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Gastrointestinal Disorders

Case Study 42

Name______________________________ Class/Group__________________ Date___________

Group Members_____________________________________________________________________________

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario

T.H., a 57-year-old stockbroker, has come to the gastroenterologist for treatment of recurrent mild to severe cramping in his abdomen and blood-streaked stool. You are the registered nurse doing his initial workup. Your findings include a mildly obese man who demonstrates moderate guarding of his abdomen with both direct and rebound tenderness, especially in the left lower quadrant (LLQ). His vital signs are 168/98, 110, 24, 100.4° F (38° C), and he is slightly diaphoretic. T.H. reports that he has periodic constipation. He has had previous episodes of abdominal cramping, but this time the pain is getting worse.

Past medical history reveals that T.H. has a “sedentary job with lots of emotional moments,” he has smoked a pack of cigarettes a day for 30 years, and he has had “2 or 3 mixed drinks in the evening” until 2 months ago. He states, “I haven’t had anything to drink in two months.” He denies having regular exercise: “just no time.” His diet consists mostly of “white bread, meat, potatoes, and ice cream with fruit and nuts over it.” He denies having a history of cardiac or pulmonary problems and no personal history of cancer, although his father and older brother died of colon cancer. He takes no medications and denies the use of any other drugs or herbal products.

1. Identify four general health risk problems that T.H. exhibits.

2. Identify a key factor in his family history that might have profound implications for his health and present state of mind.

3. Identify three key findings on his physical exam, and indicate their significance.

Case Study Progress

The physician ordered a KUB (x-ray of the kidneys, ureters, and bladder), CBC, and complete metabolic profile. Based on x-ray and lab findings, physical examination, and history, the physician diagnoses T.H. as having acute diverticulitis and discusses an outpatient treatment plan with him.

4. What is diverticulitis? What are the consequences of untreated diverticulitis?

5. While the patient is experiencing the severe crampy pain of acute diverticulitis, what interventions would you perform to help him feel more comfortable?

6. What is the rationale for ordering bed rest?

Bed rest helps decrease intestinal spasm and pain.

Case Study Progress

T.H. is being sent home with prescriptions for metronidazole (Flagyl) 500 mg PO q6h, ciprofloxacin (Cipro) 500 mg PO q12h, and dicyclomine (Bentyl) 20 mg qid PO × 5 days.

7. For each medication, state the drug class and the purpose for T.H.

8. Given his history, what questions must you ask T.H. before he takes the initial dose of metronidazole? State your rationale.

9. What is a disulfiram reaction?

10. When teaching T.H. about the metronidazole prescription, which instructions need to be included? (Select all that apply.)

a. Avoid all alcohol-containing products while on this medication.

b. If his urine turns reddish brown, notify his doctor immediately.

c. Take the medication exactly as scheduled, without skipping doses.

d. He might feel some tingling or numbness in his hands, which is an expected effect.

e. Take the medication with or after meals.

f. This medication might cause a metallic taste.

11. What specific information would you want to know before T.H. starts the antibiotics?

12. What are the signs and symptoms of an allergic reaction?

13. T.H. asks you if he can take a laxative for his occasional constipation. What is your answer?

14. T.H. asks you about his diet. “I’m confused. I was always told that I needed to be eating a high-fiber diet, which is difficult for me. But the doctor just told me that I need to be on a low-fiber diet for now, so now I’m confused. Which is it supposed to be?” How will you answer his question?

Case Study Progress

To help T.H. work through his dietary concerns, you obtain a referral to a registered dietitian.

15. What measures do you think the dietitian will discuss with T.H. to avoid recurrent diverticulitis once his acute symptoms are resolved?

Case Study Outcome

T.H. returns for a checkup 14 days later; all signs and symptoms of diverticulitis are gone. He is working on his lifestyle changes and reports he is walking 30 minutes every day.

Case Study 43

Name______________________________ Class/Group__________________ Date___________

Group Members_____________________________________________________________________________

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario

T.B. is a 65-year-old retiree who is admitted to your unit from the emergency department (ED). On arrival, you note that he is trembling and nearly doubled over with severe abdominal pain. T.B. indicates that he has severe pain in the right upper quadrant (RUQ) of his abdomen that radiates through to his mid-back as a deep, sharp, boring pain. He is more comfortable walking or sitting bent forward rather than lying flat in bed. He admits to having had several similar bouts of abdominal pain in the last month, but “none as bad as this.” He feels nauseated but has not vomited, although he did vomit a week ago with a similar episode. T.B. experienced an acute onset of pain after eating fish and chips at a fast-food restaurant earlier today. He is not happy to be in the hospital and is grumpy that his daughter insisted on taking him to the ED for evaluation.

