Posted: July 17th, 2022

9, Assessment and Management of Patients With Hepatic Disorders essay

Case Study, Chapter 49, Assessment and Management of Patients With Hepatic Disorders

1. John Adams, 55 years of age, is admitted to the intensive care unit with the diagnosis of acute esophageal varices bleed. The patient has a long-standing history of alcoholism and cirrhosis of the liver. Six months ago, the patient received an EGD, which diagnosed the esophageal varices. The patient has quit drinking alcohol for the past 6 months and has been active in Alcoholics Anonymous. The patient has a history of coronary artery disease and angina. The patient has been taking nadolol (Corgard) and isosorbide (Isordil). The admission vital signs include: BP, 88/50; P, 110; R, 26; and T, 99°F. The supplemental oxygen is on room air and the patient is placed on 2 L/min of oxygen per nasal cannula with supplemental oxygen. The patient’s hemoglobin is 6 g/dL, the hematocrit is 12%, and the platelets are 75,000. The patient has a prolonged PT and PTT. The liver profile shows a mild elevation of the aspartate aminotransferase (AST) and the alanine aminotransferase (ALT). The BUN and serum creatinine are also elevated. The patient has in place from the emergency department a nasogastric tube to low wall suction. The emergency department physician placed a right subclavian triple lumen catheter and there is NS infusing at 100 mL/hr. The emergency department nurse administered vitamin K. Additional orders on the chart from the gastroenterologist include the following: octreotide (Sandostatin) 5-mcg bolus followed with continuous infusion 500 mcg in 250 mL D5NS at 25 mcg/hr. Type and cross of 6 units of PRBCs STAT and transfuse 2 units of PRBCs over 2 hours each and administer furosemide (Lasix) 20 mg IVP in between each unit. Repeat CBC 1 hour after the transfusion is completed. (Learning Objective 4)

a. In what order should the nurse institute the physician orders that are listed above? Perform dosage calculations and state how to administer the medications.

b. The nurse observes the nasogastric secretions and, upon admission to the ICU, there was 200 mL of dark red-colored drainage. The nurse continues to monitor the drainage and, as the nurse hangs the first unit of PRBCs, 200 mL of bright red bloody drainage is dumped into the collection canister. What should the nurse do?

c. The gastroenterologist orders for the nurse to increase the octreotide to 50 mcg/hr and the endoscopy nurse and the physician will be up shortly to perform a vertical band ligation (VBL). What does the nurse need to do in preparation for this procedure?

2. Carl Vinson, a 65-year-old Caucasian man, was admitted today with increased shortness of breath, fatigue, and decreased level of consciousness. Mr. Vinson has a history of liver disease, most likely related to a long history of alcohol use. Upon arrival to the unit, he is somnolent and responds only to shouting and shaking. Upon arousal, he is only able to state his first name. His wife accompanies him to the unit, and describes that he has become increasingly restless over the last 3 days, and she is concerned for his safety. Additionally, he has not eaten or taken in any fluids in 24 hours. (Learning Objectives 2, 3, and 6)

a. Correlate the patient’s presenting clinical manifestations to hepatic encephalopathy.

b. The physician orders a STAT ammonia level, along with a CBC and complete chemistry panel. The ammonia result is elevated. What is your interpretation?

c. The physician orders Mr. Vinson to receive lactulose (Cephulac) orally. What is the rationale for this medication?

d. Mrs. Vinson asks why her husband must decrease intake of protein. How will you respond to her question?

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