Nursing critical care

Description

Read through the following case study and answer the following questions

Gastrointestinal Disorders
229
that H.C. is not a candidate for lung resection. Radiation is planned to begin as soon as possible
following this GI surgery.
5. What preop care would you expect to give?
6. In view of H.C.’s history, which part of your preoperative teaching do you think will be most
necessary for H.C., and why?
H.C. returns to the floor after surgery. She has had a large wedge resection of her stomach with a
partial selective vagotomy and a pyloroplasty. She is quite lethargic with stable VS. Her EBL
(estimated blood loss) during surgery was minimal (100 mL). Her postop orders are as follows:
Monitor H&H q8h. Transfuse 2 U PRBC (packed red blood cells) slowly (each over 4 h) and give
furosemide 20 mg IVP (intravenous push) between units. Check HGB/HCT after second unit and call
MD. CXR (chest x-ray) in Am with CBC, CMP, PT/PTT.
7. What is the rationale for ordering furosemide 20 mg IVP between units of PRBCs?
8. Why did the MD order a CXR in the morning?
9. The second postop day, H.C. still has a nasal O, cannula and a pulse oximeter. Where might you
expect H.C. to have some skin breakdown?
10. How can the nurse best prevent skin breakdown?
Copyright © 2005 by Mosby, Inc. All rights reserved.
Gastrointestinal Disorders
230
H.C. has no postoperative complications and is discharged to her home with her husband on the
fifth POD (postoperative day).
11. What warning signs would you teach H.C. to call her surgeon for?
12. H.C. is preparing for discharge when she turns on her call light. As you enter the room, she says,
“I’m leaking.” You examine her incision and note that her surgical wound has opened slightly
(dehiscence). What action should you take?
After examining H.C., the physician instructs you to dress the wound with a wet- to-moist dressing.
You contact the home health nurses for follow-up care for H.C., and she is discharged to her home.
13. In addition to dressing changes, what related services might the home health nurses provide for
H.C. and her husband?
Three weeks later, H.C. was discharged from home care and started her radiation treatments.
Copyright © 2005 by Mosby, Inc. All rights reserved.
4
Gastrointestinal Disorders
Case Study 1
Name
Class/Group
Date
Group Members
INSTRUCTIONS: All questions apply to this case study. Your responses should be brief and to
the point. Adequate space has been provided for answers. When asked to provide several
answers, they should be listed in order of priority or significance. Do not asume information that
is not provided. Please print or write clearly. If your response is not legible, it will be marked as ?
and you will need to rewrite it.
Scenario
The charge nurse on your surgical floor notifies you that your next admission will be H.C., a 70-year-old
woman who has an active GI (gastrointestinal) bleed and has just been informed that she has
adenocarcinoma of the lung. Her VS are 130/80, 80, 18, 37.2° C.
When H.C. arrives on the floor, no family members are present, she has slightly pink coloring, and
she denies pain, although she does appear anxious. Her PMH (past medical history) includes PUD
(peptic ulcer disease) with reflux esophagitis, COPD (chronic obstructive pulmonary disease), HTN
(hypertension), hypothyroidism, and “fluid retention.” PSH (past surgical history) includes TAH (total
abdominal hysterectomy) and appendectomy (1965), benign R breast biopsy (1994), and laparoscopic
Nissen fundoplication (1994). Her regular medications include ranitidine 150 mg bid, FeSO4 325 mg qd,
potassium chloride (K-Dur) 20 mEq bid, hydrochlorothiazide (HCTZ) 25 mg qd, levothyroxine (Synthroid)
0.1 mg qd, albuterol/ipratropium (Combivent) 2 puffs q6h, and salmeterol (Serevent) disk 1 puff bid.
H.C.’s admission orders brought up from the ED (emergency department) include the following:
admit to GI (gastrointestinal) unit; Dx (diagnosis) of gastric ulcer, adenocarcinoma of the lung,
longstanding COPD; VS q4h; NPO (nothing by mouth); IV (intravenous) D NS with 20 mEq KCI/L at
125 ml/h; l&O (intake and output); PT/PTT (prothrombin time/partial thromboplastin time), CBC
(complete blood cell count), and CMP (complete metabolic profile) in AM; UA (urinalysis) on admission;
O2 (oxygen) at 4 LINC (liters throught nasal cannula) pr (as needed) to keep Saoz (arterial oxygen
saturation) >92%; pantoprazole 80 mg then drip at 8 mg/h; no NSAIDs (nonsteroidal antiinflammatory
drugs) or ASA (aspirin); Hemoccult all stools; call MD (doctor) when husband arrives.
1. Which orders would require some clarification? Why?
227
Copyright © 2005 by Mosby, Inc. All rights reserved.
Gastrointestinal Disorders
228
You put in a call to the physician for clarification of the orders. In the meantime, you proceed with
the admission process.
2. What are the major components of the assessment you will perform on H.C.?
Throughout the assessment, H.C. appears to be SOB (short of breath). Her sentences are getting
shorter with pauses in between for breathing. You ask H.C. to stand on the bedside scale. As she
stands, she suddenly sits back on the bed, C/O (complains of) dizziness and nausea.
3. H.C. had been admitted for a GI bleed. Review the previous data, and list possible indicators of
gastrointestinal hemorrhage.
The physician calls to clarify H.C.’s orders: draw stat H&H (hematocrit and hemoglobin), change IV
to D5%NS at 100 ml/h, titrate Oą to maintain Sao, between 88–90%, stat PT/PTT, CBC, CMP. The lab
work returns: Hgb 10 g/L, Hct 30%, K 3.4 mmol/L.
4. Based on these laboratory findings, what are you going to do?
Dr. B. arrives and completes an emergent EGD (esophagogastroduodenoscopy) but was
unsuccessful in his attempt to stop the bleeding. Dr. B. discusses the options with H.C. and her
husband. A decision is made to go ahead with partial gastrectomy to remove the ulcer. The pulmonary
consultant indicates that H.C.’s adenocarcinoma has metastasized to adjacent tissues to the extent
Copyright © 2005 by Mosby, Inc. All rights reserved.

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