NR 340 Module 8+9 Case

Studies

J.R.
J.R. is a 35-year-old female with a
history of hypothyroidism and alcohol
abuse. She presents to the
emergency department with
complaints of vomiting bright red
blood.
Her vital signs
Temperature
36.6 Care as follows:
Heart Rate- HIGH

110 bpm

Respiratory Rate

22 breaths/min

Blood pressure- LOW

96/60 mmHg

Oxygen Saturation

100% on 2L nasal
cannula

J.R.
An NGT is inserted and attached
to suction which revealed 300
mL of bright red blood. Labs
reveal
the following:
Hemoglobin
9.2 mg/dL
Hematocrit

27.6%

Potassium

3.0 mEq/L

Magnesium

1.4 G/L

All other labs are within normal values including

liver enzymes

What are your concerns and what does J.R.

need at this time? 300mL of bright red
bloodgive fluid or blood transfusion

J.R.
Two 18 gauge IVs are inserted one in
the left antecubital space and the
other in the right forearm. The
patient is given a one liter bolus of IV
0.9 normal saline. J.R. is taken to the
endoscopy suite and undergoes an
EGD to determine the cause of
bleeding.

J.R.
J.R. undergoes the endoscopy and a
Mallory-Weiss tear Longitudinal
tear is discovered in her esophagus.
The site is injected with epinephrine
to stop the bleeding and she is
transferred to the ICU for airway
management and hemodynamic
monitoring.

J.R.
Six hours after J.R.s arrival to the
hospital, she begins to tremor and
sweat profusely. Her vital signs are
as follows:
Temperature

38 C

Heart Rate- HIGH

122 bpm

Respiratory Rate- HIGH

24 breaths/min

Blood Pressure-HIGH

150/90

Oxygen Saturation

96% on 2L nasal
cannula

What is the cause of J.R.s symptoms and

change in vital signs? What information do you
need to know?

J.R.
J.R. informs the nurse that her last
alcoholic beverage was 2 hours before she
went to the hospital. She is diagnosed
with delerium tremens and is started on
Ativan and a banana bag.
What is the purpose of these interventions?
Ativan- to calm her down
Banana bag- has vitamins, minerals, folic
acid to replenish electrolytes

J.R.
J.R. eventually recovers from her
DTs and discharged to an outpatient
alcohol rehabilitation program. She
does well for a few months but
presents to the ED again with
complaints of abdominal pain.

J.R.
J.R. arrives to the ED with complaints of
10/10 knife-like epigastric pain which is
relieved when she puts her knees to her
chest. She also reports nausea and
vomiting. Her assessment is positive for
Chvostek sign.
What are you thinking of now? What labs or
tests might be ordered?
Pancreatitis pain- puts knees to her chest
Hypocalcemia- Chovstek sign

J.R.
J.R.s vital signs are as followed:
Temperature

38.5 C

Heart Rate HIGH

116 bpm

Respiratory Rate

24 breaths/minute

Blood Pressure LOW

92/60 mmHg

Oxygen Saturation

92% on RA

J.R.
Labs are obtained with the following
results
Amylase HIGH
556 U/L
Lipase HIGH

320 U/L

Glucose HIGH

186 mg/dL

Calcium LOW

7.0 mg/dL

Potassium LOW

2.9 mEq/L

WBCs HIGH

15,200/mL

Hematocrit

48%

Albumin LOW

3.0 g/dL

All other labs are within defined

parameters

J.R.
J.R. is diagnosed with acute
pancreatitis. What interventions are
required at this time?

J.R.
J.R. received the following orders:
1. Insert 2 18 gauge IVs
2. Give a 500 mL bolus of 0.9 normal saline
3. Administer oxygen and titrate for an O2 Sat of
greater than 94%
4. Give 2 mg of Morphine Sulfate IVP and start the
patient on a PCA pump 1 mg every 10 minutes with
a 6 mg lock out.
5. Give 40 mEq of Potassium Chloride IV over 4 hours
6. Give 2 Grams of Magnesium Sulfate IV over 2 hours
7. Insert an NGT to LIWS

Which order should be implemented

first and why?

J.R.
J.R.s oxygen saturation increases to 96%
with 2L nasal cannula, her blood pressure
increases to 110/70 mmHg and her heart
rate decreases to 100 bpm after the fluid
bolus. Her morning accucheck reveals a
blood glucose of 205 mg/dL. Why is this
occurring? What needs to be done?
b/c shes not producing insulinyou need
to give her insulin

J.R.
J.R. is given 2 Units of Regular insulin
and her blood sugar decreases to
170 mg/dL.

J.R.
J.R. ultimately recovers from her
pancreatitis and is discharged home.
Because of the pancreatic damage
related to her episode of pancreatitis,
J.R. now requires insulin therapy

J.R.
J.R returns to the emergency
department 3 weeks later with
complaints of dizziness, increased
thirst and increased urination. She
has a fruity acetone odor noted on
her breath.
She also mentions that she has lost 5
pounds in the past few days.
What do you think is happening to
J.R.?

