GI Adpie PDF

Preview

Summary

ADPIE SBAR chart...

Description

Assessment Findings Patient is febrile, dizzy, and restless

Diagnosis/Problem/Analysis Having a febrile non-hemolytic reaction during blood transfusion

Plan Administer oxygen Discontinue transfusion Contact provider

Implementation 2L Oxygen via nasal canula

Evaluation Patient is no longer febrile, feels relaxed, and provider notified for prescription of anti-pyretic.

Patient is experiencing GI bleeding and abdominal pain

Knowledge deficit

Provide written and verbal education on the importance to diet adherence for patient’s condition.

Emphasize importance of avoiding ibuprofen, and products that contain ibuprofen. In addition to avoiding foods high in fiber, and excessive caffeine intake.

Patient can repeat back taught information verbally and demonstrate physical activities necessary.

Patient has a hemoglobin level of 7.0g/dL

Decreased levels of hemoglobin, involves the oxygen delivery system

Administer packed RBC’s Administer oxygen and monitor SPO2, titrate as needed Continue monitoring hemoglobin levels

Transfuse blood according to orders and protocol Report critical values to provider Manage any symptoms acquired from low hemoglobin

Increase in hemoglobin (closer to normal range 12.5-15 g/dL) Regulation of oxygen (above 92%)

April Pickell and Salma Aldi NSG – 385 Clinical Makeup – GI Bleed FINAL SBAR Situation: This is April SNPC. I am caring for Ms.Lieberman in room 5206, She is a 36 year old female admitted from the ED at 1500 for a GI Bleed, and was transferred to Med/Surg for a blood transfusion. She received 1unit of packed RBCs at 1845. She began to receive her second unit at1930 which I had to stop halfway through when the patient developed chills, body aches, and an elevated temperature of 101.8 F. Baseline temperature prior to starting the transfusion was 98.6 F. I suspect she is having a febrile reaction to the infusion. Background: Ms.Lieberman has a history of Crohn's disease. She had an ileostomy six months ago. She receives infliximab IV infusions every 8 weeks, her last being 7 weeks ago. She has an allergy to sulfa medications. Assessment: Patient reports increased pain, headache, chills, nausea, dizziness, and is requesting ibuprofen for her pain. BP is 103/60, pulse is 96, respirations are 22, temperature is 101.8 F, she is alert oriented x 3, breath sounds are clear, bowel sounds are hyperactive though her abdomen is soft, flat and symmetrical. SpO2 of 97% on room air. Hemoglobin was 7g/dL. and hematocrit was 21% from ED lab draw. The patient has an order for IV morphine sulfate 4mg every 2 hours as needed for pain, which has not been administered according to MAR and verified by the patient. Recommendation: I stopped her second packed RBC infusion at 1945 and initiated a new bag of 0.9% sodium chloride. Ms.Lieberman is requesting ibuprofen for her pain, which I don't recommend while she is experiencing GI bleeding. My recommendation is an antipyretic other than an NSAID and for you to see the patient as soon as possible. The patient has an order for IV morphine sulfate 4mg every 2 hours as needed for pain which has not been administered, can I administer that now? Is there anything else I should be doing until you are able to see her

DEBRIEF:

After doing my care planning, I felt I did not know enough information about not only Crohn’s disease but what nutritional advice one would give a patient with this condition. This patient had many morbidities along with many stressors in her life and recommending diet changes was a bit daunting. One recommendation could be the norm for one condition she has but completely contraindicated for another. The patient asked for ibuprofen when she was experiencing pain, I knew that ibuprofen can cause ulcers and bleeding, which is only exacerbated by her Crohn’s disease. She has a knowledge deficit in regards to the medications she should avoid that can lead to life threatening complications. This patient probably requires a thorough break down of her dietary limitations and recommendations I'm not sure it qualifies strictly as an "ethical dilemma", but it grabbed my attention enough times to wonder about its use as it relates to best practice. I'm talking about the use of NSAIDs, specifically ibuprofen, in a patient with a GI bleed. First, the patient continually mentions that she uses ibuprofen regularly at home to manage pain. Although the nursing priority, especially as her condition degrades during her febrile reaction to the packed RBC infusion, is not education, it was not discussed upon her early transfer from the ED to ICU by either her ED nurse, or either of her ICU nurses. I noted this early in the simulation, and assumed it would be covered later. Instead, the patient continues to mention the use of ibuprofen and requests it multiple times for her pain while being treated. When her symptoms worsen in response to the infusion, she asks for ibuprofen to help with her pain. Its contraindicated use in patients with GI bleeds is again neglected. I was especially surprised when the nurse during her SBAR with the provider, mentions that the patient is requesting ibuprofen, and she thinks it would also help to lower her fever. While she does not recommend ibuprofen specifically, she also surprisingly does not discourage its use. According to Davis's Drug Guide for Nurses, extreme caution should be use in patients with a history of GI bleeding, and GI bleeding is also listed in red as an adverse reaction/side effect fo ibuprofen (Vallerand, A., 2018, p. 667). Vallerand, A. H. (2018). Davis's drug guide for nurses. F.A. Davis.

Assessment Findings Diagnosis/Problem/Analysis Patient is experiencing Ineffective breathing pattern r/t labored breathing and systemic reaction audible wheezing upon auscultation of lungs

Patient is experiencing GI bleeding and abdominal pain

Knowledge deficit

Plan Assess respiratory system Apply continuous SpO2 monitor Administer oxygen Position the client in upright position Maintain patent airway

Implementation Titrate oxygen to maintain SpO2>88% Use high flow cannula or simple/non rebreather mask if >6L Patient position in fowlers of high fowlers according to preference and respiratory status Expect to administer epinephrine, bronchodilators or other antihistamines Carefully monitor patient airway- look for signs of laryngeal edema. Provide written and Emphasize verbal education on importance of the importance to diet avoiding ibuprofen, adherence for patient’s and products that condition. contain ibuprofen. In addition to avoiding foods high in fiber, and excessive caffeine intake.

Evaluation Goal: Met Patient is no longer exhibiting signs of labored breathing, O2 was titrated back down and returned to nasal cannula.

Patient can repeat back taught information verbally and demonstrate physical activities necessary.

Patient has a hemoglobin level of 7.0g/dL

Decreased levels of hemoglobin, involves the oxygen delivery system

Administer packed RBC’s Administer oxygen and monitor SPO2, titrate as needed Continue monitoring hemoglobin levels

Transfuse blood according to orders and protocol Report critical values to provider Manage any symptoms acquired from low hemoglobin

Increase in hemoglobin (closer to normal range 12.5-15 g/dL) Regulation of oxygen (above 92%)...