GI bleeding Jim Olsen Case Study PDF

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Summary

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....

Description

GI Bleed/Hypovolemic Shock SKINNY 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 © 2018 Keith Rischer/www.KeithRN.com

Covered in Case Study

✓

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

✓ ✓

6-12% 12-18%

✓ ✓

• Reduction of Risk Potential • Physiological Adaptation

9-15% 11-17%

✓ ✓

SKINNY Reasoning

Part I: Recognizing RELEVANT Clinical Data 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: 1. History of cirrhosis and ETOH abuse 2. No medical care in past 10 years 3. Vomiting large amounts of bright red blood 4. Passed out due to being weak and lightheaded 5. Hypotensive 6. Sinus Tachycardia 7. Patient takes ibuprofen daily

RELEVANT Data from Social History: 1. Patient recently lost his job 2. Patient divorced 6 months ago and ex-wife has full custody of their two children. © 2018 Keith Rischer/www.KeithRN.com

Clinical Significance: 1. Untreated cirrhosis and continuous ETOH abuse leads to worsening of damage on liver tissue. If the diagnosis remains untreated liver failure will occur. 2. Patient has not had treatment for liver function and his health may have declined further without it being addressed. 3. ETOH abuse can cause severe scarring of the tissue and blood vessels may burst which leads to the presence of blood in the patient’s vomit. 4. Syncope occurs when there is insufficient blood flow to the brain which is often due to low blood pressure. 5. As liver failure progresses, the patient may present with hypotension which is caused by portal hypertension. (Portal HTN is very high BP in the vein that brings blood to the liver from the intestine). Very low BP may also indicate shock! 6. Sinus tachycardia may be caused by the patient’s low BP 7. Ibuprofen risk for hepatotoxicity is low. However, GI bleeding may occur and hepatic impairment can occur as well. Clinical Significance: 1. Patient may be under financial stress. 2. Patient’s mood and emotional state may be declining, he may be experiencing depression. 3. Patient is not coping with his personal situation very

3. Patient has been drinking more heavily.

well.

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: 1. Pulse 138 (reg) 2. Resp 28 (reg) 3. BP 74/30

Clinical Significance: 1. Patients who are in shock may experience tachycardia as a compensatory method due to vasoconstriction and trying to make up for decreased cardiac output. 2. Increased respiratory rate is seen in patients when their body is attempting to remove excess CO2 when the body is in shock. 3. Hypotension in patients with cirrhosis of the liver is due to dilation of the systemic blood vessels. The heart is then overworked and may lead to cardiac problems such as heart failure.

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 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 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

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: 1. Patient is lethargic and body is tense 2. Patient is pale, pulses are weak 3. Patient feels nauseated 4. No urine output present

© 2018 Keith Rischer/www.KeithRN.com

Clinical Significance: 1. Lethargy can be due to the patient’s low blood pressure but it is also a symptom seen in patients with chronic liver diseases. Patient may be tense due to stress and anxiety of being in the hospital. 2. Weak pulse and paleness may be due to insufficient blood flow. There might be decreased blood flow to vital organs. 3. Nausea may be a sign of digestive distress and the

body attempting to remove excess waste. Nausea is also a characteristic of shock. 4. If the patient is going into hypovolemic shock, his body is shutting down blood flow and diverting it to more vital organs (such as the heart and brain) this may cause a decrease in urine output. The patient may also be dehydrated (BMP should be checked).

Diagnostic Results: Current:

Na 134

Current:

WBC 8.5

Basic Metabolic Panel (BMP ) K Gluc. 4.8 145 Complete Blood Count (CBC) HGB PLTs 5.5 68

Current:

Albumin 2.1

Total Bili 3.5

Liver Panel Alk. Phos. 152

Current:

Lactate 3.4

Mg 1.3

MISC. PT/INR 8.5

Creat. 1.9

% Neuts 75

ALT 68

AST 75

What data must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Diagnostic Data: 1. Na 134 2. Glu 145 3. Creat 1.9 4. HGB 5.5 5. PLTs 68 6. Alb 2.1 7. Total Bili 3.5

Clinical Significance:

1. Patient is in the beginning stages of hyponatremia; this is commonly seen in patients with liver problems. 2. Impaired glucose tolerance and insulin resistance are seen in patients with a chronic liver disease. 3. Patients who experience cirrhosis of the liver are at risk for developing acute kidney injury. 4. Low Hgb indicates anemia, low Hgb is commonly seen in patients with cirrhosis of the liver. 5. Low Plt count is seen in patients who consume too much alcohol and in patients who have cirrhosis of the liver.

© 2018 Keith Rischer/www.KeithRN.com

8. Alk Phos 152 9. ALT 68 10.AST 75 11.Lactate 3.4 12.Mg 1.3 13.PT/INR 8.5

6. Decreased albumin levels are seen in patients with cirrhosis of the liver. Patient might be malnourished. 7. High Total bilirubin level are seen in the later stages of cirrhosis. 8. Increased Alk Phos levels indicate that the liver is not working properly, seen in patients with cirrhosis. 9. Liver disease is the most common reason for a patient to have increased ALT levels. 10.Increased AST may indicate liver damage and disease. 11.Increased lactate levels not related to low SaO2 levels may indicate an increase demand for oxygen or metabolic problems, this may be caused by liver disease. High lactate levels may also indicate shock from extreme blood loss. 12.Decreased Mg levels can be due to low dietary intake (malnourished or ETOH abuse) 13.Increased INR indicates a slower blood clotting time, can be caused by blood thinning medications, liver problems, vitamin K deficiency.

