What is the discharge plan for a patient admitted for a GI bleeding?
Added by Valerie P.
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Ensure that vital signs are stable, and any necessary interventions (such as IV fluids, blood transfusions, or medications) have been administered to manage the GI bleeding. Show more…
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John Adams, 55 years of age, is admitted to the intensive care unit with the diagnosis of acute esophageal varices bleed. The patient has a long-standing history of alcoholism and cirrhosis of the liver. Six months ago, the patient received an EGD, which diagnosed the esophageal varices. The patient has quit drinking alcohol for the past 6 months and has been active in Alcoholics Anonymous. The patient has a history of coronary artery disease and angina. The patient has been taking nadolol (Corgard) and isosorbide (Isordil). The admission vital signs include: BP, 88/50; P, 110; R, 26; and T, 99°F. The supplemental oxygen is on room air and the patient is placed on 2 L/min of oxygen per nasal cannula with supplemental oxygen. The patient’s hemoglobin is 6 g/dL, the hematocrit is 12%, and the platelets are 75,000. The patient has a prolonged PT and PTT. The liver profile shows a mild elevation of the aspartate aminotransferase (AST) and the alanine aminotransferase (ALT). The BUN and serum creatinine are also elevated. The patient has in place from the emergency department a nasogastric tube to low wall suction. The emergency department physician placed a right subclavian triple lumen catheter and there is NS infusing at 100 mL/hr. The emergency department nurse administered vitamin K. Additional orders on the chart from the gastroenterologist include the following: octreotide (Sandostatin) 5-mcg bolus followed with continuous infusion 500 mcg in 250 mL D5NS at 25 mcg/hr. Type and cross of 6 units of PRBCs STAT and transfuse 2 units of PRBCs over 2 hours each and administer furosemide (Lasix) 20 mg IVP in between each unit. Repeat CBC 1 hour after the transfusion is completed. In what order should the nurse institute the physician orders that are listed above? Perform dosage calculations and state how to administer the medications. The nurse observes the nasogastric secretions and, upon admission to the ICU, there was 200 mL of dark red-colored drainage. The nurse continues to monitor the drainage and, as the nurse hangs the first unit of PRBCs, 200 mL of bright red bloody drainage is dumped into the collection canister. What should the nurse do? The gastroenterologist orders for the nurse to increase the octreotide to 50 mcg/hr and the endoscopy nurse and the physician will be up shortly to perform a vertical band ligation (VBL). What does the nurse need to do in preparation for this procedure?
Jennifer S.
Title: Case Study 18: Cirrhosis Patient's chief complaint: Provided by wife: "My husband's very confused and he has been acting strangely. This morning, he couldn't answer my questions and seemed not to recognize me. I think that his stomach has been swelling up again, too. He stopped drinking four years ago, but his cirrhosis seems to be getting worse." HPI: S.G. is a 46-year-old white male with a history of chronic alcoholism and alcoholic cirrhosis. He was admitted to the hospital with abdominal swelling and confusion. He unintentionally gained 15 lbs during the last 4 weeks. He has not been sleeping well and has been lethargic, experiencing memory issues, and losing his temper uncharacteristically. PMH: Pneumonia 9 years ago, cirrhosis secondary to heavy alcohol use diagnosed 4 years ago with ultrasound and liver biopsy, history of uncontrolled ascites and peripheral edema, history of two upper GI hemorrhages from esophageal varices, history of anemia, history of E. coli-induced bacterial peritonitis 4 years ago, history of acute pancreatitis secondary to alcohol abuse. No history to suggest cardiac or gallbladder disease, and no previous diagnosis of viral or autoimmune hepatitis. SURG: Status post-appendectomy requiring blood transfusions 30 years ago, status post open reduction internal fixation of right femur secondary to motor vehicle accident 5 years ago. FH: Father died at age 52 from liver disease of unknown etiology, mother had rheumatoid arthritis and ulcerative colitis, died from a massive stroke at age 66, maternal aunt (age 71) with Graves disease. The patient has no siblings. SH: History of ethanol abuse, quit 5 years ago following a motor vehicle accident. Previously drank 3 cases of beer a week for 15 years. History of intravenous drug abuse (heroin) and intranasal cocaine, quit 5 years ago. Prior smoker (1/2 pack per day for many years). Meds: Propranolol 10 mg orally three times a day, Spironolactone 50 mg orally once a day, Furosemide 20 mg orally once a day, MVI 1 tablet orally once a day. Occasionally takes ibuprofen or acetaminophen for headaches. Patient has a history of non-compliance with medications. Allergies: No known drug allergies. ROS: Increasing abdominal girth. Patient Case Question 1: Hematemesis and tarry stools are clinical signs of which serious potential complication of cirrhosis?
Sri K.
LOCATION: Inpatient, Hospital PATIENT: Elaine Snow PHYSICIAN: Andy Martinez, M.D. ADMITTING DIAGNOSIS: Endometrial hyperplasia and postmenopausal bleeding. DISCHARGE DIAGNOSES: 1. Adenomatous endometrial hyperplasia. 2. Intramural and subserosal leiomyomata. 3. Hypertension. PROCEDURE PERFORMED: Total abdominal hysterectomy with bilateral salpingo-oophorectomy carried out. COMPLICATIONS: Bleeding from small bowel mesentery, oversewn by Dr. White at the time of the procedure. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old woman who had been seen with complaints of postmenopausal bleeding. Dilation and curettage had been carried out and showed evidence of endometrial polyp along with simple endometrial hyperplasia without atypia. Due to the hyperplasia, Elaine was started on high-dose Progesterone therapy with 20 mg daily. Unfortunately, she developed very heavy irregular bleeding on this and therefore elected to undergo definitive therapy in the form of total abdominal hysterectomy with bilateral salpingo-oophorectomy. HOSPITAL COURSE: The patient was admitted on January 19, and I performed her total abdominal hysterectomy with bilateral salpingo-oophorectomy. During the course of the procedure, there was some bleeding noted from the small bowel mesentery. Dr. White was consulted intraoperatively, and he oversewed the bleeding area using a figure-of-eight suture. The procedure was otherwise uncomplicated, and the estimated blood loss was 350 cc. The patient had then a completely uncomplicated postoperative course. By the second postoperative day, she was feeling well enough to go home. She was eating and passing flatus and ambulating on her own. She had adequate pain control with Ibuprofen alone. DISCHARGE INSTRUCTIONS: The patient was instructed to avoid abdominal and pelvic strain for six weeks. She was to return to the clinic in one week for staple removal. The pathology report subsequently showed adenomatous hyperplasia of the endometrium and multiple intramural and subserosal leiomyomata. DISCHARGE MEDICATIONS: 1. Ibuprofen 600 mg p.o q 6 to 8 hours p.r.n. 2. Ferrous sulfate 325 mg p.o tid. 3. Peri-Colace 200 mg p.o q h.s. p.r.n. Need CPT codes and HCPCS.
Shaiju T.
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