Question

The patient is a 29 year old woman admitted 20 hours ago for an acute exacerbation of Crohn’s disease with intense abdominal pain. She is NPO and receiving normal saline intravenously at 175 mL per minute. She was last given hydromorphone (Dilaudid) 4 mg IV 30 minutes ago. Because she did have an episode of hypotension earlier after Dilaudid, you now take her vital signs. On inflating the blood pressure cuff, she develops palmar flexion. The flexion remains after the cuff is deflated. What is most likely the cause of this problem? What electrolytes are most likely to be out of balance and why? What is your best first action? Should the Rapid Response Team be called? Why or why not? What additional assessment data are most important to collect? Explain your answer.

Answer 1

Ans1) She is probably dehydrated from the watery stool lost as a result of Crohn's exacerbation. This is more likely the cause of her hypotension. With dehydration, she is probably experiencing some degree of hypovolemic shock with hypoxemia.

2) She has probably lost a lot of calcium in the stool, making her hypocalcemic. This fits with the palmar flexion (positive Trousseau's sign) she experienced when her blood pressure was taken, especially because she is only receiving sodium and chloride intravenously.

3) Apply oxygen to help relieve the palmar flexion.

4) Yes, the team should be called. With persistent palmar flexion, she is getting close to muscle tetany, which would impair ventilation. She needs immediate calcium replacement.

5) Assess her other deep tendon reflexes to determine whether she is hyperreflexive. Assess her oxygen saturation by pulse oximetry to determine the degree of hypoxemia. Assess her abdomen for hyperactive bowel sounds, which are associated with hypocalcemia, as is an increase in the number of bowel movements. If possible, assess her with an electrocardiogram for changes associated with hypocalcemia (prolonged ST interval, prolonged QT interval).