Question

CARE PLAN - DEHYDRATION 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 morning, she decided to bring him to the hospital. Mr. West's vital signs were BP 70/-(diastolic blood pressure inaudible) Pulse 1 10 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 Toimentin 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 S 3 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 an below the costal margin. A Swanz-Ganz catheter and an arterial line are inserted. d the liver margin is 4cm

Answer 1

1.When there is severe hypovolemia the intracellular and extracellular fluid shifts happens.when the  blood plasma volume decreases ,the blood concentration of blood increases causing the Hct level to decrease and resulting in low heamoglobin.The potassium exchange is interrupted inbthe renal and cardiac function due to low blood volume resulting in deposition of potassium and thus increasing it called hyperkalemia. The kidney tries to eliminate these wastes as a result creatinine increases .In heart the clotting factors are altered leading to increased PT and INR level which may cause bleeding and simultaneously low heamoglobin. Infection indicates a rise in WBC level

2.An increased level of potassium level is dangerous to the function of heart which may cause palpitation,changes in cardiac rhythm (changes seen in P wave and there is elevated T waves)cardiac arrhythmia, cardiac arrest.So it is very important to monitor patient's vital parameters

3.Some of the safety precautions to be done based on the PT/INR value are

• Keep patient environment free of Sharp items
• Do not prick the patient unnecessarily
• Avoid blood thinners as per order
• Avoid bruising or invasive procedures
• Monitor blood parameters

4.The following documentation in regards to patient education in nurses notes are

• In regards to medication,diet (to increase fluids), precautions in taking blood thinners,infection prevention techniques

5Some of the intervention which could have been dine to the patient's wife are

• Provide psychological support
• Explain her all the procedures to be performed ,this gains the support of the patient relative
• Encourage her to verbalize her feeling this can reduce fear and gain knowledge about the treatment
• Update the patient status frequently, this gives her a reassurance that things are carried out in the right way
• Allow her to visit the patient ,this gives an internal strength when the patient progresses
• Encourage her to follow relaxation techniques like yoga ,meditation to ease her from tension1