JACKSON STATE COMMUNITY COLLEGE
Department of Nursing
NUR 214 Adult Health I
Adult Simulation
59 year-old Hispanic male.
Admitting Diagnosis: cellulitis of left lower leg
Concurrent Illnesses: hypertension and adult onset diabetes or type 2 diabetes mellitus
and COPD
Social History: Lives alone, minimum wage job with no health care benefits
Signs and Symptoms or Clinical Manifestations
 Hard to arouse, not oriented to place or time.
 Poor skin turgor
 Mucous membranes dry and sticky
 Skin dry and flushed
 Tongue furrowed
 Eyes sunken
 Complains of abdominal pain and thirst
 Vital signs: Temperature 99.8 degrees F, radial pulse irregular rate of 96 with 1+
pulse volume or amplitude, apical pulse rate 96 and irregular
 bilateral breath sounds equal and clear with labored rapid breathing. Respiratory
rate 25 breaths per minute
 S1 and S2 auscultated
 PMI 5th ICS 1 mm left of midclavicular line
 CRT > 3 seconds
Diagnostic Findings
 Serum glucose 545 mg/dl
 Serum sodium 150 mEq/l
 Serum potassium 3.0 mEq/l
 WBC SI Units 0.6
 RBC SI Units 160 g/l
 Serum sodium bicarbonate SI units 16 mmol/L
 Pulse oximetry SpO2 90%
JACKSON STATE COMMUNITY COLLEGE
Department of Nursing
NUR 214 Adult Health I
Adult Simulation
Focus: Diabetic Ketoacidosis
Give students a brief case scenario in which they have to determine that patient is in DKA.
Type 1 diabetic
Concurrent illness: COPD
Intervention
Ensure patient airway
Clinical Manifestations
Airway patent
Check oxygen saturation
Administer Oxygen via nasal cannula at 2 liters/min
 After 30 minutes recheck oxygen saturation
Oxygen Saturation < normal
Establish EKG monitoring capability
tachyarrhythmia
Establish 2 IV lines with large-bore catheter
Hang either 0.45% or0. 9% NaCl at
1 liter/hr
Insert either #16 or #18 Foley catheter
Monitor every ______ for urine output
 One hour later
Output 20 ml/hr
 Urine output 40 ml/hr
Diagnostic Findings
Arterial blood gases
 pH
6.96
 PCO
22 mm Hg
 HCO3 10 mE/l
 PO2
80
Administer IV sodium bicarbonate
JACKSON STATE COMMUNITY COLLEGE
Department of Nursing
NUR 214 Adult Health I
Gastrointestinal Bleed (GI Bleed) Learning Activity Exercise
Etiology and Pathophysiology
1. The greatest incident of upper GI bleeding in older adults is related to
___________________________________________________________.
2. How do you determine if the GI bleed is from an arterial source?
3. What does the bright red blood indicate?
4. Describe “coffee ground emesis”.
5. What defines a massive upper GI bleed?
6. Describe the term “melena” and what does it indicate?
7. What drugs can induce an upper GI bleed? (see p. 1023 Table 40-15)
8. What is “occult bleeding”?
9. What are the most common sites of GI bleeding?
Esophageal Origin
10. Bleeding from an esophageal source is most likely caused by?
11. What causes chronic esophagitis?
12. _______ and _________ are known irritants of the esophageal mucosa.
13. What is a Mallory-Weiss tear?
14. Esophageal varices usually occurs secondary to _____________?
15. What is the pathophysiology of esophageal varices?
16. __________ and __________ may result in massive, sudden bleeding from
esophageal varices. Give examples.
Stomach Origin
17. What accounts for the majority of cases of upper GI bleeding?
18. Most bleeding ulcers area related to the presence of ___________.
19. List 3 drugs that can cause irritation and disruption of the gastric mucosal barrier.
20. When taking a medical history on a client with a GI bleed, why is it important to ask
specifically about OTC medications such as Alka-Seltzer, Bufferin, B.C. powder, and
Excedrin?
