A patient has developed TURP syndrome postoperatively and is experiencing generalized tonic-clonic seizures due to severe hyponatremia and cerebral edema. As the nurse managing this patient, what is the most critical intervention to prioritize immediately?

A) Administer a benzodiazepine to control the seizures.

B) Increase the rate of hypertonic saline infusion to quickly correct sodium levels.

C) Position the patient in a lateral recovery position to maintain airway patency.

D) Prepare for immediate intubation to protect the airway.

A patient who underwent transurethral resection of the prostate (TURP) is experiencing severe hyponatremia with signs of cerebral edema. Despite the administration of hypertonic saline, the patient develops generalized tonic-clonic seizures. What is the most appropriate immediate nursing intervention to prioritize in this situation?

A) Administer intravenous lorazepam to control the seizures.

B) Increase the rate of hypertonic saline infusion to rapidly correct sodium levels.

C) Prepare the patient for urgent hemodialysis to remove excess fluid.

D) Monitor for signs of central pontine myelinolysis due to rapid sodium correction.

A patient with acute pulmonary edema secondary to fluid overload is on non-rebreather oxygen therapy but continues to exhibit shallow, labored breathing with a respiratory rate of 28 breaths per minute. Blood gas analysis shows worsening metabolic acidosis. Which nursing intervention should be prioritized to prevent further respiratory compromise?

B) Initiate non-invasive positive pressure ventilation to improve oxygenation and ventilation.

A) Increase the flow rate of the non-rebreather mask to maximize oxygen delivery.

B) Initiate non-invasive positive pressure ventilation to improve oxygenation and ventilation.

C) Administer a stat dose of loop diuretics to rapidly reduce pulmonary fluid overload.

D) Prepare for immediate intubation and mechanical ventilation to secure the airway.

A patient with worsening metabolic acidosis and respiratory compromise due to acute pulmonary edema is being managed with non-invasive ventilation and diuretic therapy. Which of the following is the most appropriate nursing intervention to monitor the effectiveness of these treatments and prevent further decompensation?

C) Evaluate urine output and daily weights to assess the effectiveness of diuretic therapy.

A) Increase the oxygen flow rate on the non-rebreather mask to ensure maximum oxygen delivery.

B) Monitor for changes in level of consciousness as an indicator of improving or worsening acidosis.

C) Evaluate urine output and daily weights to assess the effectiveness of diuretic therapy.

D) Prepare for intubation and mechanical ventilation as the primary intervention for acidosis correction.

A patient with acute kidney injury and pulmonary edema is experiencing confusion, agitation, hypotension, and oliguria. Despite non-invasive ventilation and diuretics, the patient's condition is deteriorating, with a serum potassium of 5.9 mmol/L, creatinine of 2.3 mg/dL, pH of 7.25, and lactate of 4.2 mmol/L. As a nurse, what is the priority intervention to address the patient's current condition?

A) Increase the rate of diuretic therapy to manage fluid overload.

B) Administer sodium bicarbonate to correct metabolic acidosis.

C) Prepare for endotracheal intubation and mechanical ventilation.

A patient with acute kidney injury and fluid overload has been started on diuretics and non-invasive ventilation. The patient's condition deteriorates with confusion, agitation, and hypotension. Lab results indicate hyperkalemia and metabolic acidosis. Which nursing action is the most critical to prioritize at this time?

D) Start an inotropic agent to stabilize hemodynamics and improve organ perfusion.

A) Administer sodium polystyrene sulfonate to address hyperkalemia.

B) Initiate a fluid bolus to improve renal perfusion and correct hypotension.

C) Prepare for the initiation of invasive mechanical ventilation to manage respiratory failure.

D) Start an inotropic agent to stabilize hemodynamics and improve organ perfusion.

A patient in the ICU presents with worsening bilateral pulmonary infiltrates, mixed respiratory and metabolic acidosis, and rising lactate levels. The critical care team is considering renal replacement therapy due to fluid overload and metabolic derangement, but the patient is hemodynamically unstable. Which intervention should the nurse prioritize to stabilize the patient and prevent further deterioration?

B) Administer vasopressors to stabilize blood pressure before considering renal replacement therapy.

A) Initiate invasive mechanical ventilation to improve oxygenation and ventilation.

