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 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 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 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. are 1. State the home medication(s) that probably precipitated Mr. West's Gl bleeding. 2. Ex plain the most serious potential complication of Mr. West's bleeding and the rationale for your selection. e documentation of the patient's admission assessment in the n e a list of signs and symptoms (both direct and indirect) of GI bleeding and loss 4. Prepar 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. 1. Explain the rationale for the use of fresh frozen plasms

Answer 1

1. The home medication that probably precipitated Mr Wests G.I. bleeding is coumadin . It is a anticoagulant and does not allow blood to clot .

2. The most serious complication due to West's G.I bleeding is Hypovolemic shock due to bleeding . It would result in drastic decrease in body fluids and result in shock .

3. Nurses note - patient came to the emergency at 4.30 am ,he was sleepy but arousable and oriented . He is feeling dizziness. Vitals signs were pulse - 110 bpm , respiratory rate -24bpm ,bliss pressure - 70/ diastole unable to detect . On assessment S3and S4 were present ,lung sounds clear bowel sound clear ,pedal edema present ,gastric tenderness is also present . Liver margin is 4cm below costal margin.

4. Signs and symptoms ( direct and indirect ) are :-

- pale appearance

- sleepy

- dizziness

- disoriented

- tachycardia

- tachypnea

- hypotension