Case study help

[newrnnurse2b]

I just need some help working through this.

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?

[AliNajaCat]

You can't decide to give more oxygen without an order, but you should get one

Your set up needs suction for the NG tube, and NS and a toomey syringe for irrigation to keep it open.

NO CRACKERS. He's nauseated because he isn't getting his stomach drained because you dont have his salem sump working yet and besides you have to figure theres a really good chance he's going to the OR really soon for his big GI bleed and has to be npo just in case for that. and crackers will gum up your salem sump lol.

Number 1 assessment is BP and P because you already know he's bleeding. Other indications of circulation are u/o and skin temp and mentation.

Oxygen doesn't help circulation, BP will be dropping so you need to be sure you can put him head down quick, not elevated

You should check sats but he could have great sats and not be carrying much oxygen because his hemoglobin is in the laundry now. Check crits often even if the doc forgot to order them.

Your priority ought to be clear now. Let's hear your ideas on that. One of mine would be get somebody else to take your other pts until you transfer him to OR or ICU, this guy is too sick for intermediate care.