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Case Study 14
Katrin Larusson
Scenario
Summary
Patient Info
 70 year old male
 3 days of dysentery (bloody
diarrhea)
 Pt. dizzy, disoriented and weak
 Idiopathic dilated
cardiomyopathy-dx several years
ago
 HX:







Hypertension
Arthritis,
Cardiomyopathy (EF 13%)
Heart failure
Cardiac arrest d/t hypokalemia,
Atrial fib. (under control)
Peptic Ulcer (15 years prior)
Clinical Presentation
 Vital signs




BP: 70/diastolic inaudible
HR:110
RR: 20
Temp: 99.1°F
 Endoscopy: 25x15mm duodenal ulcer
with adherent clot
 Pale, sleepy, oriented, dizzy, HTN
 Sinus Tachycardia, S3 and S4 with a
grade ll/lV systolic murmur, peripheral
pulses 2+, with trace pedal edema
 Lung sounds clear
 BS present, midepigastric tenderness,
liver margin 4 cm below costal margin
Duodenum Ulcer
 Most common cause?




H. pylori
Smoking
Stress
Over use of NSAIDs
 Pain
 Mid-epigastric
 After eating
 Intervention
 Control secretions
 Neutralize acid
 Antibiotics
 Complications
 Internal hemorrhage
 Perforated duodenal ulcer
Patient’s Medications
 Enalapril 5mg PO BID
 ACE inhibitor; treats HTN and HF
 Warfarin 5mg/day PO
 Anticoagulant; used to prevent clots
 Digoxin 0.125mg/day PO
 Antiarrhythmic, Inotropes; treat atrial fib. and HF
 Potassium chloride 20 mEq PO BID
 Prevent low potassium levels in blood
 Diclofenac Sodium 50 mg PO TID
 Anti-inflammatory (NSAID); treat arthritis
Plan of Care
 Admit pt. to ICU
 Treat for volume deficit
 16 gauge catheter inserted with LR infusing
 Swan-Ganz Catheter and Arterial Line inserted
 What else should
be addressed?
What may have precipitated C.W.’s
Gastrointestinal Bleeding?
 The Duodenal Ulcer is most likely cause of the GI
bleeding
 Other common causes are:



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Diverticulitis
Gastrointestinal cancers
Inflammatory Bowel Disease
Hemorrhoids
Gastritis (inflammation of stomach lining)
The Value of U/S to Determine Priority for Upper Gastrointestinal
Endoscopy in Emergency Room

Abstract: In countries endemic for liver and GIT diseases, frequent emergency department (ED)
patients contribute to a disproportionate number of visits consuming substantial amount of medical
resources. One of the most frequent ED visits is patients who present with hypovolemic shock,
abdominal pain, or confusion with or without signs of upper gastrointestinal bleeding (UGIB). The use of
conventional two-dimensional ultrasound (2D-U/S) may provide immediate and useful information
on the presence of esophageal varices, gastrointestinal tumors, and other GIT abnormalities.

The current study investigated the feasibility of using (2D-U/S) to predict the source of UGIB in ED and
to determine patients’ priority for UGE.

Between February 2003 and March 2013, we retrospectively reviewed the profiles of 38,551 Egyptian
patients, aged 2 to 75 years old, who presented with a history of GI/liver diseases and no alcohol
consumption. We assessed the value of 2D-U/S technology in predicting the source of UGIB.

Of 38,551 patients presenting to ED, 900 patients (2.3%), 534 male (59.3%) and 366 female (40.7%)
developed UGIB. Analyzing results obtained from U/S examinations by data mining for emergent UGE
were patients with liver cirrhosis (LC), splenomegaly, and ascites (42.6% incidence of UGIB), followed
by LC and splenomegaly (14.6%), LC only (9.4%), and was only 0.5% who had no morbidity finding by
2D-U/S.

