Grand Rounds

1. Grand Rounds Brittni M. Smith Middle Tennessee State University February 14, 2008

2. Patient Demographics • Female • Caucasian • 50 years of age • Height: 5 ft. 3 in. • Weight: 107 lbs. • Married, no children

3. 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

4. Risk Factors • Portal Hypertension • Esophageal Varices • Prior bleeding episodes • Increased abdominal pressure

5. 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

6. Additional Medical Diagnoses

7. Laboratory Values

8. Laboratory Values

9. Laboratory Values

10. Diagnostics

11. Diagnostics

12. Medications

13. Medications

14. Medications

15. Medications

16. Medications

17. Medications

18. Collaboration • Physicians • Nurses • Dieticians • Instructors • Peers

19. Assessment • Respiratory • Cardiovascular • Neurological • GI/GU • Musculoskeletal • Skin/IV • Psychosocial

20. 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

21. Respiratory • Respirations 16/min • SpO2 96% • O2 @ 2L NC • Coarse bilaterally • Diminished in bases bilaterally • No wheezes or ronchi present

22. 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

23. 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

24. 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

25. Psychosocial • Anxious, apprehensive • Fearful • Denial • Positive mood • Numerous visitors • Husband present

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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.

40. 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.