After orienting him to the room, you perform your physical assessment. The findings are as follows: He is awake, alert, and oriented × 3, and he moves all extremities well. He is restless, is constantly shifting his position, and complains of fatigue. Breath sounds are clear to auscultation. Heart sounds are clear and crisp, with no murmur or rub noted and with a regular rate and rhythm. Abdomen is flat, slightly rigid, and very tender to palpation throughout, especially in the RUQ; bowel sounds are present. He reports having light-colored stools for 1 week. The patient voids dark amber urine but denies dysuria. Skin and sclera are jaundiced. Admission vital signs are BP 164/100, pulse of 132 beats/min, respiration 26 breaths/min, temperature of 100° F (37.8° C), SpO₂ 96% on 2 L of oxygen by nasal cannula.

1. What structures are located in the RUQ of the abdomen?

2. Which of the previously mentioned organs are typically palpable in the RUQ?

3. As you palpate T.B.’s abdomen, you deeply palpate the costal margin in the RUQ, and ask him to take a deep breath. This causes T.B. to stop inspiration abruptly, midway, and exclaim, “Oh, that hurts!” What does this finding indicate?

a. Rebound tenderness

b. Hepatomegaly

c. Splenomegaly

d. Murphy’s sign

Case Study Progress

T.B.’s abdominal ultrasound demonstrates several retained stones in the common bile duct and a stone-filled gallbladder. T.B. is admitted to your floor, NPO status, and is scheduled to undergo an endoscopic retrograde cholangiopancreatogram (ERCP) that afternoon. During an ERCP, the patient is sedated, and an ERCP scope is inserted through the mouth, past the stomach, to the outlet of the common bile duct, the ampulla of Vater. Typically, this muscle will be cut to widen the opening and outflow of the common bile duct, a procedure called a papillotomy. This allows the bile and stones to flow out into the small intestine. You review T.B.’s other laboratory results:

Chart View

Preoperative Laboratory Test Results

WBC	11,900/mm3
Hgb	14.3 g/dL
Hct	43%
Platelets	250,000/mm3
Alanine transaminase (ALT)	200 units/L
Aspartate transaminase (AST)	260 units/L
Alkaline phosphatase (ALP)	450 units/L
Total bilirubin	4.8 mg/dL
Prothrombin time (PT)/INR	11.5 sec/1.0
Amylase	50 units/L
Lipase	23 units/L
Urinalysis	Negative

4. Which results are abnormal, and what do they reflect?

Case Study Progress

The patient undergoes the ERCP, and stones and bile are released, but imaging reveals that a stone is still retained within the cystic duct, and multiple stones remain within the gallbladder itself. A surgical consult is obtained, and a laparoscopic cholecystectomy (“lap choley”) is planned.

5. Identify at least four preoperative orders that will likely need to be completed before T.B. goes to surgery.

6. T.B. is medicated with morphine sulfate 2 mg IV push (IVP) q2h as needed. After the first dose, he reports that on a scale of 1 to 10, his pain has decreased from a 10 to a 4 within 30 minutes. What other methods could be used to help T.B.’s pain?

7. Which data charted in the assessment are consistent with CBD obstruction?

Case Study Progress

At 2330, T.B. spikes a temperature of 101.5° F (38.6° C) (tympanic). His SpO₂ on 2 L oxygen per nasal cannula is now 90%, so you immediately increase the flow rate to raise his O₂ saturation. You inform the on-call surgeon, and she orders a STAT chest x-ray and a broad-spectrum antibiotic—imipenem and cilastatin (Primaxin) 500 mg IV now, then q6h.

8. Before you give the antibiotic, what will you assess?

9. As you review the orders, you note that the Primaxin contains cilastatin. What is the purpose of the cilastatin?

a. It enhances the action of the imipenem.

b. It reduces the chance of an allergic reaction.

c. It promotes the renal secretion of the imipenem.

d. It causes the bacterial cell wall to become unstable.

Case Study Progress

T.B. undergoes a successful laparoscopic cholecystectomy the next morning. An intraoperative cholangiogram shows that the ducts are finally cleared of stones at the conclusion of the surgery. When he returns to the nursing unit, his stomach is soft but quite distended. His wife asks you whether anything is wrong.

