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 Diagnoses
Prior to Admission:
Pancreatic
Portal
Cancer
HTN
GERD
Hypothyroidism
Post Admission:
Right
hepatic lobe
abscess
Splenomegaly
Ascites
Pleural Effusion
Laboratory Values
Lab
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
Hgb
8.8%
12-16
liver
abscess
hemorrhage
Hct
27.5%
35-47
hemorrhage
Laboratory Values
Lab
Result
red=high
blue=low
Platelets
126mm^3
Normal
Range
Reason for
Abnormality
150-400mm splenomegaly
Creatinine
0.3mg/dl
0.5-1.1
T. Protein
4.3g/dl
6.3-8.3
Albumin
2.1g/dl
3.8-5.0
muscle
wasting
muscle
wasting
malnutrition
Laboratory Values
Lab
Result
red=high
blue=low
Normal
Range
Reason for
Abnormality
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
Diagnostics
Test
Reason
Results
Chest X-ray
Baseline study
Abdominal US
Abdominal
distention/
firmness
W/O masses,
edema, pneumo
splenomegaly,
ascites, irregular
shaped liver
Abdominal CT
Comparison from
12/27/07
R hepatic lobe
abscess
Diagnostics
Test
Transthorasic
Echocardiogram
Reason
R/O endocarditis
Results
Large pleural
effusion left lung
Medications
Medication
Colace
docusate sodium
Class/ Dose
Route/ Frequency
Rationale for Use
Laxative, emollient stool softener,
100mg PO BID
prevent
Nexium
esomeprazole
Proton Pump Inhibitor
Duragesic
fentynl
Opioid analgesic
50mcg TD q72h
40mg in 5ml
INJ BID
constipation
treat and
prevent gastric
ulcers
chronic pain r/t
cancer
Medications
Medication
Class/ Dose
Route/ Frequency
Rationale for Use
Pancreatic hormone lower blood
Novolin R
short acting insulin WBG-100/15= #u
glucose levels
SUBQ q6h
Synthroid
Levothyroxine
Thyroid hormone
50mcg PO daily
thyroid hormone
replacement
Medications
Medication
Class/ Dose
Route/ Frequency
Rationale for Use
Merrem
Meropenem
Ultra-Broad
Tx for liver
Spectrum
abscess
Antibiotic
1g in 100ml IVq8h
Zosyn
piperacillintazobactam
Extended Spectrum
Beta-Lactam
Antibiotic
3.375g in 100ml
IV q6h
Tx for liver
abscess
Medications
Medication
Class/ Dose
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
Medications
Medication
Class/ Dose
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
Morphine
Opioid analgesic
4mg IV q4h PRN
muscle relaxant
and decrease
anxiety
moderate to
severe pain
Medications
Medication
Zofran
odenastone
sodium chloride
NaCl
TPN
Class/ Dose
Route/ Frequency
Antiemetic
4mg IV q4h PRN
Rationale for Use
prevention, Tx
of nausea/
vomiting
Isotonic 0.9%
Fluid
1000ml @ 30ml/h replacement,
keep vein open
IV continuous
1440ml @ 60ml/h source of
IV continuous
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
Evaluation
1. 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 # 2
Acute pain related to distention and
increased pressure in esophageal veins as
evidenced by restlessness, increased heart
rate, and patient’s verbalization of pain
Goals
1. 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
Evaluation
1. 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 #3
Imbalanced 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
Goals
1. 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
Evaluation
1. 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.