Ultrasonographic instrumentation increases the feasibility of predictive emergency medicine. The area
has recently not only gained a fresh impulse, but also a new set of complex problems that needs to be
addressed in the emergency medicine setting according to each priority.
Identify 5 signs and symptoms of GI
bleeding and loss of blood volume
Signs (objective)
 Dysentery
 Low Blood Pressure
Symptoms (subjective)
 Abdominal Pain- especially in
the epigastrium for ulcers
 Short of Breath
 Pale Skin
 Fatigue
 Weakness
 Dizziness
 Positive guaiac test
 Confusion
 Blood in Vomit
 Loss of consciousness
 Abdominal or chest pain
 Low urine output
What is the most serious potential
complication of C.W.’s bleeding
 Hypovolemic Shock
 Loss of excess amounts of fluid: dysentery for 3 days
 Volume Deficit d/t excessive blood loss
What is the effect of C.W.’s blood pressure
on his kidneys?
 Low blood pressure results in lack of blood flow to vital
organs
 Heart
 Brain
 Kidneys
 Lungs
 Liver
 Low blood pressure can develop into shock- causing heart
attacks, stroke and Kidney Failure
 Kidney Failure s/s: lethargy, weakness, SOB, edema,
anemia, anorexia, HF, uremia, hypocalcaemia, pain
Case Progress
 CW receives:
 4 units of Packed Red Blood Cells (PRBCs)
 5 units of Fresh Frozen Plasma (FFP)
 Several Liters of crystalloids
 To keep mean BP above 60mm HG
 Day 2 ICU:
 Total fluid intake: 8.498 L Total Output: 3.66 L
 Positive fluid balance of 4.838 L
 Hemodynamic Parameters after fluid resuscitation:
 Pulmonary capillary Wedge Pressure 30mmHg
 Normal range: 8-12mm Hg
 Cardiac Output 4.5L/min
Why will you wan to monitor his fluid
status very carefully?
 Patient has positive fluid volume status
 Recently received 9+ units of blood products
 Pulmonary wedge is above average- indicating fluid
excess
List at least 6 things you will monitor to
asses C.W.’s fluid balance?
 Intake and Output
 Monitor blood chemicals/electrolytes
 Such as Na, K, Mg, Cl, BUN
 Assess
 mouth and oral mucosa
 Capillary refill
 Skin turgor
 Vital signs (especially pulse, BP, RR)
Measuring and managing Fluid balance
Research article on a nurses role
Abstract: This article discusses the importance of hydration, and the health implications of
dehydration and over hydration. It also provides an overview of fluid balance, including how and why
it should be measured, and discusses the importance of accurate fluid balance measurements.
Explain the purpose of the
FFP for C.W.
 Fresh Frozen Plasma: concentrated source of all
clotting factors without platelets, red blood cells, or
leukocytes
 Indications:
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


