Gastrointestinal Case Study 1 The charge nurse on your surgi
Gastrointestinal Case Study 1 The charge nurse on your surgical… Gastrointestinal Case Study 1 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 gastrointestinal (GI) 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 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), hypothyroidism, and “fluid retention.” PSH (past surgical history) includes TAH (total abdominal hysterectomy) and appendectomy (1985), benign R breast biopsy (2014), and laparoscopic Nissen fundoplication (2014). Her regular medications include nizatidine (Axid) 150 mg bid, FeSO 325 mg qd, potassium chloride (K-Dur) 20 mEq bid, hydrochlorothiazide (HCTZ) 15 mg qd, levothyroxine (Synthroid) 0.1 mg qd, salmeterol (Serevent) 2 puffs bid, and theophylline (Slo-Bid) 200 mg PO tid. H. C.’s admission orders brought up from the ED include the following: admit to Gl unit; Dx (diagnosis) of gastric ulcer, adenocarcinoma of the lung, longstanding COPD; VS q4h; NPO (nothing by mouth); D5NS with 20 mEq KCI/L at 125 ml/hr; 1&O; CBC with differential; electrolytes, Chem 20, PT/PTT in AM; UA (urinalysis) on admission; O2 at 4 L/min via nc prn to keep SaO2 > 92%; famotidine (Pepcid) 20 mg IV at 12 h; no NSAIDs, ASA; Guaiac all stools; call MD when husband arrives. 1. Which orders would require some clarification? Why? You put in a call to the physician for clarification of orders. In the meantime, you proceed with the admission process. 2. What are the major components of the nursing assessment you will perform on H. C.? Throughout the assessment, H. C. appears to be SOB. Her sentences are getting shorter with pauses for breathing between. You ask H. C. to stand on the bedside scale. As she stands, she suddenly sits back on the bed c/o dizziness and nausea. 3. H.C. had been admitted for a GI bleed. Reviewing the data above, list possible indicators of gastrointestinal hemorrhage. The physician finally calls to clarify H. C.’s orders: draw STAT H&H, change IV to D5 1/2NS at 100 ml/hr, titrate O2 to maintain SaO2 >86%, and give furosemide (Lasix) 10 mg IVP (IV push) if K>3.8 mEq/L. the lab work returns: Hgb 10 g/dL, Hct %, K 3.4 mEq/L. 4. Based on these laboratory findings, what are you going to do? Dr. B. arrives and discusses the options with Mr. and Mrs. C. It was decided 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 that H. C. is not a candidate for lung resection. Radiation is planned to begin as soon as possible following the GI surgery. 5. What preop care would you expect to give? 6. In view of H. C.’s history, which part of your preop teaching do you think will be most necessary for H.C. and why? 7. H.C. returns to the floor after surgery. She has had a large wedge resection of her stomach with partial selective vagotomy and a pyloroplasty. She is quite lethargic with stable VS. Her EBL (estimated blood loss) during surgery was minimal (100 mL). She has an NGT in place to intermittent LWS (low wall suction). What should you know about NGT postoperative management? 8. If H. C.’s NGT is pulled partially out, what is the best action? Why? 9. The second day postop, H. C. still has an NGT and a pulse oximeter. Where might you expect H. C. to have some skin breakdown? 10. How can the nurse best prevent skin breakdown? H. C. has no postop complications and is discharged to her home with her husband on the 5th POP (postop day). 11. What warning signs would you teach the patient 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 would 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 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. Health Science Science Nursing
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