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Grand Rounds
Brittni M. Smith
Middle Tennessee State University
February 14, 2008
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Patient Demographics Female Caucasian 50 years of age Height: 5 ft. 3 in. Weight: 107 lbs. Married, no children
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Events Prior to Hospitalization Hospitalized 12/2007 for GI bleed D/C on 01/08 01/12 home, episode of hematemesis and
dizziness Presented to ER with hematemesis,
syncope, sinus tachycardia, and SBP of 60
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Risk Factors Portal Hypertension Esophageal Varices Prior bleeding episodes Increased abdominal pressure
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Admitting Medical Diagnosis
Gastrointestinal Bleed r/t Esophageal Varices (4) Obstruction of venous flow (portal HTN) Increased pressure in portal vein Thin walled varicosities Rupture / hemorrhage Tx: band ligation
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Additional Medical DiagnosesPrior to Admission: Post Admission:
Pancreatic CancerPortal HTNGERDHypothyroidism
Right hepatic lobe
abscess SplenomegalyAscitesPleural Effusion
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Laboratory ValuesLab Result
red=high
blue=low
Normal Range
Reason for Abnormality
RBC 3.07x10/ul 4.0-5.4 hemorrhage
WBC 15.4mm^3 4.3-10 liver abscess
Hgb 8.8% 12-16 hemorrhage
Hct 27.5% 35-47 hemorrhage
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Laboratory ValuesLab Result
red=high
blue=low
Normal Range
Reason for Abnormality
Platelets 126mm^3 150-400mm splenomeg-aly
Creatinine 0.3mg/dl 0.5-1.1 muscle wasting
T. Protein 4.3g/dl 6.3-8.3 muscle wasting
Albumin 2.1g/dl 3.8-5.0 malnutrition
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Laboratory ValuesLab Result
red=high
blue=low
Normal Range
Reason for Abnormality
Bilirubin T. 1.6mg/dl 0.3-1.1 portal HTN
ALP 138units/L 32-119 portal HTN
ALT 46units/L 9-43 liver abscess
Blood Culture
pending
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DiagnosticsTest Reason Results
Chest X-ray Baseline study W/O masses,
edema, pneumo
Abdominal US Abdominal distention/ firmness
splenomegaly, ascites, irregular shaped liver
Abdominal CT Comparison from 12/27/07
R hepatic lobe abscess
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DiagnosticsTest Reason Results
Transthorasic
Echocardiogram
R/O endocarditis Large pleural effusion left lung
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MedicationsMedication Class/ Dose
Route/ Frequency
Rationale for Use
Colace
docusate sodium
Laxative, emollient
100mg PO BIDstool softener, prevent constipation
Nexium
esomeprazole
Proton Pump Inhibitor
40mg in 5ml
INJ BID
treat and prevent gastric ulcers
Duragesic
fentynl
Opioid analgesic
50mcg TD q72hchronic pain r/t cancer
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MedicationsMedication Class/ Dose
Route/ Frequency
Rationale for Use
Novolin R
short acting insulin
Pancreatic hormone
WBG-100/15= #u
SUBQ q6h
lower blood glucose levels
Synthroid
Levothyroxine
Thyroid hormone
50mcg PO dailythyroid hormone replacement
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MedicationsMedication Class/ Dose
Route/ Frequency
Rationale for Use
Merrem
Meropenem
Ultra-Broad Spectrum Antibiotic
1g in 100ml IVq8h
Tx for liver abscess
Zosyn
piperacillin-tazobactam
Extended Spectrum Beta-Lactam Antibiotic
3.375g in 100ml
IV q6h
Tx for liver abscess
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MedicationsMedication Class/ Dose
Route/ Frequency
Rationale for Use
Vancocin
vancomycin
Glycopeptide Antibiotic
750mg in 100ml
IV q12h
Tx for suspected MRSA infection
Tylenol
acetaminophen
Nonopiod analgesic
650mg PO q6h PRN
mild to moderate pain
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MedicationsMedication Class/ Dose
Route/ Frequency
Rationale for Use
Dulcolax
bisacodyl
Laxative, stimulant
10mg rectal q12h
PRN
Tx for constipation
Diazepam
valium
Antianxiety
2.5mg in 100 ml
IV TID PRN
muscle relaxant and decrease anxiety
Morphine Opioid analgesic
4mg IV q4h PRNmoderate to severe pain
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MedicationsMedication Class/ Dose
Route/ Frequency
Rationale for Use
Zofran
odenastone
Antiemetic
4mg IV q4h PRNprevention, Tx of nausea/ vomiting
sodium chloride
NaCl
Isotonic 0.9%
1000ml @ 30ml/h
IV continuous
Fluid replacement, keep vein open
TPN 1440ml @ 60ml/h
IV continuoussource of nutrition
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Collaboration Physicians Nurses Dieticians Instructors Peers
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Assessment Respiratory Cardiovascular Neurological GI/GU Musculoskeletal Skin/IV Psychosocial
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Neurological Alert, oriented x3 Pupils 2mm bilaterally, briskly reactive Followed verbal commands Clear speech pattern Recent, remote memory intact Full ROM in RUE, LUE Weakness present RLE, LLE
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Respiratory Respirations 16/min SpO2 96% O2 @ 2L NC Coarse bilaterally Diminished in bases bilaterally No wheezes or ronchi present