B) Administer vasopressors to stabilize blood pressure before considering renal replacement therapy.

C) Increase inotropic support to enhance cardiac output and improve perfusion.

D) Implement a fluid restriction protocol to manage fluid overload.

A patient in the ICU is exhibiting signs of mixed respiratory and metabolic acidosis, with worsening pulmonary infiltrates and rising lactate levels. The healthcare team is considering initiating renal replacement therapy and invasive mechanical ventilation. Which of the following actions should the nurse prioritize to address the patient's current condition?

C) Initiate invasive mechanical ventilation to improve oxygenation and correct respiratory acidosis.

A) Administer a fluid bolus to improve hemodynamic stability and support renal perfusion.

B) Begin continuous renal replacement therapy (CRRT) to address metabolic derangements and fluid overload.

C) Initiate invasive mechanical ventilation to improve oxygenation and correct respiratory acidosis.

D) Administer sodium bicarbonate to correct the metabolic acidosis and stabilize pH levels.

A patient in critical care presents with severe metabolic acidosis, fluid overload, and suspected septic shock due to a gram-negative bacilli infection. The team has initiated continuous renal replacement therapy (CRRT) and high-flow nasal cannula (HFNC) oxygen therapy. As the critical care nurse, what immediate intervention should take priority to address the patient's worsening hemodynamic instability and respiratory distress while awaiting the effects of antibiotic therapy?

A) Increase the norepinephrine infusion to improve mean arterial pressure and systemic perfusion.

B) Prepare for immediate intubation to secure the airway and provide mechanical ventilation.

C) Administer a fluid bolus to improve peripheral perfusion and correct hypotension.

D) Collaborate with the pharmacy to ensure timely administration of meropenem and vancomycin.

A patient in critical care is receiving continuous renal replacement therapy (CRRT) for severe metabolic acidosis and fluid overload. The patient's blood cultures have returned positive for gram-negative bacilli, and the intensivist has increased norepinephrine to maintain a MAP above 65 mmHg. Despite high-flow nasal cannula oxygen therapy, the patient's oxygen saturation is 85%, and respiratory rate is 35 breaths per minute. Which nursing intervention is most critical to prioritize at this time?

A) Prepare for intubation and mechanical ventilation to address worsening respiratory distress.

B) Administer the first dose of meropenem and vancomycin to target the identified infection.

C) Monitor the patient’s electrolyte levels closely to prevent complications from CRRT.

D) Increase norepinephrine dosage further to improve peripheral perfusion and reduce capillary refill time.

turp - Nursing Case Study

Pathophysiology

• Primary mechanism: During Transurethral Resection of the Prostate (TURP), excessive resection or prolonged operation time can lead to significant absorption of irrigation fluids, especially hypotonic solutions, into the systemic circulation, causing dilutional hyponatremia known as TURP syndrome.

• Secondary mechanism: The rapid influx of hypotonic fluids results in fluid overload and electrolyte imbalance, particularly hyponatremia, leading to cellular swelling and neurological effects due to osmotic shifts across the blood-brain barrier.

• Key complication: Severe hyponatremia can cause cerebral edema, manifesting as confusion, seizures, or coma, necessitating prompt recognition and management to prevent permanent neurological damage.

Patient Profile

Demographics:

72-year-old male, retired chemical engineer

History:

• Key past medical history: Benign prostatic hyperplasia, hypertension, type 2 diabetes, chronic kidney disease stage 3

• Current medications: Tamsulosin, Lisinopril, Metformin, Insulin, Aspirin

• Allergies: Penicillin, Shellfish

Current Presentation:

• Chief complaint: Severe lower urinary tract symptoms and inability to urinate

• Key symptoms: Excruciating pelvic pain, hematuria, nausea, dizziness

• Vital signs: Blood pressure 90/60 mmHg, heart rate 120 bpm, respiratory rate 24 breaths/min, temperature 38.5°C, oxygen saturation 88% room air

Section 1

As the nursing team conducts an initial assessment post-TURP, the patient's condition is critical. Upon evaluation, the patient is found to be increasingly confused, with a Glasgow Coma Scale (GCS) score of 10, indicating a significant decline in mental status. His skin is cool and clammy, and he exhibits signs of peripheral cyanosis. The patient is disoriented to time and place, unable to follow simple commands. Neurological examination reveals sluggish pupillary response and a positive Babinski sign bilaterally, suggesting potential cerebral involvement due to severe hyponatremia and possible cerebral edema.

