Case study guidance

[seniornursingstudent]

I just need some help working through this. I'm not asking for answers, just guidance. I already gave my answers below just asking if they are in the right or wrong direction

You are the nurse on duty on the intermediate care unit, and you are scheduled to take the next admission. The emergency department (ED) nurse calls to give you the following report: "This is Barb in the ED, and we have a 42-year-old man, K.L., with lower GI [gastrointestinal] bleeding. He is a sandblaster with a 12-year history of silicosis. He is taking 40 mg of prednisone per day. During the night he developed severe diarrhea. He was unable to get out of bed fast enough and had a large maroon-colored stool [hematochezia] in the bed. His wife 'freaked' and called the paramedics. He is coming to you. His vital signs [VS] are stable--110/64, 110, 28--and he's a little agitated. His temperature is 36.8� C. He hasn't had any stools since admission, but his rectal exam was guaiac positive and he is pale but not diaphoretic. We have him on 5 L O2/NC [oxygen by nasal cannula]. We started a 16- gauge IV with lactated Ringer's [LR] at 125 ml/hr. He has an 18-gauge Salem sump to continuous low suction; the drainage is guaiac positive. We have done a CBC with differential, chem 14, PT/INR and PTT, a T&C [type and crossmatch] for 4 units RBCs, and a urinalysis [uA]. He's all ready for you."

So the first question is - How do you prepare for this patients arrival?

I said Look at the labs that have been done to see what the results were

Have IV pole ready for infusion of Lactated Ringers.

Have oxygen ready for patient

Intubation tray at bedside in case of emergency

Bed ready to transfer patient from stretcher.

Anything else you would do?

Second question is - Given K.L's history, what do you think significantly contributed to the GI bleeding?

I said - Corticosteroids put you at risk for GI bleed.

Age is also a risk factor for GI bleeds

Are there any other risk factors he has?

KL arrives on your unit, as you help him transfer from the ED stretcher to the bed, he becomes very dyspneic and expels 800 mL of maroon stool.

Question 3 - what immediate complication concerns you the most?

I wasn't sure on this one but I said, Patient is hemodynamically compromised/unstable because patient is becoming hypovolemic due to loss of blood.

Would that be correct?

Question 4 - what are the first three actions you would take?

I said - Switch patient to nonrebreather face mask to give the patient more oxygen since patients hemoglobin and hematocrit probably have decreased from bleeding

Check blood pressure and pulse to determine if patient may be going into hypovolemic shock

Increase head of the bed to assist with oxygenation

Those are the only things I could think of, would you do something differently?

KL reports nausea. VS 92/5/, 116, 32, 93%. The physician orders IV fluid bolus of 500 ml 0.9% normal saline and 2 unites of packed RBC stat.

Question 5 - What additional interventions do you need to institute?

I said - Antiemetic to prevent vomiting

Slow, deep breathing when nausea is present

Give patient crackers to help with nausea

What else could I do for the patient as far as interventions?

Question 6 - What assessment indicators would you monitor in K.L?

I said - Respiratory assessment to asses for fluid volume overload such as crackles in lungs, trouble breathing, increased reparations.

Also assess for adverse reaction to the blood

What are signs and symptoms of adverse reaction? What other assessments would I monitor?

During a colonoscopy, KL begings passing large amounts of bright red blood. He becomes paler and more diaphoretic and begins to have altered level of consciousness.

Identify 5 immediate interventions you should initiate?

I have no idea on this one. Would you want to give oxygen to help with circulation? Maybe elevated head of bed? Help?

[roser13, ASN, RN]

An apparent fellow student just asked for help with the exact same case study. I really wonder how we did this on our own, back in the day?

I also wonder if study groups are a thing of the past? And if nursing instructors advise the students to "ask the internet" for homework help insteading of encouraging personal interaction between the students?