Part II: Put it All Together to THINK Like a Nurse! 1. After interpreting relevant clinical data, what is the primary problem? (Management of Care/Physiologic Adaptation)

Problem: 1. Hypovolem ic shock

Pathophysiology in OWN Words: 1. Hypovolemic shock occurs when there is bleeding or vomiting, and it leads to decreased fluid in the circulatory system this leads to inadequate tissue perfusion. Metabolism shifts to anaerobic pathways and lactate acid accumulates. Increased HR, increased cardiac contractility, and peripheral vasoconstriction are compensatory affects.

Collaborative Care: Medical Management 2. State the rationale and expected outcomes for the medical plan of care. (Pharm. and Parenteral Therapies) Medical Management:

Rationale:

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Expected Outcome:

1. Establish two large bore IVs 2. 0.9% NS 1000 mL bolus 3. Ondansetron 4 mg IV push 4. Phytonadione (vitamin K) 2 mg in 50 mL D5W IVPB 5. Fresh frozen plasma (FFP) 4 units IV 6. Packed red blood cells (PRBC) 2 units Type O Neg

1. Establishing peripheral IV allows for the drawing of blood, infusing of fluids and medications. 2. NS is infused to aid in making the patient normotensive by aiding in the decreased circulating blood volume. 3. Prevention of nausea and vomiting 4. Phytonadione is used to prevent bleeding in people with blood clotting problems or vitamin K deficiency. 5. FFP is used for its clotting factor in trauma resuscitation. It is also used for bleeding caused by vitamin K deficiency and bleeding. 6. PRBCs are indicated for patients who have lost a lot of blood or are anemic and symptomatic. 7. Typing and crossmatching blood and blood products may take a while and having them prepared is essential for emergencies.

1. Medications and NS will be able to be administered via the patient’s IV. 2. Patient will be normotensive. 3. Patient will not experience nausea and vomiting will cease. 4. Patient’s INR will return to normal, Vitamin K lab will be normal. 5. Patient will 6. Circulating Hgb will rise in the body. 7. PRBC will be available immediately when needed.

7. Type and cross match. Have four units PRBC available

3. Review the following skills and essential knowledge that the nurse will use in this scenario to save Jim’s life: (Management of Care)

Skill: IV Insertion Administer fresh frozen plasma (FFP)

Administer PRBCs

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What does the Nurse Need to KNOW to Be Safe in Practice: IV insertion is a sterile procedure! Check that the IV site is clean and intact. 2 Nurses needed for verification. Should be administered as rapidly as tolerated due to coagulation factors becoming unstable when thawed. Stay with patient for 15-30 mins to observe for adverse reactions. PRBCs should be infused over 2-3 hours. 2 nurses needed for verification. Stay with patient for 15-30 mins to observe for adverse reactions.

Collaborative Care: Nursing 4. What nursing priority (ies) will guide your plan of care? (Management of Care) GI Bleed Nursing PRIORITY: PRIORITY Nursing Interventions: 1. Monitor Hgb 2. Monitor vital signs 3. Continuous Cardiac monitoring

4. Fall precautions

Rationale: 1. Assesses the need for a blood transfusion, assess the oxygen carrying capacity in blood. 2. BP and HR is being monitored to ensure adequate blood flow to vital organs. 3. Continuous cardiac monitoring ensures early detection of cardiac abnormalities related to loss of blood and decreased BP. 4. Patient has experienced syncope and is at risk for increased bleeding if injury occurs.

Expected Outcome: 1. Hgb will be WNL

2. Patient will be normotensive and HR will be WNL 3. Patient will not experience lifethreatening cardiac changes. 4. Patient will not fall, will receive aid if he needs to ambulate.

5. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES:

Patient needs aid with coping with divorce and job loss.

PRIORITY Nursing Interventions:

Rationale:

CARING/COMFORT: How can you engage and show that this pt. matters to you? 1. Stay with the patient when he is in emotional distress

1. The patient will not feel abandoned. 2. Being physically comfortable may make the patient more willing to listen to comforting words and feel emotionally better.

Physical comfort measures: 2. Making sure the patient is comfortable in his bed. EMOTIONAL SUPPORT: Principles to develop a © 2018 Keith Rischer/www.KeithRN.com

1. The nurse can answer questions the patient may have relating to his care

Expected Outcome: 1. Patient is comforted by the nurse’s presence; he is not scared something will occur while he is alone. 2. Patient is more open to talking. 1. Patient is reassured by

therapeutic relationship. 1. Answer the patient’s questions. 2. Ask a social worker to come speak to the patient.

and possible solutions that are available to him. 2. The social worker can provide the patient with resources to aid in his recovery, ETOH abuse, job loss and coping with his divorce as well as losing his daughters.

SPIRITUAL CARE/SUPPORT: 1. Offer the patient support group information that are consistent with his beliefs.

1. If the patient is able and willing to attend support groups with people who have similar beliefs as him he may be willing to help himself recover and make progress in his medical and personal life.

the nurse’s answers. 2. Patient is willing to work with the social worker to receive the help he needs. 1. Patient is willing to go to a support group once he is medically cleared.

6. What educational/discharge priorities need to be addressed to promote health and wellness for this patient and/or family? (Health Promotion and Maintenance) 1. The patient should be encouraged to attend a support group and perhaps go to a rehab for an alcohol detox, the 2. 3. 4. 5.

patient needs to cease drinking alcohol in a sustainable manner. Patient needs to attend therapy to learn new coping methods and be screened for depression Patient needs to engage in healthy eating habits and increased protein intake .Patient must keep all medical appointment Medications should be taken as directed and HCP should be contacted if any signs of GI bleeding occur again.

© 2018 Keith Rischer/www.KeithRN.com...