Question

You are a new graduate registered nurse working in a small local hospital emergency department.

Mr Gary MacDonald is a 52- year-old businessman. McDonald has a very stressful position, and as a coping mechanism he drinks quite heavily. Mr McDonald has been feeling increasingly unwell lately but has been too busy to go to the doctor for a check-up. His abdominal girth has increased, his ankles are a bit swollen and he gets short of breath on exertion.

Mr McDonald was attending a business meeting when he began to vomit quite a lot of bright red blood.

On arrival at the Emergency Department of the local hospital he has a vomit bag with about 350 mL of bright red blood. He is pale and complaining of feeling dizzy and appears confused as to what is happening to him and where he is. His immediate vital signs are:

Blood pressure 80/50mmHg, Pulse 130bpm, Respiratory rate 28, Oxygen saturation 91% on room air, Temperature 36.1 Celsius, Glasgow Coma Score (GCS) 13.

Question 1:

Based on your A-G assessment identify two (2) areas that are your highest priorities and express then as Nursing Diagnoses with “Related to” and “Evidenced by” statements.

Question 2:

The doctor makes an initial medical diagnosis of bleeding oesophageal varices due to alcoholic cirrhosis. Explain the pathophysiology that caused his bleeding oesophageal varices.

Question 3:  

Based on Mr McDonald’s current condition, and NSW Health SAGO chart and DETECT policy requirements, outline four immediate nursing actions and their rationales within your scope of practice (as RN new graduate).

Question 4:

Briefly discuss the current best medical practice recommendations for the treatment of bleeding oesophageal varices including likely intravenous fluids, medications, and procedures.

Question 5:

Following treatment, Mr McDonald’s bleeding varices settled, and he was discharged home on the following medications: Lactulose orally 20 mL BD, Spironolactone 50mg mane. Explain the reason for each of these in relation to his underlying disease process.

SORRY FOR POSTING 5 QUESTIONS BUT ITS ALL BASED ON THE SAME SCENARIO

Answer 1

Question 1:

Based on your A-G assessment identify two (2) areas that are your highest priorities and express then as Nursing Diagnoses with “Related to” and “Evidenced by” statements.

Hypotension- as his blood pressure is 80/50

Shortness of breath-as there is desaturation (91%) and tachypnea(RR-28)

Nursing diagnosis:

-Decreased cardiac output (hypotension) related to the hypovolemic shock-Evidenced by blood pressure of 80/50,hematemesis and confusion.

-Ineffective breathing pattern related to lung collapse-Evidenced by tachypnea,desaturation and increased abdominal girth.

Question 2:

The doctor makes an initial medical diagnosis of bleeding oesophageal varices due to alcoholic cirrhosis. Explain the pathophysiology that caused his bleeding oesophageal varices.

Scarring of liver tissues due to liver cirrhosis leads to blockage in the portal blood supply and portal hypertension.In response to the blockage in portal circulation the formation of collateral blood circulation is achieved by the small blood vessels that are not designed to carry large amount of blood.This in turn make the blood vessel stretched to maximum and form a varices ,presence of varices in oesophagus called oesophageal varices.Due to increase pressure in these varices it can cause leak or rupture and lifethreatening bleeding.

Question 3:  

Based on Mr McDonald’s current condition, and NSW Health SAGO chart and DETECT policy requirements, outline four immediate nursing actions and their rationales within your scope of practice (as RN new graduate).

Nursing actions	Rationale
Intiate a continous cardiac and respiratory monitoring	-To Monitor the progress of ongoing hypotension and respiratory distress.(Any further alteration to be escalated to medical officer)
Intiate oxygen therapy targeting SpO2 above 94%.	-To improve oxygenation
Intiate IV cannulation and draw blood for CBC,Coagulation ,Liver enzymes,cross match as per physician requirements.	-IV cannulation is to give fluids or blood products on emergency basis. -Blood works to rule out the HB status and cross match to prepare for transfusion.
Administer iv fluid as ordered	-Iv fluids to treat hypovolemic shock .

Question 4:

Briefly discuss the current best medical practice recommendations for the treatment of bleeding oesophageal varices including likely intravenous fluids, medications, and procedures.

Medications:

• Administration of IV fluids to treat hypovolemia.
• Blood transfusion as ordered.
• Administration of splanchnic constrictors to reduce the bleeding egs-vasopressin,terlipressin,somatostatin and Octreotide.
• Antibiotics

Procedures:

• Endoscopic sclerotherapy
• Endoscopic varices ligation and banding.
• Balloon tamponade-Intiating a pressure over the bleeding varices to control bleeding using a ballon tamponade.This is used when the endoscopic ligation and banding fails to control the bleeding.
• Transjugular intrahepatic portosystemic shunt (TIPS)-Here a shunting system is achieved through surgery in case of failure to control bleeding through endoscopic procedures.

Question 5:

Following treatment, Mr McDonald’s bleeding varices settled, and he was discharged home on the following medications: Lactulose orally 20 mL BD, Spironolactone 50mg mane. Explain the reason for each of these in relation to his underlying disease process.

Lactulose :

• It helps to clear out the patient ammonia levels and prevent from going into hepatic encephalopathy.
• It helps to relive constipation and old plugged blood to washed off ,thereby reducing the pressure in the abdomen.

Spironolactone:

• Spironolactone is a potasium sparing diuretic given to treat his edema and ascites.spirinolactone is helpful in edematous states caused by exacerbated hyperaldosteronism(edema and ascites from liver cirrhosis).