Hello, i need some help. I have this case study i need assistance with. Here is the scenario:
"Mrs. Perry has been admitted to the ward via the emergency department (ED) with a historyof severe abdominal pain due to pancreatitis. Mrs Perry informed staff in the ED that she drinks a couple of cases of beer each weekâ€, stating her last drink was the early hours ofthe morning prior to her attending the ED. While doing rounds in the evening you notice thatMrs. Perry has tremors, is very anxious and restless. She has vomited approximately 250mLof bile type fluid. Her skin is cold and clammy to touch and she looks very pale. HR 121/minBP 90/42mmHg, RR 28/min, SpO2 92% on air, Temp.39.8C"
As the nurse caring for Mrs Perry assess and plan her care
Now looking at her observations, it looks like she has sepsis, I need to find one main problem, although she has pancreatitis, sepsis is a main problem so would the nursing diagnosis be: Deficient fluid volume related to vomiting secondary to sepsis as evidenced by decreased BP, High temperature and respiration rate.
Do we worry about aspiration with a vomiting patient?
We can replace fluid and electrolyte losses through giving her fluid intravenously as well as giving anti-emetics?
I wouldn't know the alterations I see in the patients VS... Looking at her VS I was thinking it could be sign of sepsis, so it could be a good reason to start the sepsis six pathway.
Do we worry about aspiration with a vomiting patient?
We can replace fluid and electrolyte losses through giving her fluid intravenously as well as giving anti-emetics?
I wouldn't know the alterations I see in the patients VS... Looking at her VS I was thinking it could be sign of sepsis, so it could be a good reason to start the sepsis six pathway.
Aspiration is definitely something we worry about with a patient who is vomiting, especially a patient who may be not so alert from alcohol withdrawal. What can aspiration lead to? Hint: Look at your vital signs. Which of these vital signs are high and which are low? What can that indicate?
HR 121/min
BP 90/42mmHg
RR 28/min
SpO2 92% on room air
Temp.39.8C
What made you think of sepsis initially? Sepsis needs a source infection. Sepsis means there is bacteremia that is symptomatic, which means that the source infection spread to the bloodstream and has become systemic. Which is why I don't think this patient is septic yet. However, I definitely think that there is some sort of infection going on. This patient is also going through alcohol withdrawal which makes things murky and kind of makes it look like a systemic infection, but I think it's the alcohol that is systemic and not the infection.
An important note here is that we are looking for nursing diagnosis and not a medical one. Its hard to think this way for those of us who are out of school (becuase once you leave school you'll never use them... EVER). A nursing diagnosis is going to look at symptoms and irregularities on how the patient is presenting, a lot of the time this is played off of your medical diagnosis, of which you dont have a formal one at this time. Given the patients status there are some nursing diagnosis that you can use.
This patient is exhibiting signs and symptoms of acute alcohol withdrawal. shes agitated, cool (or not), clammy, tachypnic, tachycardic and vomiting. This is the information that has been given to you with the hx of pancreatitis, but no mention of her actually having that diagnosis (no pain is mentioned and acute panc is very painful).
Your nursing diagnosis should reflect what information is available to you and given the situation you could come up with a few! I think you started down a good path with dehydration (which also causes impaired thermoregulation, especially those who are chronically dehydrated from alcohol use!). You mentioned the vomiting. What about some of the other signs? What about the rapid breathing (impaired gas exchange r/t tachypnea s/t anxiety?).
You're on the right track. Think of what info is available to you and thats what you'll make your diagnosis off of.
Lev, MSN, RN, NP
4 Articles; 2,805 Posts
Yes, that seems to be one of her problems. However, alcohol withdrawal alone doesn't explain some of her vitals signs.
People going through withdrawal can have borderline fevers but it wouldn't be as high as 39.8 C.
What do we worry about with a vomiting patient? What immediate intervention do we do when a patient is vomiting? What are we trying to prevent?
What alterations do you see in the patient's vital signs and what can cause these changes system by system?