Answer KEY-GIB- Unfolding Reasoning PDF

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GI Bleed/Hypovolemic Shock UNFOLDING Reasoning

Jim Olson, 45 years old

Primary Concept Perfusion Interrelated Concepts (In order of emphasis) • • • NCLEX Client Need Categories

Clotting Clinical Judgment Patient Education Percentage of Items from Each Category/Subcategory

Safe and Effective Care Environment ✓ Management of Care ✓ Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity ✓ Basic Care and Comfort ✓ Pharmacological and Parenteral Therapies ✓ Reduction of Risk Potential ✓ Physiological Adaptation © 2018 Keith Rischer/www.KeithRN.com

Covered in Case Study

17-23% 9-15% 6-12% 6-12%

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6-12% 12-18% 9-15% 11-17%

✓ ✓ ✓ ✓

✓ ✓

UNFOLDING Reasoning History of Present Problem: Jim Olson is a 45-year-old male with a history of cirrhosis and ETOH abuse who has not had any medical care the last ten years. He began vomiting large amounts of bright red blood when he woke up this morning. He was found on the floor of the bathroom by Sheila, his girlfriend, when he became lightheaded and fell on the floor and was too weak to get up. Sheila called 911. Paramedics report that there was a large dark red/black stool in the toilet. They were able to get an 18-gauge IV in the right antecubital vein, and Jim received 500 mL of 0.9% NS. His initial BP was 80/40 at the scene, and his most recent BP is 82/44 with a current heart rate of 128, sinus tachycardia.

Personal/Social History: Jim recently lost his job as a construction laborer and was divorced six months ago. His ex-wife has full custody of his two children. Jim’s girlfriend states that he has been more depressed lately and has been drinking more heavily since his divorce. He takes ibuprofen daily for chronic back pain.

What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential)

RELEVANT Data from Present Problem: History of cirrhosis and ETOH abuse who has not had any medical care the last ten years.

Clinical Significance: Medical history is always relevant and needs to be noted. The diagnosis of cirrhosis and EtOH abuse are direct contributing factors to his acute G.I. bleed.

He began vomiting large amounts of bright red blood when he woke up this morning.

Bright red blood reflects upper G.I. bleeding. Because Jim has a history of EtOH abuse, this could either be a gastric ulcer or even worse rupturing esophageal varices. This is a life-threatening complication if present.

He was found on the floor of the bathroom by Sheila, his girlfriend when he became lightheaded and fell on the floor and was too weak to get up.

Jim is symptomatic from the loss of blood which indicates the severity of his G.I. bleed and has lost a significant amount of blood.

Paramedics report that there was a large dark red/black stool in the toilet.

Dark red to black stool is consistent with digested blood that originated in the upper G.I. tract or a lower G.I. bleed. In the context of this scenario, it is more likely to be digested blood but is relevant data that the nurse must note.

They were able to get an 18-gauge IV in the right antecubital vein, and Jim received 500 mL of 0.9% NS.

Recognizing the severity of this presentation, two large bore IVs (preferably 18 gauge or larger) will be needed. One large bore IV with a fluid bolus has already been started, but one more will be needed.

His initial BP was 80/40 at the scene, and his most recent BP is 82/44 with a current heart rate of 128, sinus tachycardia.

His blood pressure is too low and his heart rate is too high. Both of these represent his decreased cardiac output as a result of hypovolemic shock. Review the essential pathophysiologic formula of CO=SV x HR. The earliest compensatory response to low output state is tachycardia. As further volume is lost the blood pressure begins to drop. When both tachycardia and hypotension are present, there is a significant loss of blood. This is a critical red flag that needs to be recognized by the nurse. Clinical Significance: These psychosocial stresses need to be recognized as contributing factors to his depression and increased drinking that his girlfriend reports.

RELEVANT Data from Social History: Jim recently lost his job as a construction laborer and was divorced six months ago.

© 2018 Keith Rischer/www.KeithRN.com

Jim’s girlfriend states that he has been more depressed lately and has been drinking more heavily since his divorce.

Drinking EtOH exacerbates feelings of depression because it is a CNS depressant.

He takes ibuprofen daily for chronic back pain.

