Problem
Bruce Eggert, age 59 years, was brought to the emergency department with complaints of dizziness, dyspnea, restlessness, and anxiety. Mr. Eggert currently works as an accountant for a large firm. He is married and has two children living at home. He reported a 2-day history of hematemesis with some bright red blood and large amounts of "coffee ground" emesis. Mr. Eggert denied any recent or chronic illnesses and was unable to remember if anyone in his family had ever had problems with gastrointestinal tract bleeding. He did admit to drinking six to eight alcoholic beverages almost every day for the past 7 years. Initial assessment revealed cool and clammy skin, a distended abdomen with hyperactive bowel sounds and tachycardia. Current vital signs and laboratory results are as follows:
BP 92/60 mm Hg, HR 120 bpm, Resp 28 breaths/min, Temp 36.9oC (98.3oF)
Ammonia 60μg/dl
glucose 87 mg/dl
LDH 500 U/L
AST 950 U/L
ALT 1000 U/L
Alkaline phosphatase 165 U/L
Total Bilirubin 2.5 mg/dl
Albumin 2.3 g/dl
PT 26 sec
PTT 85 sec
Three hours after arriving in the ED, Mr. Eggert was admitted to the ICU with an intravenous infusion of normal saline. Two units of packed red blood cells were administered. Twenty units of vasopressin (Pitressin) in 100 ml of 5% dextrose in water were given intravenously over 20 minutes. A continuous infusion of vasopressin 0.4 U/min was then initiated. Sublingual nitroglycerin was added to the medication regimen. Diagnostic fiberoptic endoscopy, immediately preceded by a saline lavage, was scheduled for th following day. ndoscopy revealed a large esophageal varix (1.5 cm) above the gastroesophageal junction. Only a small amount of bright red blood was observed, so sclerotherapy was performed. A solution of 5% ethanolamine oleate was given by intravariceal injection. Mr. Eggert's condition remained stable after sclerotherapy and he transferred to a medical floor. Sugsequent sclerotherapy sessions were scheduled on a weekly basis for 4 weeks.
A. Define and discuss the pathophysiology of esophageal varicies and portal hypertension.
B. What do Mr. Eggert's laboratory tests indicate about his current health status?
C. Explain how Mr. Eggert's history and laboratory results relate to portal hypertension.
D. Discuss the clinical manifestations of esophageal varicies.
E. Identify the diagnostic procedures and nursing implications for esophageal varicies.
F. Comapre and contrast the treatment options and nursing implications for esophageal varicies.
G. Discuss the rationale for Mr. Eggert's vasoprssin therapy, management of side effects, and nursing concerns.
H. Identify the relevant nursing diagnoses for Mr. Eggert while he is in the ICU.
I. Discuss the patient/family teaching indicated for Mr. Eggert.
J. What special nursing considerations are prompted by Mr. Eggert's past drinking pattern?
K. Discuss the psychosocial aspects of the care of Mr. Eggert and his family.