Patient D, a man 76 years of age, who fell at home yesterday and…

Question Answered step-by-step Patient D, a man 76 years of age, who fell at home yesterday and… Patient D, a man 76 years of age, who fell at home yesterday and has a history of falling. There is point tenderness at the hip joint, and the patient is unable to ambulate. The orthopedic surgeon requests an MRI of the hip and pelvic area to determine what, if any, injury could be causing this pain and dysfunction.Patient D states that he is very claustrophobic and initially refused the MRI because of the fear of the “tube.” After discussion with the surgeon, with a guarantee that he would be sedated and comfortable, Patient D agreed to the scan.Upon review of the patient’s history, it is determined that he has a history of congestive heart failure, smokes two packs of cigarettes a day, and denies alcohol ingestion. The nurse performs a pre-sedation assessment, obtaining baseline vital signs and auscultates the patient’s heart and lungs. The patient is asked to open his mouth wide, and a Mallampati score of 2 is assigned to the patient. The patient is questioned about any dentures or partials, which he denies. An anesthesia history is obtained; the patient has had two previous surgeries under general anesthesia. He denies any complications with either procedure.Due to the patient’s history of congestive heart failure, the nurse reviews the chart for a current 12-lead electrocardiogram and finds that one was obtained yesterday on admission. Additionally, Patient D’s admission laboratory values are reviewed. The only abnormality is a potassium level of 3.3 mEq. The nurse determines that the patient is a Class 3 on the ASA Risk Classification score. The nurse also reviews the patient’s current medication use, which includes digoxin, furosemide, and naproxen for arthritic pain control.Although the surgeon reviewed the moderate sedation procedure with the patient, the nurse conducts patient education as well. The nurse explains that the patient will be receiving medications to help him relax and decrease his fears about the scanner. Patient D responds, “Just knock me out. I don’t want to remember or feel a thing!” The nurse then proceeds to offer further information; it is imperative that the patient recognize that he will not be asleep. The patient may be asked to respond to questions throughout the procedure to adequately assess the level of sedation. Additionally, the nurse explains that the medications can help alleviate some of the patient’s pain, but there is discomfort that is experienced from lying on a hard table. The patient is assured that everything will be done to make the patient as comfortable as possible, but the procedure is not discomfort-free.At this point, Patient D reconsiders his decision to have the procedure performed. When he agreed to the procedure it was his understanding that he would be asleep, similar to what occurs with general anesthesia. It is unfortunate that the surgeon allowed the patient to develop this misunderstanding; it not only delayed the start of the procedure but backfired in that the patient’s level of anxiety was heightened. It took the nurse more than 20 minutes to educate the patient and receive his permission to continue with the scan.In preparing the room for Patient D, the nurse has only recently finished sedating the first patient and knows the equipment was functional. She places the patient on the monitor, pulse oximeter, and oxygen by face mask. Pre-sedation vital signs are obtained and compared to the vital signs obtained on the inpatient unit. An oxygen saturation of 91% is obtained prior to initiating oxygen therapy, as is expected. With oxygen, the saturation increases to only 93%. The existing IV line is checked for patency.The medications ordered for Patient D include midazolam 2 mg IV, fentanyl 50 mcg IV, and methohexital 10 mg IV, as needed. The nurse draws the appropriate dosages into syringes and labels each. Learning from the first patient, the nurse draws both flumazenil (0.2 mg) and naloxone (1 mg) and labels these syringes as well.The radiologist orders the sedation to be initiated, and the nurse administers 2 mg midazolam IV over one minute. The patient demonstrates a slight drop in blood pressure; however, it is within acceptable limits. The patient remains quite agitated, asking when the medication is going to work. At this point, the nurse administers 25 mcg fentanyl IV. Patient D’s blood pressure starts to fall after the dose of fentanyl, and the IV rate is increased. The patient continues to complain of discomfort and fear. His heart rate increases to a rate of 90 bpm (from a normal of 62 bpm). The radiologist requests additional sedation medication in an attempt to achieve an appropriate level of sedation in this patient.The nurse then administers an additional 2 mg IV of midazolam. Patient D appears to relax, and he is moved into the “tube.” Immediately upon entering the tube, the patient becomes severely agitated, asking to get out, and calling out, “Somebody help me.” It is obvious that the patient’s level of sedation is inadequate at this point, and the patient is removed from the scanner. The nurse enters the room and notes that the patient is very confused; he is unable to answer appropriately to his name, he is calling for his wife (who had died three years before), and his blood pressure, pulse, and respiratory rate are all quite high.The radiologist orders an additional 3 mg IV of midazolam, which the nurse administers. At this point, Patient D appears more relaxed; however, when the nurse approaches the patient to listen to his heart and lungs, the patient starts thrashing about on the table. Obviously, Patient D is at risk of further injury, especially at the injured hip joint. The radiologist orders an additional 3 mg IV midazolam. However, the nurse refuses to administer this dose based upon concern of over-sedation, common to the elderly individual. The nurse expresses this concern, and the order is changed to fentanyl 50 mcg IV. The nurse agrees to administer the fentanyl, and upon administration, the patient experiences a short burst of ventricular tachycardia that spontaneously converts to the patient’s normal rhythm.At this point, the radiologist decides to cancel the procedure until such time that the patient can be appropriately sedated. It is obvious that the radiologist blames the nurse for the patient’s deterioration.Despite the apparent animosity, the nurse’s responsibility is to stay with Patient D and provide for his safety. The patient’s oxygen flow rate is increased, after which the patient becomes quite agitated and removes the oxygen mask. While the nurse is preparing an amiodarone bolus to prevent further episodes of ventricular tachycardia, the patient becomes agitated to the point of requiring restraints. The nurse looks for assistance from other staff members but has been left alone with Patient D.At this point, the nurse remembers the naloxone and administers 1 mg IV, hoping to see a reduction in the patient’s level of agitation. However, this is not accomplished. Subsequently, flumazenil (0.2 mg IV) is administered, and the patient begins to appear more relaxed, with improving vital signs.After three minutes, the nurse administers a second dose of flumazenil, and Patient D is able to answer questions appropriately. Throughout this time period, the nurse continues to assess Patient D’s vital signs, which are slowly returning to normal.Once the patient reaches his pre-sedation level of functioning, the nurse transfers the patient back to the inpatient unit. Upon moving the patient into his bed, he asks, “What did they find?” Patient D is unaware that the procedure had not been completed.Complete a SBAR on the patient in the case study: SBARSituation:                                     Background:  Assessment:   Recommendation: Health Science Science Nursing NURS 450 Share QuestionEmailCopy link Comments (0)