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 morning, 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 idiopathie 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.The home medication which probably precipitated the GI bleeding are Tolimentin (NSAID) which generally leads to erosion of the gastrointestinal tract and bleeding.

Coumadin is an anticoagulant or a blood thinner which can aggravate the situation of bleeding if there is any erosion in the GIT

2.The most serious complications of bleeding due to diarrhea is hypovolemia or fluid volume deficit.

Acid base imbalance in case of extreme fluid loss from the body

Cardiac arrest due to electrolyte imbalance

3.Admission assessment

Subjective data:

• Bloody diarrhea
• Weakness

Objective data:

• Vitals:
  • Severe hypotension (SBP 70 mm Hg,) no DBP
  • Tachycardia (110bpm)
• Disorientation
• Dizzy

Physical examination

• General appearance:pale
• CNS:Disoriebted
• Pedal edema+

Palpation:Tenderness+

Auscultation:normal breath sounds

4.Signs and symptoms GI bleeding are

• Dizziness
• Fatigue
• Paleness
• Blood in stool
• Abdominal tenderness

The signs and symptoms for fluid volume deficit are

• Hypotension
• Tachycardia
• Disorientation
• Fatigue

Answer 2

Possible complications from hypovolemia and GI bleeding