Question

Hypovolemia

The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at 0430 this morning. She told the ED triage nurse that he had had dysentery for the past 3 days and last night he had a lot of “dark red” diarrhea. When he became very dizzy, disoriented, and weak this morning, she decided to bring him to the hospital. C.W.’s vital signs (VS) were 70/- (systolic blood pressure [BP] 70 mm Hg, diastolic BP inaudible), 110, 20. A 16-gauge IV catheter was inserted, and a lactated Ring- er’s (LR) infusion was started. The triage nurse obtained the following history from the patient and his wife. C.W. has had idiopathic dilated cardiomyopathy (IDCM) for several years. The onset was insidi- ous, but the cardiomyopathy is now severe, as evidenced by an ejection fraction (EF) of 13% found during a recent cardiac catheterization. He experiences frequent problems with heart failure (HF) because of the cardiomyopathy. Two years ago he had a cardiac arrest that was attributed to hypoka- lemia. He also has a long history of hypertension (HTN) and arthritis. Fifteen years ago he had a peptic ulcer.

An endoscopy showed a 25 ¥ 15 mm duodenal ulcer with adherent clot. The ulcer was cauterized, and C.W. was admitted to the medical intensive care unit (MICU) for treatment of his volume deficit. You are his admitting nurse. As you are making him comfortable, Mrs. W. gives you a paper sack filled with the bottles of medications he has been taking: enalapril (Vasotec) 5 mg PO bid, warfarin (Couma- din) 5 mg/day PO, digoxin 0.125 mg/day PO, KCl 20 mEq PO bid, and tolmetin (an NSAID) 400 mg PO tid. As you connect him to the cardiac monitor, you note that he is in atrial fibrillation (A-fib). Doing a quick assessment, you find a pale man who is sleepy but arousable and oriented. He is still dizzy, hypotensive, and tachycardic. You hear S3 and S4 heart sounds and a grade II/VI systolic murmur. Peripheral pulses are all 2+, and trace pedal edema is present. Lungs are clear. Bowel sounds are present, midepigastric tenderness is noted, and the liver margin is 4 cm below the costal margin. A Swan-Ganz catheter and an arterial line are inserted.

1. What medication probably precipitated C.W.’s gastrointestinal (GI) bleeding?
2. What is the most serious potential complication of C.W.’s bleeding?
3. From his history and assessment, identify five signs and symptoms (S/S) (direct or indirect) of GI bleeding and loss of blood volume.

CASE STUDY PROGRESS:

C.W. receives a total of 4 units of packed RBCs (PRBCs), 5 units of fresh frozen plasma (FFP), and many liters of crystalloids to keep his mean BP above 60 mm Hg. On the second day in the MICU, his total fluid intake is 8.498 L and output is 3.660 L for a positive fluid balance of 4.838 L. His hemodynamic parameters after fluid resuscitation are pulmonary capillary wedge pressure (PCWP) 30 mm Hg and cardiac output (CO) 4.5 L/min.

4. What is the significance of maintaining a mean BP of 60 mm Hg or greater?
5. Why will you want to monitor his fluid status very carefully?
6. List six things you will monitor to assess C.W.’s fluid balance.
7. Explain the purpose of the FFP for C.W.

CASE STUDY PROGRESS:

As soon as you get a chance, you look at C.W.’s admission laboratory results: K 6.2 mmol/L, BUN 90 mg/dl, creatinine 2.1 mg/dl, Hgb 8.4 g/dl, Hct 25%, WBC 16 thou/cmm, and PT 23.4/INR = 4.2. Other results are within the normal range.

8. Are you worried by the elevated potassium (K)? Why, or why not? Explain your answer.
9. In view of the elevated K, what diagnostic test should be performed and why?
10. Why do you think BUN and creatinine are elevated?
11. What do the low hemoglobin (Hgb) and hematocrit (Hct) levels indicate about the rapidity of C.W.’s blood loss?

12. What is the explanation for the prolonged PT/INR?
13. What should be your response to the prolonged PT/INR?
14. What safety precautions should be considered in light of his prolonged PT/INR?
15. How do you account for the elevated WBC count?

CASE STUDY PROGRESS

Mrs. W. has been with her husband since he arrived at the ED and is worried about his condition and his care.

16. List four things you might do to make her more comfortable while her husband is in the MICU.

Previous

Answer 1

MEDICATION THAT PROBABLY PRECIPITATED GI BLEEDING: tolmetin (an NSAID) 400 mg PO tid

Inhibition of COX-1 in the gastrointestinal tract leads to a reduction of prostaglandin secretion and its cytoprotective effects in gastric mucosa. This therefore increases the susceptibility to mucosal injury and thus cause GI bleeding. Also it is contraindicated in this disease condition.

COMPLICATION OF BLEEDING:

• SHOCK
• ANEMIA
• HYPOVOLEMIA
• DEATH

SIGN AND SYMPTOMS OF HIS BLEEDING:

• a lot of “dark red” diarrhea.
• very dizzy, disoriented, and weak due to blood loss.
• systolic blood pressure [BP] 70 mm Hg, diastolic BP inaudible
• trace pedal edema is present and client is pale
• tachycardic
• midepigastric tenderness and the liver margin is 4 cm below the costal margin which is a sign of HEPATOMEGALY.

SIGNIFICANCE OF MAINTAINING MEAN BP 60mmhg OR GREATER: It is necessary to provide enough blood to the coronary arteries, kidneys, and brain. The normal MAP range is between 70 and 100 mmHg. Mean arterial pressures that deviate from this range for prolonged periods of time can have drastic negative effects on the body.

If it is too high then heart has a lot of stress to work on or if is too low then many body organs dont get enough blood and nourishment.

