Case Studies 4

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A 64 year old male is admitted with hematemesis and epigastric pain following a prolonged period of alcohol abuse. On admission he is agitated and confused.  Muscle wasting and debilitation are evident.

BP 94/62, HR 134, RR 40

Assessment reveals clear lungs, fine tremors of hands, incontinence of small amount of burgundy stool, hyperactive bowel sounds, tenderness over epigastric area, incontinence of urine, 3+ edema present in feet and 1/2 up legs.
Lab values on admission:
Na    148 RBC   3.2 Albumin        1.7
K      2.5 Hgb   10.2 Total prot      3.4
Ca    7.2 PO4    2.0 Amylase       380
Mg    1.0 Glu    180 Serum osmo  310
AST  240 ALT  105 Chol                78
Ammonia        90

Admitting diagnoses include

  • Alcoholic gastritis
  • Pancreatitis
  • Hypokalemia
  • Hypomagnesemia
  • Hypocalcemia
  • Anemia
  1. Discuss his protein, carbohydrate and lipid status.

 

  1. What type of anemia does he have?

 

Following admission, he is placed on nasogastric suction and receives IV D5NS with 20 mEq K/L, multivitamins and magnesium sulfate. He is given Thiamine IM daily X 3. His respirations continue to be shallow and rapid, increasing to 44/minute. He is electively intubated and mechanical ventilation is instituted. Initial ventilator settings include FiO2 1.00, tidal volume 1200 cc, rate 14. 

ABGs after 30 minutes reveal:

pH         7.52
PaCO2     30
PaO2      100
HCO3      30

He has seizure activity and requires diazepam and phenytoin. His level of consciousness is difficult to evaluate, deep tendon reflexes are depressed and left pupil is larger than right. Hyperalimentation is begun.

  1. Discuss the oxygenation and ventilation status.
  1. What caused the seizure activity?

 

On the afternoon of the second hospital day, his urine develops a brown color and is positive for myoglobin. Repeat lab data reveal

Hgb    8.2
CK    230
PO4   0.3

  1. What caused the myoglobinuria?

  

  1. What treatments do you anticipate?

 

  1. List the 3 most important nursing interventions.

 

An 88 year old female went to her physician with progressive ankle edema for 2 days. She is admitted with a diagnosis of pulmonary edema due to a recent MI. She also has severe aortic stenosis with loud S3 and S4.  She is treated with furosemide and bicarbcarbonate without results. Then she is given zaroxyline and furosemide in increasing amounts resulting in diuresis and hypotension by hospital day 3.

Admission  Evening of day 1
WBC 5.8 8.5
Hgb 11.2 14.4
Hct 35.3 43.1
Plat 109 176
Na 127 129
K 4.2 3.9
Cl 99 93
Serum CO2 11 22
Ca 8.7 9.0
PO4 5 4.6
Glucose 319
Digoxin 0.9
PT/INR 13.5/1.21
PTT 62.8 28.3
CK 138 310
CK-MB 6.2 15.6
CK index 3.74
BUN 47 70
Creat 2.3 2.3
AST 35 28
LDH 189 180
Albumin 3.4 3.5
Total prot 6.3 6.2
Chol 186
Alk phos 60 60
T. bili 4.7
Uric acid 10.2 9.6

  1. Do the labs support a diagnosis of a recent MI?

  2. Could her nutritional status be the cause of the peripheral edema?

  3. Discuss her fluid status. How did it change by the end of day 1? What lab changes support this change?

  4. Does she have renal failure? Is so, what type?

  5. Do the labs support liver dysfunction?

  6. Discuss her nutritional status.

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