grand rounds

Grand Rounds

Brittni M. Smith

Middle Tennessee State University

February 14, 2008

Patient Demographics Female Caucasian 50 years of age Height: 5 ft. 3 in. Weight: 107 lbs. Married, no children

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

Risk Factors Portal Hypertension Esophageal Varices Prior bleeding episodes Increased abdominal pressure

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

Additional Medical DiagnosesPrior to Admission: Post Admission:

Pancreatic CancerPortal HTNGERDHypothyroidism

Right hepatic lobe

abscess SplenomegalyAscitesPleural Effusion

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


red=high

blue=low

Normal Range


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


red=high

blue=low

Normal Range


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

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

DiagnosticsTest Reason Results

Transthorasic

Echocardiogram

R/O endocarditis Large pleural effusion left lung

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


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


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


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


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


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

Collaboration Physicians Nurses Dieticians Instructors Peers

Assessment Respiratory Cardiovascular Neurological GI/GU Musculoskeletal Skin/IV Psychosocial

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

Respiratory Respirations 16/min SpO2 96% O2 @ 2L NC Coarse bilaterally Diminished in bases bilaterally No wheezes or ronchi present

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

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

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

Psychosocial Anxious, apprehensive Fearful Denial Positive mood Numerous visitors Husband present

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

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

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

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

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

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

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

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

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

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

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

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

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

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.

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.

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