Mrs. Terry was admitted to the ICU yesterday for severe acute septic shock. She was started on vasopressors and intubated for airway protection. During your morning assessment, you suction her ET Tube and find specks of blood in the sputum. You also note oozing at her PIV site.
You notify the provider and Respiratory Therapist (RT). Neither are concerned about the blood specks in the sputum due to a possible traumatic intubation the day before. Two hours later, you and a UAP are turning the patient when you notice a large flank hematoma and petechiae on the patient’s legs, arms, and abdomen. The patient’s left leg feels cool to touch.
You note that Mrs. Terry has even more bleeding from her IV site when you go to draw her blood. Before you can get the results back, the patient begins to vomit blood. You suction her mouth and throat, then the ET Tube and note even more blood secretions from the lungs. After a coughing fit, Mrs. Terry is now oozing blood from her eyes and nose. You immediately call the provider to the bedside and notify your charge nurse of the situation.
Over the next 8 hours, you transfuse a total of 6 units of Packed Red Blood Cells (PRBCs), 3 units of FFP, 1 unit of Cryo, and 3 liters of crystalloids. Mrs. Terry’s BP is 92/49, HR 118, Hemoglobin 7.2, Hematocrit 22%, and she is still bleeding from her ET Tube, nose, eyes, IV sites, and now rectally. The provider orders for you to insert a foley catheter to measure I&O.
During the night, Mrs. Terry develops severe acute kidney injury and is requiring 3 vasopressors. The nephrologist determines that she needs dialysis, but it is not possible because at this point it is not safe to place a Vascular Access Device. Despite continuous treatment, blood transfusions, and administration of clotting factors, Mrs. Terry’s heart stops. You and your coworkers perform CPR for more than 20 minutes, while blood is still coming from Mrs. Terry’s mouth, nose, etc. After 6 minutes in Asystole, the provider calls time of death.
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
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