Daily ibuprofen use can cause a G.I. bleed. In the context of daily EtOH abuse, ibuprofen use can exacerbate the development of GI bleeding. This will require patient education before discharge.

Patient Care Begins: Current VS: T: 98.2 F/36.8 C (oral) P: 138 (regular) R: 28 (regular) BP: 74/30 MAP: 45 O2 sat: 95% room air

P-Q-R-S-T Pain Assessment: Provoking/Palliative: Denies Quality: Region/Radiation: Severity: Timing:

What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data:

Clinical Significance:

P: 138 (regular)

Review the essential pathophysiologic formula of CO=SV x HR. The earliest compensatory response to low output state is tachycardia. As further volume is lost, the blood pressure begins to drop. When both tachycardia and hypotension are present, there is a significant loss of blood. This is a critical red flag that needs to be recognized by the nurse.

R: 28 (regular)

Tachypnea is expected when the clinical data in this scenario has been correctly interpreted due to hypovolemic shock. This is a compensatory response to improve oxygenation with a lack of tissue perfusion.

BP: 74/30

Though his blood pressure has been low since he was found at the scene, an intervention of a saline bolus was administered by paramedics. An essential construct of clinical reasoning is trending clinical data over time. Though this patient just arrived, the trend of blood pressure is a clinical red flag. You would expect the blood pressure to increase, but it has decreased with the IV bolus. This is a clinical RED FLAG!

MAP: 45

MAP, or mean arterial pressure, is defined as the average pressure in a patient's arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood pressure (SBP). In order to maintain adequate perfusion, the mean arterial pressure needs to be 60 or greater, though a MAP >65 is what care providers want to see in practice.

Current Assessment: GENERAL Lethargic, body tense, appears uncomfortable but denies pain APPEARANCE: RESP: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort Pale, extremities cool, no edema, heart sounds regular with no abnormal beats, pulses weak, CARDIAC: equal to palpation at radial/pedal/post-tibial landmarks, 1-2 second capillary refill NEURO: Alert & oriented to person, place, time, and situation (x4), whispers responses GI: Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four quadrants, feels nauseated GU: No urine output present SKIN: Skin integrity intact, skin turgor elastic, no tenting present © 2018 Keith Rischer/www.KeithRN.com

What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data: GENERAL APPEARANCE: Lethargic, body tense, appears uncomfortable, but denies pain

Clinical Significance: Lethargy is expected because he is hypotensive and critically ill. He is tense and appears uncomfortable which could be nonverbal indicators of pain. But he currently denies pain. This will require ongoing assessment.

CARDIAC: Pale, extremities cool, no edema, heart sounds regular with no abnormal beats, pulses weak, equal to palpation at radial/pedal/post-tibial landmarks, 1-2 second capillary refill

Though expected in hypovolemic shock, his pale color and cool extremities are a clinical RED FLAG that supports the critical nature of his presentation. Also his pulses are weak and though his capillary refill is technically within normal limits, 1 to 2 seconds is sluggish. Patients with normal cardiac function will have brisk or immediate capillary refill.

NEURO: Alert & oriented to person, place, time, and situation (x4), whispers responses

Though his mentation is currently normal, this is relevant because of his hypotensive state. He currently has adequate perfusion to his brain to remain oriented. This will also require an ongoing assessment to note if this changes over time.

GI: Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four quadrants, feels nauseated

Though his primary problem is a G.I. bleed, his overall assessment is benign except for nausea.

Cardiac Telemetry Strip:

Interpretation: Regular/Irregular: Regular

P wave present? Yes

PR: 0.16

QRS: 0.06

QT : 0.24

Interpretation: Sinus tachycardia Clinical Significance: Review the essential pathophysiologic formula of CO=SV x HR. The earliest compensatory response to low output state is tachycardia. As further volume is lost, the blood pressure begins to drop. When both tachycardia and hypotension are present, there is a significant loss of blood. This is a critical red flag that needs to be recognized by the nurse.

