GI Bleed/Hypovolemic Shock RAPID Reasoning
History of Present Problem:
Jim Olson is a 45-year-old male with a history of cirrhosis and
ETOH abuse who has not had any medical care the last ten years.
He began vomit
...
GI Bleed/Hypovolemic Shock RAPID Reasoning
History of Present Problem:
Jim Olson is a 45-year-old male with a history of cirrhosis and
ETOH abuse who has not had any medical care the last ten years.
He began vomiting large amounts of bright red blood when he
woke up this morning. He was found on the floor of the bathroom
by Sheila, his girlfriend, when he became lightheaded and fell on
the floor and was too weak to get up. Sheila called 911. Paramedics
report that there was a large dark red/black stool in the toilet.
They were able to get an 18-gauge IV in the right antecubital vein,
and Jim received 500 mL of 0.9% NS. His initial BP was 80/40 at
the scene, and his most recent BP is 82/44 with a current heart rate
of 128, sinus tachycardia.
Personal/Social History:
Jim recently lost his job as a construction laborer and was divorced six months ago. His ex-wife has full custody of his two children. Jim’s girlfriend states that he has been more depressed lately and has been drinking more heavily since his divorce. He takes ibuprofen daily for chronic back pain.
What data from the history is important and RELEVANT; therefore, it has clinical significance to the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
History of cirrhosis, ETOH abuse, hasn’t received medical care in 10 years, large dark red/black stool, vomiting red blood, recent BP: 82/44, sinus tachycardia
According to Nursing Central, 21% of cases of liver cirrhosis are due to alcohol abuse. Jim has been dealing with alcohol abuse, so it is probably what led to his history of cirrhosis and since he has not received medical care in 10 years, his drinking could have been severely affecting his liver without the patient knowing. A sign of cirrhosis includes “bleeding from esophageal varices” (Sommers, 2019) which can be an indication as to why he was vomiting blood and why his stool is reddish black. Both the hypotension and tachycardia are due to the patient experiencing the sudden blood loss.
Sommers, M. S. (2019). Davis's diseases and disorders: a nursing therapeutics manual(6th ed.). Philadelphia: F.A. Davis.
RELEVANT Data from Social History: Clinical Significance:
Lost his job, divorced, no custody of his kids, depression, drinking more heavily, taking ibuprofen for chronic back pain
The patient’s depression due to his divorce and losing his job which led to him drinking more than his usually does could be what led to his present problem. The patient also taking ibuprofen daily while drinking could be dangerous because “high doses and long-term ibuprofen use make your stomach more likely to bleed” (2019). The signs and symptoms of gastrointestinal bleeding include both blood in a person’s vomit and stool, both symptoms the patient experienced which could indicate he is suffering from internal bleeding.
Never Mix Ibuprofen and Alcohol: MD. (2019, March 6). Retrieved November 2, 2019, from https://www.ashleytreatment.org/ibuprofen-and-alcohol/.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment (5th VS):
T: 98.2 F/36.8 C (oral) Provoking/Palliative:
P: 138 (regular) Quality: Denies
R: 28 (regular) Region/Radiation:
BP: 74/30 MAP: 45 Severity:
O2 sat: 95% RA Timing:
What VS data is RELEVANT that must be recognized as clinically significant?
RELEVANT VS Data: Clinical Significance:
Pulse: 138, BP: 74/30, MAP: 45
The patient’s pulse has increased from 128 to 138 and his blood pressure has decreased from 82/44 to 74/30 which is an indication that his present problem is getting more severe. The patient’s MAP is 45 and according to Taber’s Medical Dictionary, the normal mean arterial pressure is 70-110 mmHg (Venes, 2017). In an article written by Daniel DeMers, he states “to perfuse vital organs requires the maintenance of a minimum MAP of 60 mmHg” (DeMers, 2019). If the MAP remains below the required number for too long, the patient can experience either ischemia or even infarction, so MAP must be regulated so the organs can continue to be sufficiently perfused.
Venes, D. (2017). Taber’s cyclopedic medical dictionary(23rd ed.). Philadelphia: F.A. Davis Company.
DeMers, D. (2019, February 24). Physiology, Mean Arterial Pressure. Retrieved November 2, 2019, from https://www.ncbi.nlm.nih.gov/books/NBK538226/.
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(Psychosocial Integrity)
The patient is most likely going to be frightened and feeling anxious.
2. What can I do to engage myself with this patient’s experience, and show that he/she matters to me as a person? (Psychosocial Integrity)
As the nurse, I can make sure to explain to the patient all the procedures in order to provide reassurance, I can touch the patient’s hand or arm to provide reassurance as well, explain the treatment alternatives and keep the patient and family updated with the patient’s response to the therapies, explain and answer the patient’s questions about the risks involved with blood component therapy (Sommers, 2019). I can also acknowledge the beliefs, values, and expectations of the patient and family, remain with the patient during procedures, maintain a clean environment, speak slowly and calmly, allow family members access to the patient when feasible, and provide anticipatory guidance to prepare for recovery or death and to support realistic hope (LeMone, Burke, Bauldoff & Guburd, 2016).
Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention at the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
I learned a lot from this scenario. I learned how to take the patient’s history in account when diagnosing their current problem, and how to assess the lab results in order to connect them to the patient’s diagnosis and once the diagnosis is found, which interventions are best to be used, and what the interventions mean and how they can positively affect the patient. I also realized how important it is to include the patient in the care and to make sure they understand why each procedure is being done, and to make sure as a nurse, we are there to support and care for the patient not only medically, but emotionally as well. Overall, I learned how important each intervention is to ensure patient recovery and prevent complications, while taking care of your patient’s needs.
2. How can I use what has been learned from this scenario to improve patient care in the future?
I believe I can use what I learned to make sure I perform the correct nursing interventions for the patient, but I also care for the patient emotionally such as making sure they are comfortable by reducing their anxiety by being by their side through their entire stay, answering any questions they have regarding their care, physically maintaining their comfort such as integrating touch to provide reassurance or grouping nursing activities to increase rest periods, etc. This scenario has just opened my eyes to the many different ways I can address my patient’s needs through management of care and comfort.
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References
DeMers, D. (2019, February 24). Physiology, Mean Arterial Pressure. Retrieved November 2, 2019, from https://www.ncbi.nlm.nih.gov/books/NBK538226/.
LeMone, P. M., Burke, K. M., Bauldoff, G. M., & Gubrud, P. M. (2016). Clinical handbook for medical-surgical nursing: clinical reasoning in patient care(7th ed.). Boston: Pearson.
Never Mix Ibuprofen and Alcohol: MD. (2019, March 6). Retrieved November 2, 2019, from https://www.ashleytreatment.org/ibuprofen-and-alcohol/.
Sommers, M. S. (2019). Davis's diseases and disorders: a nursing therapeutics manual (6th ed.). Philadelphia: F.A. Davis.
Venes, D. (2017). Taber’s cyclopedic medical dictionary (23rd ed.). Philadelphia: F.A. Davis Company
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