Coagulation factor deficiencies
Active bleeding
Preoperative
Treatment of thrombotic thrombocytopenic purpura
 Used for volume expansion if patient has significant
coagulopathy and is bleeding- extreme conditions
Case Progress
 Labs prior to receiving PRBCs
Result Name
Pt. Value
Normal Range
Sodium
138 mEg/L
135-145
Potassium
6.9 mEg/L
3.5-5.1
BUN
90 mg/dL
8-20
Creatinine
2.1 mg/dL
0.50-1.00
WBC
16,000/mm3
5,000- 10,000
Hgb
8.4 g/d
12.0-15.5
Hct
25%
35-45
PT
23.4 seconds
11-14 seconds
INR
4.2
0.8-1.2
After Examining Lab Results, are there any
concerns with C.W.’s electrolyte levels
 High potassium= hyperkalemia
 Indicated Acute Kidney Failure
 Treatment if related to kidneys is hemodialysis, diuretics,
 High BUN
 Indicates kidney function: poor
 High Creatinine
 Indicated kidney function, dehydration
In view of previous lab results, what diagnostic
test will be preformed and why?
 Kidney Function
 Glomerular Filtration rate (GFR): measure kidney
function
 Ultrasound/CT scan: structural abnormalities or
obstructions
 Biopsy: identify disease process
 Urine Tests: protein leakage, kidney production
 Clotting
 Fibrinogen test
 Coagulation factor test
 Von Willebrand factor
Result Name
Pt. Value
Normal Range
Sodium
138 mEg/L
135-145
Potassium
6.9 mEg/L
3.5-5.1
BUN
90 mg/dL
8-20
Creatinine
2.1 mg/dL
0.50-1.00
WBC
16,000/mm3
5,000- 10,000
Hgb
8.4 g/d
12.0-15.5
Hct
25%
35-45
PT
23.4 seconds
11-14 seconds
INR
4.2
0.8-1.2 *2.0-3.0*
Evaluate this ECG strip
Note the effect of any electrolyte imbalances
Abnormal ECGs secondary to
electrolyte abnormalities
 Article provides case studies with example ECG strips
to
 Illustrates how individual electrolytes effect ECG’s
What do the low hemoglobin and
hematocrit levels indicate about the rapidity
of C.W.’s blood loss?
 Hemoglobin: 8.4
 Hematocrit: 25%
 Despite other clinical indicators, the h/h has remained
surprisingly high
 “Hemoglobin changes according to the degree of blood loss
and fluid replacement. When volume losses are not
replaced during hemorrhage, hemoglobin concentration will
remain constant” (Gutierrez, 2004)
 EBL=EBV x In (Hi/Hf)
 Indicating that CW has been gradually losing blood with a
rapid increase recently
What is the explanation for
the prolonged PT/INR
 INR of 4.2 indicates minor bleeding
 Pt. is receiving Warfarin
 Minor bleeding
 PT of 23.4 seconds
 Factor deficiencies
 Vitamin K deficiency
 Minor bleeding
What will be your response to the
prolonged PT/INR?
(select all that apply)
 A. Prepare to administer a STAT dose of protamine
sulfate
 B. Hold the warfarin
 C. Monitor C.W. for signs and symptoms of bleeding
 D. Obtain an order for aspirin if needed for pain
 E. Avoid injections as much as possible
What safety precautions should be considered in
light of his prolonged PT/INR
 Increased fall risk and injury
 Protect the Skin
 Electric razor
 Wear shoes
 Mouth care
 Loose fitting clothing
 Monitor for minor bleeding, bruising or hematomas
 Avoid Injections
 Fresh frozen Plasma
 Vitamin K
How do you account for the
elevated WBC count?
 Reasons
 Fighting infection
 Drug reaction
 Immune system disorder
 Stress due to
 excessive blood loss
 acute kidney failure
 hospitalization
Case Progress
 Mrs. W has been with her husband since he arrived at
the ED and is worried about his condition and care
 Ease her comfort while her husband is in the MICU

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


Explain what is happening in basic terms
Give her updates on her husbands status (communicate)
Allow Mrs. W to visit with her husband
Provide emotional support for pt. and wife (holistic care)
VALUE
Work Cited

Ali Hussein, A. M., Mahfouz, H., Elazeem, K. A., Fakhry, M., Elrazek, E. A., Foad, M., & Shehab,
A. (2015). The Value of U/S to Determine Priority for Upper Gastrointestinal Endoscopy
in Emergency Room. Medicine, 94(49), 1-7 7p.

Formeister, J., Shanty, C., Cuevo, R., & Read, G. (1981). The natural leukocyte response to
hemorrhagic shock. Advances in shock research, 5(79).

Gutierrez, G., Wulf-Gutierrez, M., & Reines, D. (2004). Clinical review: Hemorrhagic shock.
Care.

Kuntjoro, I., Teo, S., & Poh, K. (2012). Abnormal ECGs secondary to electrolyte abnormalities.
Singapore Medical Journal, 53(3), 152-156 5p.

Nolen, Kalie, "Meeting the Needs of Family Members of ICU Patients." (2013). Undergraduate Honors
theses. Paper 120

Prevent Bleeding When Taking Blood Thinners. (2012, November 12). The Ohio State University
Comprehensive Cancer Center.

Shepherd A (2011) Measuring and managing fluid balance. Nursing Times; 107: 28, 12-16

Tests to measure kidney function, damage and detect abnormalities (2015). In National Kidney
Foundation. Retrieved March 1, 2016.
Critical