Question

Case Study, Chapter 49, Assessment and Management of Patients With Hepatic Disorders 1. John Adams, 55 years of age, is admited to the intensive care unit with the diagnosis of acute esophageal varices bleed. The patient has a long standing history of alcoholism and cirrhosis of the liver. Six months ago, th patient received an EGD, which diagnosed the esophageal varices. The patient has quit drinking alcohol for the past 6 months and has been active in Alcoholics Anonymous. The patient has a history of coronary artery disease and angina. The patient has been taking nadolol (Corgard) and isosorbide (Isordil). The admission vital signs include: BP, 88/50; P, 110; R, 26; and T, 990F. The supplemental oxygen is on room air and the patient is placed on 2 ymin of oxygen per nasal cannula with supplemental oxygen. The patient's hemoglobin is 6 g/dL, the hematocrit is 12%, and the platelets are 75,000 The patient has a prolonged PT and PTT. The liver profile shows a mild elevation of the aspartate aminotransferase (AST) and the alanine aminotransferase (ALT). The BUN and serum creatinine are also elevated The patient has in place from the emergency department a nasogastric tube to low wall suction. The emergency department physician placed a right subclavian triple lumen catheter and there is NS infusing at 100 mL/hr. The emergency department nurse administered vitamin K. Additional orders on the chart from the gastroenterologist include the following: octreotide (Sandostatin) 5-mcg bolus followed with continuous infusion 500 mcg in 250 Type and cross of 6 units of PRBCs STAT an transfuse 2 units of PRBCs over 2 hours each and administer furosemide Lasix) 20 mg IVP in between each unit. Repeat transfusion is completed. (Learning Objective 4) CBC 1 hour after the a. In what order should the nurse institute the physician orders that are listed above? Perform dosage calculations and state how to administer the medications. b. The nurse observes the nasogastric secretions and, upon admission to the ICU, there was 200 mL of dark red-colored drainage. The nurse continues to monitor the drainage and, as the nurse hangs the first unit of PRBCs, 200 mL of bright red bloody drainage is dumped into the collection canister. What should the nurse do? c. The gastroenterologist orders for the nurse to increase the octreotide to 50 mcg/hr and the endoscopy nurse and the physician will be up shortly to perform a vertical band ligation (VBL). What does the nurse need to do in preparation for this procedure?

Answer 1

1a. ANS: According to the given scenario during the process of transfusion beginning stage a nurse should double check the blood products and after the finishing of proper checking administers Sandostatin bolus followed by the continuous infusion @ 13 ml/hr. After that lasix IVP should be administered during each unit of blood dilute with NS and slowly pushed over 3-5 minutes and after one hour of successfully transfusion a nurse should draw the CBC.

1b. ANS: After noticing nasogastric secretions at first a nurse can clearly observe the patient vital signs like oxygenation status and mental status and immediately notify to the gastroenterologist of the finding. According to the given situation a nurse should administer vitamin K and the octreotide drip was gradually increasing can give good result and later the nurse should carefully monitor the patient for a possibility of hemolytic transfusion reaction.

1c. ANS: According to the given situation at first the nurse should increase the suction and after that ensure the patient is NPO and position the patient properly for the procedure. The nurse should also gather necessary supplies for the procedure to help the process be completed as quickly as possible.