10. How will you respond to her question?

11. When you remove the tape the next day to change the dressing, you note that the skin is red and blistered underneath. Otherwise, he is doing well; his vital signs are 128/72, 80, 16, 99.8° F (37.7° C), and SpO₂ of 95% on room air. He even tolerated a light breakfast. To protect the blistered area from further damage, you apply a hydrocolloid dressing to the damaged skin. What has T.B. experienced, and what are the benefits of this type of dressing?

Case Study Progress

The rest of the day is uneventful, and the next day T.B. is discharged to home.

12. What discharge teaching does T.B. need?

Case Study 44

Name______________________________ Class/Group__________________ Date___________

Group Members_____________________________________________________________________________

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario

M.R. is a 56-year-old general contractor who is admitted to your telemetry unit directly from his internist’s office with a diagnosis of chest pain. On report, you are informed that he has an intermittent 2-month history of chest tightness with substernal burning that radiates through to the mid-back intermittently, in a stabbing fashion. Symptoms occur after a large meal; with heavy lifting at the construction site; and in the middle of the night when he awakens from sleep with coughing, shortness of breath, and a foul, bitter taste in his mouth. Recently, he has developed nausea, without emesis, that is worse in the morning or after skipping meals. He complains of “heartburn” three or four times a day. When this happens, he takes a couple of Rolaids or Tums. He keeps a bottle at home, at the office, and in his truck. Vital signs (VS) at his physician’s office were 130/80 lying, 120/72 standing, 100, 20, 98.6° F (37° C), SpO₂ 92% on room air. A 12-lead ECG showed normal sinus rhythm with a rare premature ventricular contraction (PVC).

1. What are some common causes of chest pain?

2. What mnemonic can you use to help you better evaluate his pain?

3. What other history is important?

Case Study Progress

M.R. indicates that usually the chest pain is relieved with his antacids, but this time they had no effect. A “GI cocktail” consisting of Mylanta and viscous lidocaine given at his physician’s office briefly helped decrease symptoms.

4. What tests can be done to determine the source of his problems?

Case Study Progress

M.R. has smoked one pack of cigarettes a day for the past 35 years, drinks two or three beers on most nights, and has noticed a 20-pound weight gain over the past 10 years. He feels “so tired and old now.” M.R. has dark circles under his eyes and complains of constant daytime fatigue. His wife is even sleeping in another bedroom because he is snoring so loudly. He also reinjured his lower back a month ago at work, lifting a pile of boards, so his physician prescribed ibuprofen (Motrin) 800 mg bid or tid for 4 weeks.

5. Which factors in M.R.’s life are likely contributing to his chest pain and nausea? Explain how.

Case Study Progress

M.R. explains that 6 months ago his physician prescribed famotidine (Pepcid) 20 mg PO at bedtime for heartburn, and that it helped a little, but that it never really “did the job.” Now he keeps a bottle of Tums or Rolaids in his truck and at his bedside, in addition to the ranitidine, “because I always seem to need them.”

6. Why do you think the famotidine did not help M.R.?

Case Study Progress

M.R.’s 12-lead ECG was normal, and the first set of cardiac enzymes was normal. CBC showed WBC 6000/mm³, Hgb 15.0 g/dL, Hct 47%, platelets 220,000/mm³. Complete metabolic panel (CMP) revealed Na 140 mEq/L, K 3.7 mEq/L, BUN 20 mg/dL, creatinine 1.0 mg/dL, lipase 20 units/L, amylase 18 units/L, PT 12.0 sec, INR 1.0. The H. pylori antibody test came back as 20 units/mL. The chest x-ray showed no abnormalities. Room air SpO₂ is 94%, and breathing is unlabored. Suddenly, M.R. begins to complain of nausea; as you hand him the emesis basin, he promptly vomits coffee-ground emesis with specks of bright red blood. VS remain stable.

7. What concerns do you have about the coffee-ground emesis?

8. What is the significance of the H. pylori antibody test result?

Case Study Progress

You ask the charge nurse to contact the gastrointestinal (GI) consulting doctor to explain the recent events while you stay with M.R. The gastroenterologist gives several orders and states he will be there in 45 minutes. The orders are as follows:

Chart View

Physician’s Orders

• NPO status for emergent esophagogastroduodenoscopy (EGD)

• STAT CBC

• Oxygen by nasal cannula; titrate oxygen to maintain SpO₂ over 92%

• Type and crossmatch (T&C) 2 units packed RBCs (PRBCs), and hold

• Start a pantoprazole (Protonix) drip at 8 mg/hr, preceded by an 80-mg bolus IV over 8 minutes.

