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NURS 6560 iHuman Week 3. (ASSURED A)

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NURS 6560 iHuman Week 3. (ASSURED A) Primary Diagnosis: Esophageal Varices Status/Condition: Fair Code Status: Full Allergies: NKA Admit to Unit: TCU Activity Level: Up with assist Diet: NPO IVF: NaCl 150mL/hr C ...

NURS 6560 iHuman Week 3. (ASSURED A) Primary Diagnosis: Esophageal Varices Status/Condition: Fair Code Status: Full Allergies: NKA Admit to Unit: TCU Activity Level: Up with assist Diet: NPO IVF: NaCl 150mL/hr Critical Drips: None needed Respiratory: 2L O2 NC Medications: Ceftriaxone 1g IV daily; octreotide 20mcg BOLUS followed by infusion 25mcg/ hr; thiamin/ folid acid/ b6 infusion “banana bag” PRN: Ativan 2-4mg IV if CIWA >8; Zofran 4mg IV q6hrs Nursing Orders: Vital signs per unit routine; assist pt with all ambulation; complete CIWA and follow protocol; place NG tube to low wall suction if still vomiting Notify provider for: SBP <90 or >150; DBP <60 or >90; MAP <65; O2 <90 with 2L O2; CIWA >8; active bleeding/ hemorrhage; increase in vomiting; bloody stools; respiratory distress; cardiac arrest; acute change in mental status; any critically reported labs Follow Up Lab tests : H&H in 2hrs; repeat CBC, CMP in AM; type and screen Diagnostic testing: Endoscopy: possible TIPS procedure, establish severity of bleeding; echo due to fluid retention 2/2 possible cirrhosis; EKG: possible demand ischemia; abdominal US: r/o portal vein thrombosis Consults: GI: bleeding esophageal varices/ cirrhosis; surgery: possible TIPS procedure or other surgical measure for esophageal varices In future: nephrology if BUN/ Cr does not improve with pt stability; social work: ETOH abuse resources once stable Patient Education and Health Promotion: Given this patient’s history, he should get a colonoscopy for colon cancer prevention. Follow up EGDs may be necessary. He should be educated on alcohol abuse and given community resources to aid in recovery. He should remain up to date on all vaccinations. Discharge planning and required follow-up care: Patient will need strict follow up with PCP and GI physician after discharge. ETOH abstinence will be vital to his survival and rehabilitation is strongly encouraged. He should refrain from other abuse such as tobacco or recreational drugs. He should return to hospital if bleeding/symptoms occur again, if he has rectal bleeding, severe abdominal pain, intractable vomiting, chest pain, shortness of breath, or fever uncontrolled at home. References Bajaj, J., & Sanyal, A. (2019). Methods to achieve hemostasis in patients with acute variceal

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