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CLINICAL DECISION MAKING CASE STUDIES IN MEDICAL-SURGICAL NURSING Second Edition Gina M. Ankner CASE STUDY 3 Ms. Winnie GENDER Female AGE 33 SPIRITUAL/RELIGIOUS Jehovah’s Witness PHARMACOLOGIC – Norgestimate/ethinylestradiol Onno Tri-Cyclont ibuprofen Advil pantoprazole (Protonix): prochlorperatine (Comparine omeprazole (Prilosec LEGAL SETTING Hospital ETHNICITY White American CULTURAL CONSIDERATIONS ETHICAL PREEXISTING CONDITION ALTERNATIVE THERAPY PRIORITIZATION COEXISTING CONDITION Flulike symptoms for one week COMMUNICATION DELEGATION Delegating within the scope of assistant nursing personnel responsibilities DISABILITY MODERATE SOCIOECONOMIC Recently promoted to project manager THE DIGESTIVE SYSTEM Level of difficulty: Moderate Overview: This case requires recognition of the signs and symptoms of a gastrointestinal (GI) bleed and characteristics of upper versus lower GI tract bleeding. The nurse provides client education in preparation for a diagnostic procedure and explains the significance of the results. The procedure for administering a blood transfusion is reviewed. Discharge instructions are given. 79 80 Part 6 THE DIGESTIVE SYSTEM Client Profile Case Study Ms. Winnie is a 5-year-old woman who presented to the emergency department. She states. “I have been so sick. It must be the flu. Everyone at work has it. I am achy and tired. I keep vomiting and have not been able to keep anything down for the past three days. After a while, it is just these violent dry heaves since there is nothing more in my stomach to throw up. Tonight I vomited twice within three hours and it was red like blood. I got scared and came in.” Ms. Winnie’s vital signs are BP 110/60, HR 88, RR 20, temperature 100.5°F (38°C). Her skin is clammy and pale. Lab results are WBC 11.800 cells/mm. RBC 3.31 million/pl. Hgb 11 g/dl. Het 34% platelets 150.000 mm”.K3.8 mEq/. Na 140 mEq/L. An electrocardiogram (ECG, EKG) shones normal sinus rhythm. A kidneys, ureters, and bladder (KUB) abdominal X-ray is done, and she will have an csophagogastroduodenoscopy (EGD) at 7:00 A. M. the next day. She is admitted with the diagnosis of probable upper GI bleed. Ms. Winnie express concem to the murse, “Do you think I’ll be in the hospital long I have been managing an important project for the past few months at the company I work for, and although my boss has been pretty understanding about me being out sick for the past few days, there is an important deadline coming up next week. Being in the hospital long may jeopardise my job.” She is started on intravenous (IV) fluids of normal saline (NS) at 100 ml. per hour. Pantoprazole continuous IV drip and prochlorperarine as needed for nausea and vomiting are prescribed. Ms. Winnie is to have strict monitoring of her intake and output and her vital signs assessed every two hours. She will be on bed rest. Her stools are to be tested for occult blood. She will have a complete blood count (CBC) assessed every six hours Results of the KUB are reported as a nonspecific gas pattern with moderate amount of stool throughout the colon with no acute abnormality noted. The EGD reveak a normal duodenum with no vascular anomalies ulceration, or inflamma tion. There is a normal appearing gastric mucosa with no crosive changes, ulcer, oc max. A small Mallory Weiss tear is noted Questions 1. The nurse asks Ms. Winnie if she takes any medi- “Do you have some saltine crackers and ginger ale to cations at home. Ms. Winnie states, “I take Ortho try and help settle my stomach? Should the nurse Tri-Cyclen once a day and I was taking Advil three give Ms. Winnie something to cat? to four times a day for the aches and pains of being 6. The nurse recognizes the scenario in Question 5a sick. Should the nurse suggest to the health care a teaching opportunity. How might the nurse explain provider that these two medications be included in why an EGD has been prescribed for Ms. Winnie and Ms. Winnie’s admission orders? what she can expect during the procedure 2. Identify four nursing diagnoses that are appro- 7. What are the nursing responsibilities after priate for Ms. Winnie upon admission Ms. Winnie has the EGD) and refurns to her room 3. Which lab results are abnormal and what is the 8. Discuss the Mallory-Weiss tear found during significance of the abnormal results in Ms. Winnie’s Ms. Winnie’s EGD. What is a Mallory-Weiss tar? Case? What are the common symptoms of a Mallory-Weiss 4. Distinguish between the characteristics of upper tear and what causes itë and lower GI bleeding 9. Which factors determine if blood products will 5. It is 1:00 AM. and Ms. Winnie is setded into be administered to a client with GI tract bleeding her room on the nursing unit. She asks the nurse, secondary to a Mallory-Weiss tear? Questions (continued) 10. If a transfusion is needed and Ms. Winnie’s blood • Document type of blood product infused, type is A positive, what are compatible blood types? time of infusion, and any adverse reactions. Explain why a person can only receive compatible • Obtain venous access with a larger-bore blood types. needle (19-gauge), 11. Although unlikely with a Mallory-Weiss tear, the • Assess baseline vital signs, urine output, skin nurse realizes that if Ms. Winnie’s bleeding does not color, and history of transfusion reactions. resolve, she may need a blood transfusion. The nurse • With another registered nurse, verify the has not administered blood in a while and reviews client by name and identification number, the agency policy and procedure. Place the following check blood product compatibility, and note ten steps of administering a blood transfusion in the expiration time. Do not use the client’s room proper order number as a form of client identification. 12. Later in the shift, the nurse is looking through • Monitor vital signs per agency policy Ms. Winnie’s chart and comments to herself. “I think • Obtain blood products from the blood bank, I may have reviewed the policy and procedure keeping in mind that packed blood red cells book for nothing.” Why does the nurse believe she (PRBC) transfusions should be completed may not need to know how to administer blood to within four hours of removal from refrigeration. Ms. Winnie after all? . Remain with the client during the first fifteen 13. Which aspects of Ms. Winnie’s plan of care could to thirty minutes of the transfusion (infusion of the first 50 ml of blood product) to assess the registered nurse assign to assistive nursing per- sonnel such as a certified nursing assistant (CNA)? for adverse reactions. Administer the blood product using appropri. What do you anticipate will be her length of stay in 14. Should Ms. Winnie be concerned about her job? ate filter tubing, Filters remove aggregates and possible contaminants. Il blood is to be the hospital? diluted, use only normal saline. 15. If it is determined that Ms. Winnie has a bacte Verify the medical prescription for type of rial infection and she is discharged with a prescrip- blood product, dose, and transfusion time. tion for an antibiotic, what teaching is appropriate • Discontinue the transfusion when complete regarding the use of an antibiotic with an oral and dispose of the bag and tubing properly. contraceptive?
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