[seniornursingstudent]

I am a commuter, I am not on campus often and work. I don't have time to meet with other students. I am either at school or work. I don't know why no one can just help instead of criticizing? I am not asking for answers, just for someone to look at mine and guide me in the right direction. Not hard at all.

[roser13, ASN, RN]

Well yes, it CAN be hard. You are not the only student who comes here asking for homework help. Some of the requests (not necessarily yours) ask incredibly detailed and time-consuming questions of experienced nurses. My questions were not rhetorical at all. I really do wonder what student nurses are thinking when they ask others for homework help. And I truly wonder if instructors are encouraging this trend.

Displaying a sense of entitlement, as in "I am not asking for answers, just for someone to look at mine and guide me in the right direction. Not hard at all" does nothing to help your cause. What you have just described as your request of us ("look at my answers and guide me") is the responsibility of your instructor, not strangers on an Internet forum.

How do you even know that those who have the time/inclination to help you with your homework are even nurses?

Answer: you don't.

NETY, NETY, NETY. Bring it on.

[Barnstormin' PMHNP]

I personally love case studies and this one is fun, I really hope the nurses chime in as I learn a lot by reading these types of threads. I am in a grad program but it is for psych lol so I have a few things to add but I am sure there are nurses here that can add much better info. I think this case study has good detail so it is pretty tough for a nursing student to wade through and seperate what is important and what is not.

First bit of advice: Oxygen is important, BP is important, remember your Maslow's and make sure you understand perfusion and how it works and why it is important to keep it working.

First I would get another large bore IV in him if he doesn't have one already. One for fluid, one for blood.. I doubt he is at risk for fluid overload, the opposite is the problem right now.

Raising the head of the bed is making it more difficult for oxygen to get to the brain, his BP is low so it is more important to make the heart's work easier to oxygenate that vital organ by keeping the head of the bed lower (but not flat, which makes it more difficult for the lungs to work efficiently). Usually raising the legs is more appropriate.

Keep the crackers away, if he needs to go into surgery (almost a certainty) he should be NPO.

If he is dsypnic, good luck trying to get him to breath slow and steady.....

I hope he is on continuous monitoring for BP, O2, etc. and I would be watching him VERY closely.

A good text to get is "Symptom to Diagnosis", by Stern, Cifu, & Altkorn. It has many case studies for every system, is not above your training, and will help you piece together the puzzle of the what and why of common presentations seen.

Looking forward to reading the other responses...

[SnowShoeRN]

I think that by and large you're doing pretty well. Normally it irritates me when students post, but you're showing quite a bit of critical thinking and I appreciate your thinking beforehand and posting answers instead of just asking us to answer the questions for you like so many other students do. I haven't seen you in clinical, but if you're answering most of these without having to look anything up, I'd say you're right on track for where you are in your program. I'm not saying you'll get 100 on your case study, but I think your thinking is in the right place.

I agree with most of what barnstormin' has to say. And I don't give answers, but I like to ask questions to help students better understand things. Here are a few thoughts to help you think a bit more. Is he currently already on telemetry? Do you think he should be? Why or why not? Does the facility have a rapid response team? What do you think is happening to him that would be causing an altered level of consciousness? If he continues to worsen, what do you think will happen? How can you try to nip that in the bud or treat it if it does crop up?

One of the big pieces of understanding and being successful in nursing is understanding, physiologically, why people are reacting to certain things. It can take practice, but it can enable you to anticipate emergencies, treatments, and plans of care for a variety of scenarios.

The answers to these questions may help you find answers to the questions you have before you.

As for the blood...It's pretty easy to look up adverse reactions to blood or blood products (and how you treat them) so you should be able to find that pretty readily.

Good luck! :)

Oh...and just as a post-script... if you're new to the community and asking a question, it's best to approach it humbly and use "please" and "thank you." I don't mean to sound sarcastic. I'm sure you're probably just frazzled. But it's good form and will get you on better footing with people. When students, or new members, come on here and it's "Hey! Help me! Peace out!" they don't get a good response.