21. Physiologic stress ulcers occur after ______________________________. What
contributes to the mucosal damage in the stomach?
22. Can gastric cancer cause a GI bleed? Why or why not?
Emergency Assessment and Management
1. What should your immediate nursing assessment include?
2. What are the signs and symptoms of shock?
3. What indicates peritonitis or perforation?
4. What questions should you ask the client or the family (if the client is unable to
respond)?
5. What laboratory values do you anticipate the doctor to order and why?
6. In the urinalysis results, what is specific gravity indicative of?
7. Should you obtain an IV line? What gauge needle? Why?
8. What IV solutions do you anticipate being ordered in the beginning?
9. Why is packed RBCs preferred over whole blood?
10. When administering blood products, what should the nurse assess for?
11. Initially, are hemoglobin and hematocrit lab values helpful in determining immediate
blood loss? Why or why not?
12. Why is supplemental oxygen important in GI bleeding cases?
13. What is the purpose of an indwelling catheter? A central venous pressure line?
14. What is the purpose of the nasogastric tube (NGT)? Where is the NGT placed and
why?
15. What is the purpose of aspiration of stomach contents?
16. What is the purpose of gastric lavage and how do you perform it?
Diagnostic Studies
1. What is the endoscopic procedure used for?
2. What is an angiography and when is it used?
3. Are barium contrast studies valuable in determining the cause of GI bleeds?
Collaborative Care
Endoscopic Therapy
1. What is the goal of endoscopic hemostasis?
2. In what circumstances has this technique proven useful?
3. What techniques are utilized?
Surgical Therapy
1. When is surgery indicated?
2. _________________________ determines the choice of operation.
Drug Therapy (Refer to p. 1025, Table 40-16)
1. During the acute phase, drugs are used to _______________________,
____________________, and ________________________________.
2. What drugs are utilized in injection therapy and how are they effective?
3. What is a sclerosant?
4. What medication is used for variceal bleeding? What function does it perform?
What nursing assessment should be performed while giving this medication?
5. Determine the mechanism of action and examples of the following drugs:
a. Antacids
b. H2-Receptor Blockers
c. Proton Pump Inhibitors
6. When is the medication, octreotide (Sandostatin) used? How is it given?
Nursing Management
1. What should your nursing assessment include (refer to p. 1026, Table 40-17):
a. Subjective data:
b. Objective data:
2. How often are vital signs taken? How should you take the blood pressure? Why?
Nursing Diagnosis
1. Name 3 priority nursing diagnoses for the client with upper GI bleeding.
a.
b.
c.
Planning
1. What are the overall goals for a client with upper GI bleeding?
Nursing Implementation
1. What clients are in the high-risk category and why?
2. For health promotion, what would you instruct the client to do?
3. If the client must take aspirin, how should they be taken?
4. What is misoprostol (Cytotec) and why is it used (refer to Davis drug guide)?
5. What health promotion instructions should the nurse provide to the client with a
history of liver cirrhosis with varices?
Acute Intervention
1. Why should the nurse use caution when administering sedatives?
2. How can you monitor the client’s hydration status?
3. What urine output rate indicates adequate perfusion?
4. Urine specific gravity readings >0.125 indicate what? Why is this important?
5. The client with a history of cardiovascular disease should be closely monitored for
signs of ___________________________. What assessment should the nurse
perform?
6. True or False. Most upper GI bleeding episodes cease spontaneously, even without
intervention.
7. Should all vomitus be checked for occult blood? Why or why not?
8. How does the nurse perform gastric lavage? Can electrolyte imbalances occur?
What about cardiac arrhythmias?
9. How often are hemoglobin and hematocrits drawn during an active bleeding episode?
10. Why would the client’s BUN level be elevated?
11. What should the nurse assess for when the client begins PO intake? Initially how is
the feeding started?
12. The client has a history of alcoholism. What should the nurse assess for? What are
the signs and symptoms?
Ambulatory Care
1. The client is being discharged from your floor. What discharge teaching will you
provide?