Laboratory results confirm the clinical suspicion of TURP syndrome. Serum sodium level is critically low at 118 mmol/L, indicating severe hyponatremia. Additionally, serum osmolality is decreased, corroborating the dilutional effect of the absorbed irrigation fluids. Renal function tests show elevated blood urea nitrogen (BUN) and creatinine, consistent with the patient's known chronic kidney disease, but now exacerbated by acute kidney injury due to fluid overload. The arterial blood gas reveals metabolic acidosis with a pH of 7.30, further complicating the patient's hemodynamic instability.

The nursing team urgently initiates interventions, administering hypertonic saline cautiously to address the hyponatremia while closely monitoring for signs of rapid sodium correction that could lead to central pontine myelinolysis. Despite these efforts, the patient suddenly develops generalized tonic-clonic seizures, indicating progression of cerebral edema. This acute complication prompts an immediate call for a neurologist consultation and preparation for possible transfer to the intensive care unit for advanced neurocritical care. The patient's deteriorating neurological status necessitates a reevaluation of the treatment plan and continuous monitoring to prevent further complications.

Section 2

As the nursing team continues to manage the patient's critical condition, they observe a rapid decline in his respiratory status. The patient's oxygen saturation drops to 85% on room air, prompting the initiation of supplemental oxygen therapy via a non-rebreather mask. Despite these measures, his respiratory rate increases to 28 breaths per minute, and he begins to exhibit shallow, labored breathing with audible crackles upon auscultation of the lung fields. Review of the patient's fluid balance indicates significant positive fluid status, pointing towards pulmonary edema secondary to fluid overload as a potential cause of the respiratory compromise.

In response to these new findings, the healthcare team orders a stat chest X-ray, which reveals diffuse bilateral infiltrates consistent with acute pulmonary edema. Concurrently, repeat blood gas analysis shows worsening metabolic acidosis with a pH now at 7.28 and a base excess of -6 mmol/L, indicating the need for aggressive intervention. Given the patient's compromised respiratory function and metabolic derangement, the decision is made to initiate non-invasive ventilation to support oxygenation and ventilation while considering diuretic therapy to manage fluid overload, all under close monitoring to prevent further decompensation.

The team remains vigilant for any signs of further deterioration, particularly given the risk of acute respiratory distress syndrome (ARDS) in the context of the patient's complex clinical picture. The interdisciplinary team, including nephrology and pulmonology, is consulted to ensure a comprehensive approach to the patient's worsening condition. This multifaceted scenario demands advanced clinical judgment to balance the correction of electrolyte imbalances, management of fluid status, and support of respiratory function, highlighting the critical nature of the patient's evolving condition and the necessity for coordinated critical care interventions.

Section 3

As the healthcare team implements non-invasive ventilation and administers diuretics, there is a brief improvement in the patient's respiratory status. His oxygen saturation increases to 92%, and his respiratory rate decreases to 22 breaths per minute, offering a momentary reprieve. However, shortly thereafter, the patient begins exhibiting signs of confusion and agitation, suggestive of worsening cerebral perfusion or metabolic imbalance. New lab results indicate a serum potassium level of 5.9 mmol/L and a creatinine level rising to 2.3 mg/dL, suggesting acute kidney injury potentially exacerbated by both the fluid overload and diuretic therapy. The blood pressure, previously stable, now reads at 88/54 mmHg, raising concerns about systemic perfusion and the potential progression to a state of shock.

In response to these alarming changes, the interdisciplinary team urgently reassesses the patient's overall condition. The nephrology consultant recommends cautious fluid management, emphasizing the delicate balance required to alleviate pulmonary edema while ensuring adequate renal perfusion. The pulmonology team evaluates the potential need for escalation to invasive mechanical ventilation, weighing the risks and benefits in the context of the patient's deteriorating mental status and persistent metabolic acidosis, now with a pH of 7.25 and a lactate level of 4.2 mmol/L.