Lab Results: Complete Blood Count (CBC:) WBC (4.5–11.0 mm 3) Neutrophil % (42–72) Hgb (12–16 g/dL) Platelets (150-450 x103/µl)

Current: 8.5 75 5.5 68

© 2018 Keith Rischer/www.KeithRN.com

High/Low/WNL? WNL WNL LOW LOW

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

WBC: 8.5

• •

ALWAYS RELEVANT based on its correlation to the presence of inflammation or infection Usually increased if infection present, though it may be decreased in the elderly or peds 4 reflects a 28 percent mortality. • Lactate builds up in the serum and can be seen as a marker of strained cellular metabolism. • Reflects the severity of his shock state and will need to be repeated to assess cellular perfusion as he receives fluid resuscitation and other lifesaving interventions.

PT/INR: 8.5

• Measures time required for a firm fibrin clot to form and measures the clotting cascade • Dependent on vitamin K synthesis from the liver • Elevated in liver disease without being on warfarin. Because he is not on warfarin, this is a significant red flag that identifies why he is bleeding and will have a difficult time stopping! • Standard anti-coagulant ordered for those on warfarin (Coumadin) to maintain therapeutic goal of INR 2–3 • RELEVANT and must be noted for any patient on warfarin, but especially when a bleeding complication secondary to warfarin presents Warfarin can be reversed quickly if patient is actively bleeding by administering vitamin K IV and/or fresh frozen plasma.

© 2018 Keith Rischer/www.KeithRN.com

Liver Function Test (LFT:) Albumin (3.5–5.5 g/dL) Total Bilirubin (0.1–1.0 mg/dL) Alkaline Phosphatase

Current: 2.1 3.5 152

High/Low/WNL? LOW HIGH HIGH

68 75

HIGH HIGH

male: 38–126 U/l female: 70–230 U/l

ALT (8–20 U/L) AST (8–20 U/L)

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

Albumin: 2.1

• Large colloid plasma protein made by the liver • Comprised of protein, it will be decreased if patient suffers from malnutrition and alcoholics tend to be malnourished as a result of chronic ETOH abuse.. • Contributing factor to ascites or edema

Total Bilirubin: 3.5

• Total of both direct/indirect bilirubin • Bilirubin is metabolized by the liver and a broken down by-product of heme protein in RBCs. • Relevant to any patient who has liver disease • Nonspecific hepatic iso-enzyme that has a large concentration in the liver, but found in other parts of the body • If primary liver disease, focus on ALT and AST; these are much more specific to liver function. • Relevant to any patient who has primary liver disease • Enzyme found in liver • Released into circulation when liver cells are damaged.

Alkaline Phos: 152

AST: 75

• Relevant to any patient who has primary liver disease • Enzyme found in liver • Released into circulation when liver cells are damaged.

ALT: 68

• Relevant to any patient who has primary liver disease • Enzyme found in liver • Released into circulation when liver cells are damaged • Has a higher specificity to liver than AST

Lab Planning: Creating a Plan of Care with a PRIORITY Lab: (Reduction of Risk Potential/Physiologic Adaptation)

Lab:

Normal Value:

Clinical Significance:

Nursing Assessments/Interventions Required:

Hemoglobin

13–17

Value:

Critical Value: 18

Primary protein of erythrocytes that is composed of heme (iron) and globin (protein) *Carries O2 to cells and CO2 back to lungs *Parallels Hematocrit, which is the % of RBC in proportion to total plasma volume

THINK BLOOD LOSS/ANEMIA *Identify early signs of blood loss: tachycardia, then hypotension *Assess for signs of tissue hypoxia (see above) *Assess skin color as well as tolerance to activity

5.5

© 2018 Keith Rischer/www.KeithRN.com

*GOLD STANDARD for evaluating blood/RBC adequacy (anemia, blood loss)1

Clinical Reasoning Begins… 1. What is the primary problem your patient is most likely presenting? (Management of Care/Physiologic Adaptation) Acute upper GI bleed 2. What is the underlying cause/pathophysiology of this primary problem? (Management of Care/Physiologic Adaptation) The cause of the upper GI bleed in this scenario is complex. It could be a result of a bleeding gastric ulcer or ruptured esophageal varices. From a nursing perspective, it does not really matter because it will not change how the nurse will manage this potential life-threatening crisis. Knowing that this patient has a history of cirrhosis, the nurse needs to recognize the connection between chronic liver disease and portal hypertension that results in esophageal varices that can rupture and cause profuse bleeding as a clinical red flag in this presentation. Other causes of upper GI bleeding include a bleeding gastric ulcer due to the erosion of the mucosa of the lining of the stomach due to irritants that in this scenario could include EtOH as well as chronic ibuprofen usage.

Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies) Care Provider Orders: Establish two large bore IVs

Rationale: Will require aggressive fluid resuscitation to improve blood pressure. A large bore IV, preferably greater than 18 gauge, allows fluids to flow more quickly into the body than a smaller IV such as a 20 or 22-gauge.

Expected Outcome: IV access successfully obtained

0.9% NS 1000 mL bolus

To raise his blood pressure, a fluid bolus is needed, but the nurse must recognize that fluids do not carry oxygen! In this scenario, Jim requires early administration of blood products as soon as possible to both give volume and oxygen carrying capacity to his cells that are currently deprived.

Decrease in heart rate and increase in blood pressure if fluid resuscitation is successful

Ondansetron 4 mg IV push

Blocks the effects of serotonin at receptor sites located in the vagal nerve terminals. This decreases the incidence and severity of nausea and vomiting.

Nausea resolved

Octreotide 50 mcg IV push

Given as an infusion for management of acute hemorrhage from esophageal varices in liver cirrhosis on the basis that it reduces portal venous pressure, though current evidence suggests that this effect is transient and does not improve survival.

Portal hypertension is decreased, which will also decrease the amount of upper GI bleeding if this is the source.

Octreotide 50 mcg/hour IV gtt

See above.

Phytonadione (vitamin K) 2 mg in 50 mL D5W IVPB

Replacement of vitamin K that is essential for clotting factors in the body. Because of his liver disease, he does not have adequate amounts of this essential vitamin to create the clotting factors he desperately needs.

Amount of bleeding decreases over time

Fresh frozen plasma (FFP) 4 units IV

Fresh frozen plasma is rich in clotting factors that Jim currently lacks. FFP contains all factors of the soluble coagulation system, including the labile factors V and VIII. FFP is indicated when a patient has MULTIPLE

Amount of bleeding decreases over time

© 2018 Keith Rischer/www.KeithRN.com

factor deficiencies and is BLEEDING. Packed red blood cells (PRBC) 2 units Type O Neg

Type O negative blood is a universal blood type that can be safely administered in a crisis. Obtaining this from the blood bank would give him the blood products that he needs until a type and cross can be completed. Give him cross matched blood is best once it is available.

Heart rate decreases and blood pressure increases as blood is replaced. Hemoglobin will also increase from current baseline if bleeding is controlled.

Type and cross match. Have four units PRBC available

Because this is a crisis, having four units available is expected and will likely be needed. Packed red blood cells (PRBCs) are made from a unit of whole blood by centrifugation and removal of most of the plasma, leaving a unit with a hematocrit of about 60%. One PRBC unit will raise the hematocrit of a standard adult patient by 3%. In clinical practice, I see the hemoglobin increase by approximately 1 g for each unit of packed cells that are given.

See above

PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care) Care Provider Orders: • Establish two large bore IVs • 0.9% NS 1000 mL bolus • Ondansetron 4 mg IV push • Octreotide 50 mcg/hour IV gtt • Phytonadione (vitamin K) 2 mg in 50 mL D5W IVPB • Fresh frozen plasma (FFP) 4 units IV • Packed red blood cells (PRBC) 2 units Type O Neg • Type and cross match. Have four units PRBC available

Order of Priority: 1. Establish two large bore IVs 2. 0.9% NS 1000 mL bolus 3. Packed red blood cells (PRBC) 2 units Type O Neg 4. Octreotide 50 mcg/hour IV gtt 5. Phytonadione (vitamin K) 2 mg in 50 mL D5W IVPB 6. Fresh frozen plasma (FFP) 4 units IV 7. Type and cross match. Have four units PRBC available 8. Ondansetron 4 mg IV push

© 2018 Keith Rischer/www.KeithRN.com

Rationale: Use the priority setting tool of the ABCs to set priorities in this life-threatening scenario. Since there are no A or B priorities, everything will focus on C or circulation, and because so many of the orders address circulation. In practice, what...