John East, a 68 y/o male was brought to the Emergency department (ED) at 7:00am by his daughter. Daughter told the ED triage nurse that her father told her that he had a large amount of dark red diarrhea stools for the past 2-3 days and it continued last night. This am, he became dizzy, light-headed, disoriented and weak, he called his daughter to come to his home, and they decided to come to the ED for evaluation. VS: B/P: 84/52, P: 106 weak, R: 22. An 18 gauge IV catheter was established and 0.9 Normal Saline is started at 125 ml/hr. The ED triage nurse received the following information from the patient and daughter. Patient has had idiopatic dilated cardiomyopathy (ICDM) for several years. The onset was insidious, but the cardiomyopathy is now severe, as evidenced by a left ventricle ejection fraction of 13% found during a recent cardiac catheterization. Mr. East experiences frequent problems with Congestive Heart Failure (CHF) because of the ICDM. Two years ago, he experienced cardiac arrest that was caused by hypokalemia. He also has a previous medical history (PMH) of hypertension (HTN) and arthritis. Ten years ago he was diagnosed with a peptic ulcer. Mr. East is sent for an endoscopy and it showed a 25 mm x 15 mm duodenal ulcer with adherent clot. The ulcer was cauterized, and Mr. East was admitted to the Medical intensive care unit for treatment of his volume deficit. You are the assigned nurse, and as you are orientating the patient/daughter to the room/unit, the daughter hands you a bag with her father's home medications. Home Medications; Amlodipine 10 mg daily Coreg 12.5 mg twice a day Coumadin 2.5 mg daily KCL 10 mEq po daily Indomethacin 25 mg three times a day Initial assessment, a pale male who is sleepy, but arousable and oriented. He complains of dizziness and is tachycardic. S 3 and S 4 heart sounds. Peripheral pulses present. Trace pedal edema noted. Lung sounds clear bilaterally. Bowel sounds are present. Gastric tenderness is noted and the liver margin is 4 cm below the costal margin. A Swanz-Ganz catheter and an arterial line are inserted. 1. List the home medication(s) that probably contributed to Mr. East's GI bleeding? What patient education would you provide for this patient if these medications are continued on discharge? 2. Explain the most serious potential complication associated with Mr. East's bleeding and the rationale for your selection? 3. Document the initial assessment in a progress note format, include VS, admitting signs/symptoms, IV site and PMH? 4. What risk factors does this patient have for dehydration? 5. List signs/symptoms (both direct and indirect) of GI bleeding and fluid loss from the history the patient and daughter provided and your initial assessment? 6. List additional complications that you would anticipate as a result of the patients' hypovolemia as well as the rationale for your selections? Case Study Continues: Mr. East receives 4 units of packed red blood cells (PRBC). 5 units of fresh frozen plasma (FFP). 7. Explain the rationale for the use of PRBC's and FFP? 8. Explain why you will be monitoring the patients fluid status very carefully as well as how you would do this? 9. List six nursing actions that you would implement to assess Mr. East's fluid balance? Current Labs K 5.8 mEq/L Na 138 mEq/L BUN 80 mg/dl Creatinine 5.4 mg/dl Hgb 8.6g/dl Hct 28% WBC 14,000 PT 21 INR 3.8 10. Explain why the laboratory values are not within range? 11. The potassium level is 5.8 mEq/L, why would you do a focused assessment and continue to monitor the patient's condition? What medication may be given to reduce the potassium level and how does this medication effect the potassium level? 12. What safety precautions would you initiate for this patient based on the current PT/INR values? 13. Document the patient education you would provide based on the patients current condition while inpatient, as well as what they need to continue to do upon discharge home in a progress note format? Case Study Continues: Mr. East's daughter remains at his bedside and is very concerned about her father's condition. 14. List 5 interventions that you could provide for the daughter to make her more comfortable during this difficult time?