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Cardiovascular Heart rate 107 beats/min Sinus tachycardia S1, S2 present BP 112/88 Peripheral pulses present Capillary refill >3 sec Edema 2+, non-pitting feet/ankles bilaterally
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Gastrointestinal / Genitourinary Bowel sounds active in all four quadrants Abdomen firmly distended Hepatic drain in RLQ- dark green/red Foley catheter draining clear yellow urine TPN @ 60ml/h
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Integumentary Dry, pink, appropriate for ethnicity Fingers and toes cool, core temp warm Central line site clean, no redness, edema
or drainage present Hepatic drain site clean, dry
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Psychosocial Anxious, apprehensive Fearful Denial Positive mood Numerous visitors Husband present
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Research
Animal Fat Consumption and Pancreatic Cancer
Study investigated correlation between animal fat consumption and incidence of pancreatic cancer
Data obtained from 35 countries Meats included: beef, veal, pork, poultry Results: animal fat consumption increases the
incidence of pancreatic cancer
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Nursing Diagnosis # 1 Ineffective Tissue Perfusion related to
bleeding of esophageal veins as evidenced by increased heart rate, capillary refill greater than 3 seconds, and cool extremities
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Goals 1. Patient will have pulse rate of 60-100
beats/min during shift
2. Patient will have capillary refill time less than 3 seconds during shift
3. Patient will have warm perfused extremities during shift
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Interventions Encourage patient to increase fluid intake Place patient in an upright position Provide client with adequate clothing and
extra blankets Maintain room temp above 70 degrees Administer IV fluids as ordered
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Evaluation1. Partially met: patient’s pulse ranged from
94-106
2. Met: patient’s capillary refill time was less than 3 seconds
3. Met: patient’s hands, fingers, feet, and toes were warm and perfused
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Nursing Diagnosis # 2Acute pain related to distention and increased
pressure in esophageal veins as evidenced by restlessness, increased heart rate, and patient’s verbalization of pain
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Goals1. Patient will have a pain score of 2 or less
on a 0-10 scale during shift
2. Patient will verbalize a decrease or absence of pain
3. Patient will exhibit a decrease in restlessness related to pain
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Interventions Elevate HOB 30 degrees or more as
tolerated Administer pain medications at scheduled
times Provide ice water for drinking Provide distraction: TV, music, visitors
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Evaluation1. Met: Patient rated pain as a 0 or 1
2. Met: Patient stated a decrease in pain level
3. Met: Patient remained comfortable and relaxed throughout the day
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Nursing Diagnosis #3Imbalanced nutrition: less than body
requirements related to esophageal pain and venous distention as evidenced by muscle wasting, refusal to eat, and use of total parenteral nutrition
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Goals1. Patient will remain at current weight or
greater
2. Patient will have no new evidence of muscle wasting
3. Patient will increase the amount of food and fluid intake during meals
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Interventions Patient will sit in an upright position while
eating Diet will consist of soft bland foods Encourage fluid intake Add ice to liquids Administer TPN as scheduled
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Evaluation1. Met: Weight on admission 107lb. Weight
on day of care 107lb
2. Unmet: Patient exhibited extreme weakness in legs
3.Met: Patient drank two 240ml cans of Ensure and consumed approx. 50% of breakfast and lunch
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References
Ignatavicius, D.D. & Workman, M.L. (2006). Medical Surgical Nursing: Critical Thinking for Collaborative Care. St. Louis: Elsevier Saunders.
Mattson, C.P. (2005). Pathophysiology: Concepts of Altered Health States. Philadelphia: Lipincott Williams & Wilkins.
Pagana, K. D. & Pagana, T.J. (2007). Mosby’s Diagnostic and Laboratory Test Reference. St. Louis: Mosby Elsevier.
Skidmore-Roth, L. (2007). Mosby’s Drug Guide for Nurses. St. Louis: Mosby Elsevier.
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References
Ulrich, S. P. & Canale, S. W. (2005). Nursing Care Planning Guide for Adults in Acute, Extended, and Home Care Settings. St. Louis: Elsevier Saunders.
www.astrazeneca.com. Retrieved February 6, 2008.www.vancocin.com. Retrieved February 6, 2008. www.wikipedia.com. Retrieved February 6, 2008.Zhang, J., Zijin, Z., & Berkel, H. J. (2005, August). Animal
fat consumption and pancreatic cancer incidence: evidence of interaction with cigarette smoking. Annals of Epidemiology. 15(7), 500-508. Retrieved February 6, 2008 from CINHAL database.