• Insert a Salem Sump nasogastric tube (NGT) and start a gastric lavage with normal saline.

• Insert two large-bore IVs and start normal saline (NS) at 100 mL/hr.

9. List the previous orders in order of priority.

10. Explain the rationale for each of the preceding orders.

Case Study Progress

The gastroenterologist finds erosive esophagitis LA Class B, a moderately sized hiatal hernia, diffuse erosive gastritis, and an ulcer in the antrum of the stomach that is oozing blood. The duodenal bulb yielded a normal endoscopic appearance. During the EGD, the bleeding was stopped with cautery. Biopsies were obtained of the gastric mucosa, and the biopsies are negative for H. pylori bacteria; his bleeding ulcer is attributed to the NSAIDs (i.e., ibuprofen). He is kept NPO until the next morning to allow good hemostasis of the cauterized site. Clear liquids are allowed at breakfast. His hematocrit (Hct) dropped to 32%, but he remained asymptomatic from the mild anemia; the drop was believed, in part, to reflect that he was dehydrated on admission, and the decrease reflected the dilution of the blood from the IV fluids added. Thus, he did not receive a transfusion of blood.

M.R. tolerated the liquid diet without any nausea and vomiting and is discharged to home the next day with the following instructions:

• Advance diet slowly, as tolerated, to mechanical soft.

• Take pantoprazole 40 mg PO q AM on an empty stomach, at least 30 minutes before eating.

• Make a follow-up appointment in 6 to 8 weeks with physician (give name and telephone number).

• Stop all aspirin and over-the-counter (OTC) or herbal pain relief medications (ibuprofen, naproxen, etc.).

• Stop or limit alcohol intake and smoking.

11. Why does the patient need to take the pantoprazole first thing in the morning?

12. After discussing lifestyle modifications for controlling acid reflux with M.R., which statement by M.R. indicates a further need for teaching?

a. “I will try to stop smoking.”

b. “I will wait thirty minutes before lying down or sitting in my recliner after meals.”

c. “I will avoid fatty foods, caffeine, and chocolate.”

d. “I will avoid eating two to three hours before my bedtime.”

Case Study 45

Name______________________________ Class/Group__________________ Date___________

Group Members_____________________________________________________________________________

INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will need to rewrite it.

Scenario

While you are working as a nurse on a gastrointestinal/genitourinary (GI/GU) unit, you receive a call from your affiliate outpatient clinic notifying you of a direct admission, with an estimated time of arrival of 60 minutes. She gives you the following information: A.G. is an 87-year-old woman with a 3-day history of intermittent abdominal pain, abdominal bloating, and nausea and vomiting (N/V). A.G. moved from Italy to join her grandson and his family only 2 months ago, and she speaks very little English. All information was obtained through her grandson. Past medical history includes colectomy for colon cancer 6 years ago and ventral hernia repair 2 years ago. She has no history of coronary artery disease, diabetes mellitus, or pulmonary disease. She takes only ibuprofen (Motrin) occasionally for mild arthritis. Allergies include sulfa drugs and meperidine. A.G.’s tentative diagnosis is small bowel obstruction (SBO) secondary to adhesions. A.G. is being admitted to your floor for diagnostic workup. Her vital signs (VS) are stable, she has an IV of D5½NS with 20 mEq KCl infusing at 100 mL/hr, and 3 L oxygen by nasal cannula (O₂/NC).

1. Based on the nurse’s report, what signs of bowel obstruction does A.G. manifest?

2. Are there other signs and symptoms that you should observe for while A.G. is in your care?

3. While A.G. is on the way, you have secured the hospital’s interpreter service on the telephone. A.G. arrives on your unit with her grandson. You admit A.G. to her room and introduce yourself as her nurse. As her grandson introduces her, she pats your hand. You know that you need to complete a physical examination and take a history. What will you do first?

4. Before you begin your examination, you ask the grandson to excuse himself, explaining the hospital’s confidentiality policies. The grandson, an attorney, tells you that elderly Italian women are extremely modest and might not answer questions completely. How might you gather information, in this case?

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