QSEN Case Study

The wife of C.W., a 70-year old man, brought him to the emergency department at 0430. She told the ED triage nurse that he had diarrhea for the past 3 days and that 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 in the ED were 70/-, pulse rate 110 bpm, respiratory rate 22 breaths/min, oral temperature 99.1 F. A 16-guage IV catheter was inserted and a lactated Ringer’s solution was started. The triage nurse obtained the following history from the patient and his wife. C. W. has had idiopathic dilated cardiopyopathy for several years. The onset was insidious, but the cardiomyopathy is now severe, as evidenced by an ejection fraction of 13% found during a recent echocardiography. He experiences frequent problems with heart failure because of the cardiomyopathy. Two years ago, he had a cardiac arrest that was attributed to hypokalemia. He has a long history of hypertension and arthritis. He had atrial fibrillation in the past but it has been under control recently. Fifteen years ago he had a peptic ulcer. Endoscopy showed a 25 x 15 mm duodenal ulcer with adherent clot. The ulcer was cauterized and C. W. was admitted to the medical intensive care unit for treatment of his fluid 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: enlapril (Vasotec) 5mg PO bid , warfarin (Coumadin) PO 5mg/day, digoxin (Lanoxin) 0.125 mg/day PO, potassium chloride 20mEq PO bid, and diclofenac (Voltaren) 50 mg PO tid:NSAID. As you connect him to the cardiac monitor you note he is in sinus tachycardia. Doing a quick assessment, you find a pale man who is sleepy but arousable and slightly disoriented. He states he is still dizzy. His BP is 98/52, pulse is 118, and respiratory rate 26. 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 pulmonary artery catheter and a peripheral arterial line are inserted. 1. What may have precipitated C. W.’s gastrointestinal bleeding? Taking warfarin, digoxin, and NSAID all daily can cause GI bleeding. Diarrhea may have precipitated ulcers because as well because of irritation from acid. 2. From his history and assessment, identify five signs and symptoms of GI bleeding and loss of blood volume. Previous peptic ulcer Dark Red diarrhea Dizzy, disoriented and weak Mid epigastric tenderness pale man who is sleepy but arousable and slightly disoriented (meds pt is taking_