Question

please help answer this case study

Case Study Gastrointestinal Hemorrhage

Scenario

You are the nurse on duty on the intermediate care unit, and you are scheduled to take the next admission. The emergency department (ED) nurse calls to give you the following report: “This is Barb in the ED, and we have a 42-year-old man, K.L., with lower GI (gastrointestinal) bleeding. He is a sandblaster with a 12-year history of silicosis. He is taking 40 mg of prednisone per day. During the night, he developed severe diarrhea. He was unable to get out of bed fast enough and had a large maroon-colored stool in the bed. His wife ‘freaked’ and called the paramedics. He is coming to you. His vital signs (VS) are stable—110/64, 110, 28—and he's a little agitated. His temperature is 98.2° F (36.8° C). He has not had any stools since admission, but his rectal exam was guaiac positive and he is pale but not diaphoretic. We have him on 5 L O 2 /NC. We started a 16-gauge IV with lactated Ringer's at 125 mL/hr. He has an 18-gauge Salem Sump to continuous low suction; that drainage is also guaiac positive. We have done a CBC with differential, chem 14, coagulation times, a T&C (type and crossmatch) for 4 units RBCs, arterial blood gasses, and a urinalysis (UA). He's all ready for you.”

1. How do you prepare for this patient's arrival?

CASE STUDY PROGRESS

K.L. arrives on your unit. As you help him transfer from the ED stretcher to the bed, K.L. becomes very dyspneic and expels 800 mL of maroon stool.

2. What are the first three actions you should take?

CASE STUDY PROGRESS

K.L. reports that he is getting nauseated but not thirsty. VS are 92/58, 116, 32.

3. What additional interventions do you need to institute?

4. What assessment indicators would you monitor in K.L.?

5. While caring for K.L., which of these care activities can be safely delegated to the nursing assistive personnel (NAP)? (Select all that apply.)

a. Initiating a pulse oximetry monitoring

b. Measuring K.L.'s vital signs every 15 minutes

c. Obtaining consent from K.L. for a possible blood transfusion

d. Assessing K.L.'s peripheral circulation

e. Emptying each Foley catheter collection bag each hour

f. Monitoring K.L.'s hemoglobin and hematocrit levels

Chart View

Arterial Blood Gases

pH 7.47

Pa CO2 33 mm Hg

Pa O2 65 mm Hg

HCO 3 23 mmol/L

Sa O2 91%

Complete Blood Count

Hgb 7.8 g/dL

Hct 23%

6. Interpret the preceding arterial blood gases (ABGs). What do they tell you?

7. Discuss K.L.'s hemoglobin and hematocrit results.

CASE STUDY PROGRESS

The gastroenterologist is notified by K.L.'s physician and schedules an immediate colonoscopy and endoscopy. You accompany K.L. to the endoscopy suite and give him midazolam (Versed) and morphine sulfate IV during the procedures

8. Given the above history, what do you think significantly contributed to the GI bleed?

9. What are midazolam (Versed) and morphine sulfate, and why are they being given to K.L.?

CASE STUDY PROGRESS

During the colonoscopy, K.L. begins passing large amounts of bright red blood. He becomes more pale and diaphoretic and begins to have an altered level of consciousness.

10. Identify five immediate interventions you should initiate.

11. You are preparing to administer the first of 2 units of packed RBCs. Evaluate each of the following statements about the safe administration of blood. Enter “T” for true or “F” for false. Discuss why the false statements are incorrect.

1. Prime the correct tubing and filter with normal saline.
2. Verify K.L.'s identification with secretary in the endoscopy suite.
3. Obtain baseline vital signs before starting the transfusion.
4. Begin the transfusion at a rate of 125 mL per hour.
5. Take K.L.'s vital signs 30 minutes after starting the transfusion.
6. Complete the transfusion within 6 hours of receiving the unit.

CASE STUDY PROGRESS

The physician is able to find the site of the bleeding and cauterize the affected vessels. There is no further evidence of active bleeding. K.L. is transferred back to the unit. His condition is stabilized with fluids, blood, and fresh frozen plasma (FFP). He received esomeprazole (Nexium) 40 mg IV push (IVP) and is placed on 40 mg PO bid.

12. Later, when he seems to be feeling better, K.L. tells you he is really embarrassed about the mess he made for you. How are you going to respond to him?

CASE STUDY OUTCOME

The physician concludes that the GI hemorrhage was prednisone-induced. Because the prednisone was being used to suppress the progression of silicosis, the physician will attempt to decrease his maintenance dose of prednisone while monitoring his respiratory status.

Answer 1