STUDENT NAME:
Case Study Simulated Virtual Clinical Fall 2020
Medical Surgical I
Week #1: Hypovolemia
Scenario
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 insidious, 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 hypokalemia. 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 (Coumadin) 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
This study source was downloaded by 100000859469624 from CourseHero.com on 08-07-2023 08:47:17 GMT -05:00
https://www.coursehero.com/file/70650014/Week-1-Hypovolemiadoc/
, 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?
Tolmetinn:
o This medication can lead to HF, MI, Stroke, GI bleeding (especially in
older. Adults), hepatotoxicity, exfoliative dermatitis, steven Johnson
syndrome, toxic epidermal necrolysis, and anaphylaxis
o This medication is also contraindicated when taking warfarin as it will
also increase the chances of bleeding
2. What is the most serious potential complication of C.W.’s bleeding?
Hypovolemic shock that could lead to renal failure or even death.
3. From his history and assessment, identify five signs and symptoms (S/S)
(direct or indirect) of GI bleeding and loss of blood volume.
Paleness
Hypotensive
Angina
Dizziness
tachycardic
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?
This will ensure enough blood flow to vital organs is being
properly maintained
5. Why will you want to monitor his fluid status very carefully?
This study source was downloaded by 100000859469624 from CourseHero.com on 08-07-2023 08:47:17 GMT -05:00
https://www.coursehero.com/file/70650014/Week-1-Hypovolemiadoc/
Case Study Simulated Virtual Clinical Fall 2020
Medical Surgical I
Week #1: Hypovolemia
Scenario
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 insidious, 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 hypokalemia. 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 (Coumadin) 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
This study source was downloaded by 100000859469624 from CourseHero.com on 08-07-2023 08:47:17 GMT -05:00
https://www.coursehero.com/file/70650014/Week-1-Hypovolemiadoc/
, 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?
Tolmetinn:
o This medication can lead to HF, MI, Stroke, GI bleeding (especially in
older. Adults), hepatotoxicity, exfoliative dermatitis, steven Johnson
syndrome, toxic epidermal necrolysis, and anaphylaxis
o This medication is also contraindicated when taking warfarin as it will
also increase the chances of bleeding
2. What is the most serious potential complication of C.W.’s bleeding?
Hypovolemic shock that could lead to renal failure or even death.
3. From his history and assessment, identify five signs and symptoms (S/S)
(direct or indirect) of GI bleeding and loss of blood volume.
Paleness
Hypotensive
Angina
Dizziness
tachycardic
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?
This will ensure enough blood flow to vital organs is being
properly maintained
5. Why will you want to monitor his fluid status very carefully?
This study source was downloaded by 100000859469624 from CourseHero.com on 08-07-2023 08:47:17 GMT -05:00
https://www.coursehero.com/file/70650014/Week-1-Hypovolemiadoc/
