Mr. R., a 33-year-old man, was involved in a motor vehicle crash in which he sustained chest injuries. Mr. R., the driver, was not wearing his seat belt, and the steering wheel was bent. At the scene, Mr. R. was unresponsive. After placing a cervical collar to stabilize his neck, the paramedics performed endotracheal intubation and provided ventilation with 100% oxygen via a bag-valve device. Vital signs included a palpable systolic blood pressure (BP) of 60 mm Hg and a heart rate of 136 beats per minute. Mr. R.’s skin was pale, cold, and clammy with a delay in capillary refill. Peripheral pulses were weak and thready. Two 14-gauge peripheral intravenous catheters were inserted, and lactated Ringer’s solution was infused at a wide open rate. He was transported to the emergency department on a backboard. The initial assessment in the emergency department noted that his palpable BP had increased to 90 mm Hg, and heart rate was 125 beats per minute. He was restless in response to pain, with no other purposeful responses. Pupils were equal and reactive to light. Chest expansion was unequal, and breath sounds were markedly diminished on the right side. A chest x-ray documented a 70% hemopneumothorax on the right side, and a 36-French chest tube was inserted at the eighth intercostal space at the right midaxillary line. Immediately, 2000 mL of blood was drained from the chest, and an additional 500 mL of drainage was recorded in the next 30 minutes. Initial laboratory results were:
An indwelling urinary catheter was inserted, and 80 mL of clear, yellow urine immediately drained. Fluid resuscitation was continued to maintain a systolic BP at 90 to 100 mm Hg. Mr. R. was taken immediately to the operating room, where a right thoracotomy was performed, with repair of the right axillary artery. In the operating room, his vital signs remained stable with continued fluid resuscitation of crystalloids, blood, and fresh frozen plasma.
After surgery, he was admitted to the critical care unit, where his BP was 116/70 mm Hg, heart rate was 90 beats per minute, and respiration rate was 24 breaths per minute on the ventilator (assist/control mode with a rate of 20 breaths per minute). He was responsive to commands and denied pain. He was medicated with morphine, 4 mg intravenous push every hour for pain. Laboratory results were:
Questions
1. What type of shock did Mr. R. demonstrate at the scene, and what components of his assessment supported this diagnosis?
2. Mr. R.’s initial assessment indicates that he is in which stage of shock?
3. In the emergency department, Mr. R. received lactated Ringer’s solution for fluid resuscitation. Is this the appropriate solution at this time?
4. Explain Mr. R.’s arterial blood gas results. What treatment is indicated?
5. Describe the nursing care Mr. R. will receive in the first 24 hours after his surgery.
6. Describe the risk factors Mr. R. has for developing sepsis.