Situation Luis Cruz Question & Answer Guide (With Explanation)
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Original Question
Situation: Luis Cruz, 44 years old, was transferred from the emergency room (ED) to the intensive care unit (ICU) with a diagnosis of probable bleeding in the gastrointestinal (GI) tract. The emergency room history established that he was seen as an outpatient a week ago for epigastric pain following heavy drinking during the New Year’s party. Luis reported feeling nauseous and hangover for 48 hours and having had several episodes of severe pain since the party. He was diagnosed with gastritis and sent home with antihistamine and antacid. He was warned not to smoke. Even though he returned to his job as a commodity trader, he hasn’t been feeling well since the party. He has taken two aspirin two to three times a day for epigastric pain in addition to his prescribed medications. He returned to the emergency room due to nausea, two episodes of vomiting large amounts of a dark brown fluid, and a complaint of extreme weakness. In addition, he has experienced dizziness when sitting down or standing up abruptly. His vital signs at admission and the 6:00 PM labs were as follows: BP 96/60 mm Hg lying down; 84/50 mmHg standing HR 102 bpn Breaths 20 breaths/min Tympanic temperature 37.9oC (100.2oF) Hgb 12.5 g/dl Hct 40% WBCs 1200/mm3 EMERGENCY ROOM RECORD A 14 nasogastric tube (NGT) was placed and there was a return of 350 ml of dark brown liquid, “coffee ground”. His stomach was lavaged with 500 ml of normal saline (NS) and was subsequently drained clean. The orders for admission to the intensive care unit were as follows: Electrocardiogram monitor, vital signs and admissions and discharges every hour. Maintain bed rest. Intermittent low-setting NGT suction: If active bleeding, notify physician and irrigate with 30 mL NS q2h and prn until drainage is clear. Keep nothing by mouth (NPO), except for sips of water with oral medication. Administer oral medication (po); close NGT for 30 minutes after drug administration. Administer Mylanta 30 ml q4h po. Administer Tagamet 300 mg 16h po. Administer Promethazine (Phenergan) 25 mg IV q6h PRN for nausea. Begin intravenous (IV) infusion of 5% dextrose in Lactic Ringer’s solution (D5LR) at 100 mL/hr. Schedule an esophagogastroduodenoscopy (EGD) at 7AM in the GI lab. Measure hemoglobin (Hgb) and hematocrit (Hct) at 9PM. Perform a complete blood and platelet count, prothrombin time (PT), partial thromboplastin time (PTT), complete electrolyte profile, and urinalysis in the morning. Mr. Cruz had an uneventful afternoon. His medical record reflects the information shown in Table I. Table I – Vital signs and nursing observations Time HR (bpm) breaths (breaths/min BP (mm Hg) Other patient data 7 pm 112 16 104/64 8 pm 115 18 100/60 Temperature 37.9oC (100.2oF) 9pm 120 20 98/60 10 pm 120 20 100/60 Hgb 12.3 g/dl Hct 36% 11 pm 120 20 96/54 Sleeping Midnight 112 20 92/50 Temperature 36.7oC (98oF) 120 ml amber urine voided At midnight, the NGT was closed to administer drugs. When the NGT was opened at 12:30 am, a return of 300 ml of blood was obtained. Mr. Cruz became anxious and did not rest. His skin turned pale and sweaty. Nasal cannula oxygenation was started at 4 L/min. Vital signs at 12:30 MN were as follows: BP 84/50 mm Hg – lying down HR 126 bpn Breaths 28 breaths/min According to the patient’s signs and symptoms, he discusses in five sentences what the patient’s physiological changes are. Support your answer with scientific evidence. Determine two nursing diagnoses for this patient in PES format and using the nomenclature NANDA, NIC and NOC. Determine two goals for the patient that are related to the nursing diagnoses you mentioned using NOC nomenclature. Mention two priority nursing interventions. Explain the scientific rationale for each of the interventions you mention using the NIC nomenclature.
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