As a nurse on a general medical floor, the RN has received a new admit. Review the client data provided.
- Richard Henderson
- 58 years old
- Male
- Admit diagnosis: GI bleed
- History: no surgical history
- Medical history: Gastritis & GERD
- Medications: Prilosec 40 mg PO daily, Atenolol 25 mg PO BID, Fiber daily, Alka Seltzer PO – states he takes this at least daily.
Report from physician’s office: Mr. Henderson arrived to the physician’s office today for a complaint of increasing abdominal pain. He states that he is now throwing up coffee-ground emesis. He states that he didn’t take his BP medication this morning because he was dizzy. The physician is admitting him with a diagnosis of GI bleed with an EGD scheduled for tomorrow. He is NPO, and has a 22G IV lock in the left forearm. Last set of vital signs BP 106/60 mm Hg, HR 98 beats/min, RR 20 breaths/min, Temp. 98.8 degrees F, P.O. 90% on room air. He last vomited about 45 minutes ago with a small amount of dark coffee-ground emesis. His pain is 4/10 at present. No pain medication is ordered at this time.
- Lab assessments ordered: CBC and chemistry panel
- CT of the abdomen shows no signs of free air (no perforation)
When he arrives to the floor, he is pale, nauseous, and his skin is cool and clammy. When he is transferred to the bed from the stretcher, he vomits a large amount of coffee-ground emesis and loses consciousness.
Instructions
In the discussion post, address the following:
- While receiving report what concerns do you have regarding the client report?
- What type of shock is occurring?
- What stage of shock is the client experiencing?
- What is your next intervention and why?
- What additional lab assessments would you anticipate?
- Provide additional thoughts and insights.
As a nurse on a general medical floor, there are several concerns regarding the client report:
- The client has a history of gastritis and GERD, which puts him at a higher risk for gastrointestinal bleeding.
- The client’s report of increasing abdominal pain and coffee-ground emesis suggests active bleeding in the gastrointestinal tract.
- The client’s vital signs indicate hypotension and tachycardia, which are signs of shock.
The type of shock occurring in this client is most likely hypovolemic shock, as the client is experiencing a loss of blood volume due to the ongoing gastrointestinal bleed.
The client is likely in the early stage of shock as evidenced by the client’s vital signs of hypotension and tachycardia. The loss of consciousness could be a sign of worsening shock.
The next intervention for this client should be to administer intravenous fluids and initiate blood transfusion as needed. The client needs to be placed on continuous cardiac monitoring, and oxygen therapy should be provided to maintain oxygen saturation above 94%. The client should also be placed on NPO status and monitored for further vomiting or bleeding. A nasogastric tube may be inserted to relieve gastric pressure and assess for ongoing bleeding.
Additional lab assessments that would be anticipated for this client include coagulation studies, liver function tests, and lactate levels to assess the severity of the shock and the extent of the bleed. Serial hemoglobin and hematocrit levels would also be monitored to assess the response to treatment.
In conclusion, the nurse should monitor the client closely for signs of worsening shock and take prompt actions to manage the symptoms and stabilize the client’s condition. Early recognition and intervention are crucial in preventing further deterioration and improving the client’s outcome.