My patient, a 70-something male, was admitted for GI bleed due to Mallory-Weiss tear. He had been feeling nauseous in the morning and vomited his coffee, and felt a little better (no hematemesis at that time). Many hours later in the day he started feeling worse, and that is when he vomited large amounts of blood. I suspect the MW tear happened during the first vomiting episode (though this is not known for sure) thus causing the subsequent hematemesis. His hct hit a low of 22 (down from 39) before transfusion the next day.
The thing that is perplexing me the most though is his WBC. He had a WBC of 19 later that evening (PRIOR to transfusion). He has no other risk factors to account for this. No known infections, no other illnesses besides whatever made him vomit, no significant leukocytosis inducing meds. No diff was done, and the physician didn't address the high WBCs in any of his notes. Could whatever caused the patient to vomit in the first place (before the tear happened) be what caused the high WBCs? I.e. could a virus or gastritis be enough to make the WBC that high? Maybe the virus/ bacterial illness plus the physical and psychological stress of being acutely ill? I can't find anywhere what the expected values would be for these conditions, but 19 is higher than what my septic patient the previous week had.
I don't have to come up with an answer for my clinical paper, but I would like to be able to explain this better. Thoughts? Would a WBC be this highly elevated due to a simple stomach virus or bacterial infection?
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Thanks, I know I am overthinking it. She will definitely give me full credit for this answer, I guess I am just going for the gold star and the pat on the back. I am definitely planning on explaining the stress response, or trying to anyway.
Do you think risk of infection sounds reasonable? Not sure I have enough to go on for that though, besides the elevated WBC and a one-time temp of 37.4 (but that could be due to the blood transfusion). Also readiness for enhanced knowledge (he is afraid of it happening again and wants to know what kind of dietary/ other changes he can make to avoid it). For my 3rd, probably activity intolerance r/t acute blood los, AEB generalized weakness and SOB with ambulation. We need 3 diagnoses, but they don't have to be prioritized. I feel like I have less data for this guy than previous patients, probably because he really is pretty healthy otherwise.
Well he is at risk for bleeding again....you mentioned stress do you ahve evidence of this?
Stress- no solid evidence, just the stress of being acutely ill. He did have very high BP initially, and high HR.
He did have a syncopal episode, and I did orthostatics on my shift. He was mildly orthostatic but improving. He had SOB when the hct was low, but it improved. I don't know if I can use DFV because he was off IV fluids by my first shift (discharged before my second shift) but that's a possibility. However I really like risk for bleeding, because he is very concerned about it happening again.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
You're welcome....I wasn't sure where he was in the process of getting better. You can still say anxiety for he expressed this. Enhanced health or learning would be good as well.
I did activity intolerance (SOB and high HR after walking, though I forgot to check O2 sat, dang it). Also readiness for enhanced learning (how to avoid a recurrence was his main concern, though I wouldn't call it anxiety) and constipation (narcotics and lots of blood in his gut will do that). :-) Those are the 3 I had the most evidence for I think. I couldn't find risk for bleeding in my NANDA book, could it be called something else?
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I did activity intolerance (SOB and high HR after walking, though I forgot to check O2 sat, dang it). Also readiness for enhanced learning (how to avoid a recurrence was his main concern, though I wouldn't call it anxiety) and constipation (narcotics and lots of blood in his gut will do that). :-) Those are the 3 I had the most evidence for I think. I couldn't find risk for bleeding in my NANDA book, could it be called something else?
Nope it's there....what resource do you use?
Risk for Bleeding NANDA-I
Definition
At risk for a decrease in blood volume that may compromise health
Risk Factors
Aneurysm; circumcision; deficient knowledge; disseminated intravascular coagulopathy; history of falls; gastrointestinal disorders; impaired liver function; inherent coagulopathies; postpartum complications; pregnancy-related complications; trauma; treatment-related side effects.
Esme12, ASN, BSN, RN
20,908 Posts
YOu mention gastritis...was this evidence from the EGD? This will also increase the WBC Gastritis: Peptic Disorders: Merck Manual Home Edition
You mentioned SOB...what is your evidence for this? What were his vitals? Was the SOB when his HCT was so low? Did you do orthostatic vitals?
Here are some others you might consider
Decreased Cardiac Output
Anxiety
Risk for Bleeding
Deficient Fluid Volume