J.R.
J.R.s vital signs are as follows
Temperature

36.5 C

Heart Rate

120 bpm

Respiratory Rate

26 breaths/minute

Blood Pressure

88/62 mmHg

Oxygen Saturation

97% on RA

J.R.s weight is 125 lbs.

J.R.
J.R.s labs reveal the following:
Glucose

402 mg/dL

Sodium

148 mEq/L

Potassium

4.6 mEq/L

pH

7.26

PaCO2

28 mmHg

PaO2

95 mmHg

HCO3

16 mEq/L

Urine Ketones

Positive

What is the significance of these labs?

Pt is partially compensated metabolic acidosis d/t
DKA

J.R.
J.R. is admitted to the ICU with the following
orders:
0.9 Normal Saline 500 mL bolus over 30
minutes followed by an infusion of 125 mL/hr
Regular insulin IV bolus of 0.1 Units/kg x1
followed by an IV infusion of 0.1 Units/kg/hr
Give IV insulin b/c faster and have better control

Accuchecks every hour

Electrolyte panel every 2 hours
2,000 calorie ADA diet

Which order would you implement first?

J.R.
Two 18 gauge IVs are inserted and
the 0.9 NS saline bolus is
administered followed by the
maintenance IV fluids
Calculate the dose for the insulin
bolus and the IV infusion rate

J.R.
The nurse hears the telemetry
monitor alarm and finds the following
rhythm

What is the cause of this ECG change?

Hypokalemia= prominent U waves

J.R.
J.R.s blood glucose levels are
trending downwards. Electrolyte
panel demonstrates the following
results:
Glucose
199 mg/dL
Potassium

2.9 mEq/L

What orders do you anticipate? Why is the

potassium low? Low b/c K is being pushed
back into cells. Need K-rider.

J.R.
The nurse notifies the physician and
receives the following orders:
Administer 40 mEq/L of Potassium
Chloride IV over 4 hours
K burns, give slowly
Piggyback to other fluid bag or have
lidocaine in fluids

Change IV fluid to D5.45 NS at 125

mL/hr
Why change to D5.45? b/c getting IV insulinneed glucose. Dont want to let blood sugar
fall too fast.

J.R.
J.R. puts on the call light stating that
she feels light-headed and sweaty.
What should you do now?
Check glucose

J.R.
Accucheck reveals a glucose of 55
mg/dL
What should you do now?
Stop insulin and give juice, carbs

J.R.
J.R. eventually recovers and is
started on maintenance insulin
therapy with the long acting insulin
glargine and the rapid acting insulin
aspart for bolus.
What is the purpose of this insulin
combination?
Long acting throughout the day, rapid
acting before meals

J.R.
J.R. continues to drink and has not
taken steps to control her diabetes.
J.R. arrives to the hospital two years
later with nausea, vomiting, fatigue
and jaundice.
She is diagnosed with alcoholic
hepatitis and is advised to stop
drinking

J.R.
J.R. returns again a year after her
hepatitis episode with difficulty
breathing, a distended abdomen,
jaundice, petechiae, and she is
vomiting bright red blood.
What is happening to J.R.? Has
cirrhosis

J.R.

Vital signs are as follows: High HR,

Low BP
Normal bilirubin 0.3-1.9
Normal ammonia is 15-45
To dx cirrhosis= elevated
bilirubin/ammonia

J.R.s Lab Results

pH

7.29

PaCO2

60 mmHg

PaO2

75 mmHg

HCO3

18 mEq/L

Sodium

130 mEq/L

Potassium

3.0 mEq/L

AST

313 U/L

ALT

105 U/L

Alkaline Phosphatase

200 U/L

Total Protein

25 g/L

Serum Albumin

10 g/L

Bilirubin

10 mg/dL

PT/INR

50 seconds/4

Ammonia

412 mcg/dL

Hgb/Hct

6.5/22

J.R.
Physical assessment reveals a
grossly distended abdomen
protubent umbilicus, dull percussion
sounds throughout, jaundice,
asterixis, clotted blood around the
lips. Her respirations are shallow,
she has thin arms and her legs have
+2 pitting edema. Her weight is 160
lbs and her previous weight one year
ago was 125 lbs.

J.R.
She is intubated and placed on a
mechanical ventilator
Why was this intervention
performed?
To help breathing w/ ascites

J.R.
In addition she is typed and cross-matched
and started on 2 units of FFP (Fresh frozen
plasma) and given one unit of PRBCs and
10mg of Vitamin K
Why are these interventions performed?
FFP= b/c Hgb is low 6.5
PRBCS= given to thicken blood b/c INR is 4
(the higher the #, the thinner the blood)
Vitamin K= for clotting factors

J.R.
The GI lab arrives at the bedside to
perform an endoscopy which reveals
bleeding esophageal varices
They are banded in hopes to stop the
bleeding
Afterward the GI doctor places a
nasogastric tube to decompress the
abdomen
A Foley was inserted as well

J.R.
A paracentesis is performed on J.R.
and 4L of fluid is removed. She is
given 50g of albumin.
She is also started on lactulose

J.R.
Despite all of these interventions,
J.R.s condition becomes worse
She is not a candidate for a liver
transplant due to her recent
ingestion of alcohol and unstable
condition
The family is contacted and they
decide to withdraw support.