Cirrhosis Case Study Assignment
Case Scenario:
John Adams is 55 years of age and is male patient who is admitted to the intensive care unit with the diagnosis of acute esophageal varices bleed. The patient has a long-standing history of alcoholism and cirrhosis of the liver. Six months ago, the patient received an EGD, which diagnosed the esophageal varices. The patient has quit drinking alcohol for the past six months and has been active in Alcoholics Anonymous. The patient has a history of coronary artery disease and angina. The patient has been taking nadolol (Corgard) and isosorbide (Isordil). The admission vital signs include: BP 88/50, P 110, R 26, and T 99°F. The O2 saturation is 88% on room air and the patient is placed on 2 liters per minute of oxygen per nasal cannula with O2 saturation of 94%. The patient’s hemoglobin is 6 g/dL, the hematocrit is 12%, and the platelets are 75,000. The patient has a prolonged PT and PTT. The liver profile shows a mild elevation of the aspartate amino-transferase (AST) and the aminotransferase (ALT). The BUN and serum creatinine are also elevated. The patient has in place from the emergency department a nasal gastric tube to low wall suction. The emergency department physician placed a right subclavian triple lumen catheter and there is NS infusing at 100 mL per hour. The emergency department nurse administered vitamin K. Additional orders on the chart from the gastroenterologist include:
octreotide (Sandostatin) IV 50-mcg bolus followed with continuous IV infusion 1000 mcg in 250 mL D5NS at 25 mcg per hour
Type and cross of 6 units of PRBCs STAT and transfuse 2 units of PRBCs over 2 hours each
administer furosemide (Lasix) 20 mg IVP in between each unit
Repeat CBC one hour after the transfusion is completed
The type and cross was drawn in the emergency department and the blood bank called and stated the blood is ready.
1. Identify and differentiate the objective and subjective data
2. Discuss any other assessment data the nurse should obtain
3. In the order:
octreotide (Sandostatin) IV 50-mcg bolus followed with continuous IV infusion 1000 mcg in 250 mL D5NS at 25 mcg per hour
a. What is meant by 50 mcg bolus? How many mLs will be administered in the bolus dose?
b. What is meant by continuous infusion? How many mL/hr will you set the pump?
4. In what order should the nurse institute the physician orders that are listed above. (hint: Think about what would happen if we don’t achieve hemostasis first). Provide the rational after each?
5. Understanding that drawing blood from a central line is an RN role, in detailed steps, discuss the process of drawing blood from a central line.
6. Lasix dose:
a. The Lasix is provided in a 40mg/4mL vial, calculate the volume to be administered after each PRBC administration.
b. Considering you will give the Lasix dose through a central line, what is the most appropriate syringe selection for the Lasix dose, 3mL, 5 mL, 10mL, and why?
7 The nurse observes the nasogastric secretions and upon admission to the ICU there was 200 mL of dark red colored drainage. The nurse continues to monitor the drainage and as the nurse hangs the first unit of PRBCs, 200 mL of bright red bloody drainage is dumped into the collection canister. What should the nurse do?
My answer: Since the blood is coming from the nasogastric tube, it means the patient is bleeding internally. Since as a nurse cannot stop the internal bleeding. They should monitor the patient's vitals(blood pressure) and make sure he is not going into hypovolemic shock.
The gastroenterologist orders for the nurse to increase the octreotide to 50 mcg per hour and the endoscopy nurse and the physician will be up shortly to perform a vertical band ligation (VBL).
8,What is the new rate for the octreotide? My answer is XmL/hr=250mL/1000mcg x 50 mcg/1hr=12.5 mcg/hr
9.How does the nurse prepare the patient and the room for this procedure?
10. What is the priority NANDA based on the patient data (There are only two that are priority). Formulate a 3 part NANDA statement based upon the objective and subjective data and complete the plan of care.
11. Based on the NANDA you have identified, formulate three specific outcome statements
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