The situation is further complicated when the patient develops hypotension and worsening oliguria, prompting the critical care team to initiate inotropic support to stabilize hemodynamics and maintain end-organ perfusion. As these interventions are enacted, the team remains vigilant for signs of further decompensation, including the possibility of septic shock or multi-organ dysfunction syndrome (MODS), necessitating continuous critical thinking and real-time adaptation of the treatment plan. The evolving case underscores the need for rigorous monitoring and dynamic reassessment, with each decision carrying significant implications for the patient's survival and recovery trajectory.

Section 4

As the healthcare team continues to monitor the patient, new diagnostic results further complicate the clinical picture. A repeat chest X-ray reveals increasing bilateral pulmonary infiltrates, suggestive of worsening pulmonary edema or possible aspiration pneumonia, given the patient's altered mental status. The arterial blood gas analysis now shows a pH of 7.22, PaCO2 of 55 mmHg, and PaO2 of 60 mmHg, indicative of a mixed respiratory and metabolic acidosis. Concurrently, the patient's lactate level has risen to 5.0 mmol/L, raising the alarm for possible progression to septic shock or further deterioration of perfusion status.

In light of these developments, the critical care team re-evaluates the current management strategy, acknowledging the growing complexity of the case. The nephrology consultant expresses concern over the persistent rise in creatinine, now at 2.6 mg/dL, and suggests renal replacement therapy as a potential measure to address both the fluid overload and metabolic derangements. However, the team must carefully weigh this option against the patient's hemodynamic instability. The pulmonology team, faced with the decision to escalate to invasive mechanical ventilation, considers the risk of barotrauma and further hemodynamic compromise in a patient with tenuous blood pressure and increasing reliance on inotropic support.

The patient's condition demands advanced critical thinking and clinical judgment, with the team navigating a precarious balance between aggressive intervention and supportive care. As they deliberate, the patient's heart rate climbs to 125 beats per minute, and he exhibits a further decrease in urine output to less than 10 mL per hour. These changes necessitate immediate action and underscore the importance of a coordinated, multidisciplinary approach to prevent further decompensation and to optimize the patient's chances for recovery. The unfolding narrative sets the stage for a critical decision-making juncture, challenging the healthcare team to adapt dynamically and effectively to the evolving clinical scenario.

Section 5

The critical care team, working under the pressure of the patient's deteriorating condition, decides to prioritize the stabilization of the patient's hemodynamics while preparing for potential renal replacement therapy. The decision is made to initiate continuous renal replacement therapy (CRRT) carefully, to address the severe metabolic acidosis and fluid overload, while minimizing rapid shifts in fluid balance that could precipitate further hemodynamic instability. As the nephrology team prepares for CRRT, the intensivist oversees adjustments to the inotropic support, increasing the dose of norepinephrine to maintain a mean arterial pressure (MAP) above 65 mmHg, recognizing the delicate balance required to support systemic perfusion without exacerbating cardiac stress.

Simultaneously, the pulmonology team initiates high-flow nasal cannula (HFNC) oxygen therapy, a less invasive option aimed at improving oxygenation while reducing the risk of barotrauma associated with mechanical ventilation. Despite this, the patient's oxygen saturation remains stubbornly low at 85%, and his respiratory rate increases to 35 breaths per minute, indicating worsening respiratory distress. The team revisits the decision to intubate, weighing the potential benefits against the risk of further hemodynamic compromise. Meanwhile, the critical care nurse notes new findings during a focused physical assessment: the patient's skin is now notably cool and clammy, with capillary refill time exceeding four seconds, indicating worsening peripheral perfusion and raising suspicions of progressing septic shock.

As the team synthesizes this complex information, a new diagnostic development adds another layer to the clinical picture: blood cultures return positive for gram-negative bacilli, suggesting a source of sepsis that demands urgent antimicrobial intervention. This finding prompts the infectious disease consultant to recommend broadening antibiotic coverage to include meropenem and vancomycin, targeting potential multidrug-resistant organisms. The team must now integrate this new information into the treatment plan, recognizing the need for rapid antimicrobial therapy to address the underlying infection while continuing to manage the patient's critical respiratory and renal challenges. This cascade of events underscores the necessity for continuous reevaluation and dynamic adaptation as the patient's status evolves.