TO MONITOR FLUID STATUS : INTAKE OUTPUT CHART IS AN EXCELLENT TOOL TO ASSESS FLUID STATUS IN BODY.

ASSESSMENT OF FLUID BALANCE CAN BE ASSESS BY:

• INTAKE OUPUT CHART
• DAILY WEIGHT
• URINE OUTPUT
• BLOOD PRESSURE
• COMPLETE BLOOD COUNT SPECIALLY HAEMOGLOBIN
• SERUM ELECTROLYTE AND UREA

PURPOSE OF FFP :

Fresh frozem plasma contains all the factor of coagulations. It is indicated forthe with with massive bleeding, or at risk of bleeding. FFP may be indicated to replace labile plasma coagulation factors during massive bleeding to control it.

WHAT IF POTASSIUM LEVEL IS 6.2mmol/dl ?

NORMAL POTASSIUM LEVEL IS 3.5 - 5.3 mmol/dl

IF IT IS 6.2 mmol/dl THEN IT IS A SIGN OF HYPERKALEMIA WHICH MAY BE VERY WORRISOME AS IT CAN INCREASE THE RISK OF PARALYSIS OR HEART FAILURE. IF LEFT UNTREATED, HIGH POTASSIUM LEVELS CAN CAUSE YOUR HEART TO STOP.

DIAGNOSTIC TEST FOR POTASSIUM:

• BLOOD TEST : to know the current status of potassium and to know the prognosis.
• URINE ANALYSIS: to know the effect of elevated potassium level on kidneys, urea and creatinine.
• ECG : as we have said that it can cause heart failure so detection at initial stage it is necessary to note any change in ECG pattern.

WHY BUN AND CREATININE IS ELEVATED? A blood urea nitrogen (BUN) test measures the amount of nitrogen in your blood that comes from the waste product urea. Around 7 to 20 mg/dL (2.5 to 7.1 mmol/L) is considered normal .BUN level rises due to dehydration.

The level of creatinine in your blood also tells how well your kidneys are working—a high creatinine level may mean your kidneys are not working properly. The normal range for creatinine in the blood may be 0.84 to 1.21 milligrams per deciliter. Causes of elevated BUN and creatinine level are:

• Gastrointestinal bleeding.
• Dehydration
• Shock. ​​​​​​

LOW LEVEL OF HAEMOGLOBIN AND HCT : When the hemoglobin level and HCT level is low, the patient has anemia.

PROLONG PT AND INR:

Prothrombin time (PT) is a blood test that how long it takes blood to clot.

INR (international normalized ratio) stands for a way of standardizing the results of prothrombin time tests, no matter the testing method.

An abnormal prothrombin time is often caused by liver disease or injury or by treatment with blood thinners.Patient was recieving NSAIDS and WARFARIN.

Response to the prolonged PT/INR : Most patients who have a high INR but are not bleeding can be managed with simple dosage omission or oral phytomenadione and an increased frequency of INR monitoring.

Oral vitamin K antagonist anticoagulants is prescribed for elevated PT and INR to prevent bleeding and blood loss.

SAFETY PRECAUTION CAN BE TAKEN SUCH AS:

• AVOID ANY KIND OF CUT, INJURY OR FALL
• USE SOFT BRUSH AND AVOID FLOSSING OF TEETH.
• USE ELECTRIC RAZOR TO PREVENT BLEEDING.
• PRECAUTIONS SHOULD BE TAKEN WHILE USING NAIL CUTTER AND TRIM NAILS IN CURVED SHAPE.
• NOTIFY DR. IF ANY UNUSAUL BLEEDING OCCURS. SUCH AS BLACK TARRY STOOL, BRUISING ETC.
• AVOID PRICKING OF NOSE OR SCRATING IT.
• CARRY AN IDENTIFICATION CARD SAYS THAT YOU ARE TAKING WARFARIN.
• AVOID TAKING ANY MEDICATIONS WITHOUT PRESCRIPTIONS.

REASON OF ELEVATED WBC COUNT: AS INCREASED COUNT OF WBC INDICATES INFECTION IN THE BODY. ALSO PATIENT HAS ARTHRITIS THEN IT CAN BE A CAUSE OF ELEVATED WBC AND ALSO INJURY TO TISSUE DUE TO BLOOD LOSS AND DEHYDRATION CAN CAUSE ELEVATED WBC.

TO MAKE CW's WIFE MORE COMFORTABLE:

• PROVIDE PRIVACY TO HER WITH HIS HUSBAND SO THAT SHE CAN GET SOME TIME AND SPACE FOR HIM TO SHOW LOVE AND AFFECTION.
• ASSESS HER EMOTIONAL CONDITION AND ENCOURGE HER TO SHARE HER FEELINGS AND CONCERN FOR HIS HUSBAND. CATHARSIS IS A GOOD TECHNIQUE.
• ADVICE HER TO KEEP A TIME FOR HERSELF ALSO SO THAT SHE CAN TAKE CARE OF HERSELF TOO.
• LACK OF KNOWLEGDE ALSO MAKE PEOPLE TO WORRY SO GIVE SUFFIECIENT KNOWLEGDE TO CLIENT AND HIS WIFE ABOUT DISEASE CONDITION, PROGNOSIS. IT SHOULD BE CLEAR, SIMPLE AND IN NON MEDICAL TERMS.
• INVOLVE HER IN PARTICIPATION IC ACTIVITIES TO TAKE CARE OF MR. CW's CARE.
• ALSO PROVIDE AN OPTION TO HER FOR COUNSELLING IF SHE HAS SERIOUS EMOTIONAL PROBLEM.