Question

PN 200 Fundamentals of Nursing II Case Study: Hypovolemia/Deficient Fluid Volume Charles West, a 70 y/o man was brought to the Emergency Department at 4:30 AM by his wife. She told the emergency room triage nurse that he has a lot of "dark red diarrhea for the past 3 days and last night. When he became very dizzy, disoriented and weak this moming, she decided to bring him to the hospital. Mr. West's vital signs were B/P 70/- (diastolic blood pressure inaudible) Pulse 110 weak and easily obliterated, and respirations 24. A 16-gauge IV catheter was inserted and Lactated Ringer's infusion at 125 m/L per hour was started. The triage nurse obtained the following history from the patient and his wife. The patient has had idiopathic dilated cardiomyopathy (ICDM) for several years. The onset was insidious, but the cardiomyopathy is now severe, as evidenced by a left ventricle ejection fraction of 13% found during a recent cardiac catheterization. He experiences frequent problems with CHF because of the IDCM. Two years ago he experienced a cardiac arrest that was attributed to hypokalemia. He also has a long history of hypertension and arthritis. Fifteen years ago he was diagnosed with a peptic ulcer. An endoscopy showed a 25mmX15mm duodenal ulcer with adherent clot. The ulcer was cauterized, and Mr. West was admitted to the Medical intensive care unit for treatment of his volume deficit. You are the admitting nurse. As you are making him comfortable, Mrs. West gives you a paper bag filled with the bottles of the medications Mr. West has been taking. Vasotec 5mgm po bid Coumadin 5mgm po qd Digoxin 0.125 mg po qd KCL 20 mEq po bid Tolimentin 400mgm po tid (non-steroid NSAID) Doing a quick assessment, you find a pale man who is sleepy but arousable and oriented. He is still dizzy, hypertensive and tachycardia. You hear S3 and S 4 heart sounds. Peripheral pulses are present and trace pedal edema is present. Lung sounds are clear. Bowel sounds are present, gastric tenderness is noted and the liver margin is 4cm below the costal margin. A Swanz-Ganz catheter and an arterial line are inserted. 1. State the home medication(s) that probably precipitated Mr. West's GI bleeding. 2. Explain the most serious potential complication of Mr. West's bleeding and the rationale for your selection. 3. Demonstrate documentation of the patient's admission assessment in the nurse's notes 4. Prepare a list of signs and symptoms (both direct and indirect) of GI bleeding and loss of fluid volume from the history the patient and wife gave you and from your assessment. 5. Prepare a list of additional complications that you would anticipate as a result of the patient's hypovolemia as well as the rational for your selections Mr. West receives a total of 4 units of PRBC's, 5 units of FFP (fresh frozen plasma) and many units of crystalloid solution to keep his systolic B/P above 90mmHg.

Answer 1

1,GI bleeding caused by taking medication like NSAIDs, anticoagulants, prolonged use of supplementary mediation, etc. The patient is taking coumadin anticoagulant and tolimentin is a non-steroidal anti-inflammatory drug, oral intake of KCL for the last 15 years that cause side effects of GI bleeding. these drugs damage the lining of the stomach and cause ulcers and bleeding.
2, Most serious potential complications of the patient due to bleeding for last 3 days cause hypovolemic shock due to severe fluid volume deficit, anemia due to loss of blood count, heart failure, and myocardial infarction due to less blood supply to heart and cardiac overload, perforation due to severe prolonged ulceration, chance of nasogastric aspiration cause aspiration pneumonia for the patient.
3, Admission assessment include
vital signs
Diastolic blood pressure -70
Pulse -weak 110
respiration -24
Appearance -pale, drowsy and oriented
Heart-s2 and s4 heart sounds heard
bowel- the sound is heard
Stomach-gastric tenderness
Liver-4cm below the costal margin
4, signs and symptoms:
direct: Dark red color diarrhea, weak, dizzy, disoriented
Indirect: low blood pressure, weak pulse, shortness of breath, anemic, dizziness, gastric tenderness, enlarged liver