
Following oral daily weight,
Bicarbonate, sodium levels
administration,  Low edema, lung
Classification: blood calcium levels
releases sounds)
antiulcer agents  Low blood
bicarbonate, which potassium levels throughout
Dosage/Frequency  Muscle spasms
is capable of (associated with low therapy. Report
:
neutralizing gastric calcium levels) symptoms of
PO (Adults): 48 mEq  Metabolic alkalosis
acid.  Belching fluid overload
(4 g) initially. Then
Indication:  Bloating (hypertension,
12– 24 mEq (1– 2 g) q  Excess fluid in
PO, IV:Management the lungs (pulmonary edema, dyspnea,
4 hr (up to 48 mEq q 4
of metabolic edema) rales/crackles,
hr) or 1 tsp of powder  Hyperosmolality
acidosis. PO, IV:  Intracranial acidos frothy sputum)
q 4 hr as needed.
Used to alkalinize is if they occur.
PO (Children): 1– 10  Milk-alkali syndro
urine and promote  Observe IV site
mEq/kg (84– 840
mg/kg) per day in excretion of certain me closely. Avoid
divided doses. drugs in overdosage extravasation,
Adverse Effect:
IV (Adults and situations as tissue
Metabolic alkalosis;
Children): 2– 5 (phenobarbital, irritation or
mood changes,
mEq/kg as a 4– 8 hr aspirin). PO: cellulitis may
infusion. Antacid. Unlabeled tiredness, shortness of occur. If
Use:Stabilization of breath, muscle infiltration
acid-base status in weakness, irregular occurs, confer

Route: cardiac arrest and with physician

heartbeat; muscle
Intra Venous (IV), treatment of life- or other health
hypertonicity, twitching,
threatening care
Per orem (PO)
tetany; hypernatraemia,
hyperkalemia professional
Contraindication hyperosmolality, regarding warm
: hypocalcaemia, compresses and

Metabolic or hypokalaemia; stomach infiltration of

respiratory site with

cramps, flatulence.
alkalosis; lidocaine or
Tissue necrosis at inj
Hypocalcemia; hyaluronidase.
site.
Hypernatremia;  Obtain arterial
Excessive chloride blood gases
loss; As an antidote (ABGs)
following ingestion frequently in
of strong mineral emergency
acids; Patients on situations and
sodium-restricted during
diets (oral use as an parenteral
antacid only); Renal therapy.
failure (oral use as  Monitor urine
an antacid only); pH frequently
Severe abdominal when used for
pain of unknown urinary
cause, especially if alkalinization.
associated with  Antagonizes
 fever (oral use as an effects of
antacid only). pentagastrin
and histamine
during gastric
acid secretion
test. Avoid
administration
during the 24 hr
preceding the
test.

References:

https://www.cdc.gov/ncbddd/heartdefects/tetralogyoffallot.html

https://www.mayoclinic.org/diseases-conditions/tetralogy-of-fallot/symptoms-
causes/syc-20353477

https://nurseslabs.com/5-congenital-heart-disease-nursing-care-plans/

Nursing Care Plans, Edition 9 - Murr, Alice, Doenges, Marilynn, Moorehouse, Mary

Pathophysiology - Concepts of Altered Health States 7th Edition - Carol Mattson Porth