Case Study #1 - Quia



Case Study #2

Student Name:________________________

For the homework assignments, the student must complete the questions on their own accord (thus not a group project or splitting). By signing your name on your homework assignment you have agreed that the work presented is of your own accord and is not completed with any collaboration with other instructors, students and healthcare workers. The answers provided cannot be copied word for word from a book or plagiarized and must demonstrate critical thinking, prioritization and decision making. Points will be deducted based on the answers provided.

Mr. Escobar is a 47 year old male with a history of cirrhosis. He lives with his wife and teenage sons. His wife brought him to the emergency department today because she noticed that Mr. Escobar ha increasing confusion and lethargy and was having difficulty walking. His wife states, “He is probably acting a little funny because he is sleep deprived. He hasn’t slept very much in the past few days.”

Gender: Male

Age: 47

Setting: Hospital

Ethnicity: Black American

Preexisting Condition: Cirrhosis secondary to alcoholic hepatitis, Hypertension,

Esophageal Varices

Coexisting Condition: Ascites

Disability: Unemployed (on disability) for past four years

Socioeconomic: Married, father of two boys (ages 19 and 17 years old), history of drinking one quart of hard liquor each day for three years prior to diagnosis of cirrhosis (His cirrhosis was dx 2 years ago)

Pharmacologic: Lactulose; neomycin sulfate

Mr. Escobar is afebrile. His blood pressure is 136/68, pulse 88, and respiration rate 18. His oxygen saturation is 98% on room air. He is awake, alert and orientated to person only. His speech is slow and he appears tired. The nurse notices a foul odor to his breath. Upon physical examination Mr. Escobar has a slightly distended abdomen. The health care provider (HCP) does not note any asterixis. The HCP requests an abdominal ultrasound, which reveals fatty infiltrates of the liver, an enlarged spleen, a polyp in his gallbladder, and a moderate amount of ascites. Results of a CBC reveal white blood cell count of 4.8 cells/mm³, RBC 2.94 million/mm³, Hgb 9.8 g/dl, Hct 28.2%, Results of a CMP are sodium 145mEq/L, potassium 3.6 mEq/L, chloride 112 mEq/L and carbon dioxide 25mEq/L. Mr. Escobar glucose is 185. His BUN is 42 mg/dL and creatinine is 1.6 mg/dL. LFT’s reveal total protein 5.7 g/dL, albumin 3.1 g/dL, total bilirubin 1.8 mg/dL, AST 17u/L, ALT 14u/L, LDH of 266 u/L. His prothrombin time is 13.1 seconds. His ammonia level is 124 umol/L. Urinalysis results are within normal limits. The HCP schedules Mr. Escobar for a gastroscopy to rule out GI bleeding. Intravenous fluids of D5 ½ NS are started at 100 ml/hr. Mediations prescribed include lactulose, neomycin sulfate. The HCP admitting Mr. Escobar also prescribes daily weights, strict intake and output documentation, monitoring for stools for occult blood, neurological assessment every four hours and a low protein, low sodium diet.

Questions:

1) Mr. Escobar has cirrhosis. Briefly discuss the pathophysiology of this disease.

2) Briefly explain how hepatic encephalopathy is related to cirrhosis.

3) Upon initial examination, the HCP did not note any asterixis. What is asterixis and how would one assess for it?

4) Identify the characteristic clinical manifestations of hepatic encephalopathy consistent with Mr. Escobar’s presentation.

5) Identify three priority nursing diagnoses for Mr. Escobar.

6) Identify which of the client’s admitting laboratory results are abnormal and provide a rationale for why each is above or below the normal range.

7) Define ascites. Explain what causes ascites and how the nurse will assess for this condition.

8) Mr. Escobar has been prescribed 30 mL of lactulose every 6 hours and neomycin sulfate 500 mg four times a day. Explain why each of these medications has been included in the client’s medical management plan and what assessment prior and post administration is needed.

9) Provide an explanation for the low protein, low sodium diet the HCP prescribed for Mr. Escobar.

10) A gastroscopy reveals that Mr. Escobar has esophageal varices, which are treated with banding. Discuss what esophageal varices are and the banding procedure used to treat them.

Taken from: Ankner, G. Delmar’s Case Study Series: Medical Surgical Nursing; 2008, Thomson Delmar.

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