Maryam Ahmarinejad April 2020

4NUR2 CA 2 –
MS
CASE 3
Care of Client with GI, PUD, Cancer, Liver Failure

PART I
Mr. MJ , 56 years old was brought to the Emergency Room because of weakness, loss
of appetite and decreasing level of consciousness. During the interview by the nurse, the wife
revealed that he was a smoker, alcoholic drinker , since he was 17 and fond of eating fatty, less
fiber food. He leads a stressful life because of his work in a multinational company. He had
undergone many diagnostic exams and procedures like colonoscopy with biopsy, esophago
gastrocopy, sclerotherapy, paracentesis for ascites , chemotherapy and radiotherapy. He had
been fatigued and anemic for the past year and had taken vitamin and iron supplements. The
wife narrated that he had undergone major abdominal surgery with colostomy, after which he
was placed on PCA morphine, post op monitors and were taught to take care of his colostomy
site.

Past medical history of MJ also revealed the following:

2017 – Hepatitis A
2018 – PUD ,managed by medications. BPH with dysuria. DRE revealed soft enlarged
prostate
2019 – Rectosigmoid cancer stage 3, underwent Abdominoperineal resection (APR) with
colostomy, underwent radiotherapy and chemotherapy
January 2020- Cirrhosis with portal hypertension.

A. What are the other possible risk factors that can contribute to his present condition?
B. When you assess Mr MJ having undergone APR, what kind of colostomy do you
expect?
C. What would you expect to drain from the colostomy? What are the different kinds of
colostomies?
D. How will he monitor his colostomy? Discuss colostomy care and colostomy irrigation.
E. Having undergone this surgery, discuss your nursing care for MJ after this abdominal
surgery.
F. Having undergone chemo/radiotherapy, the nurse knows that side effects can occur
with these therapy since these affect both abnormal and normal cells. What are these
side effects that the nurse should focus on her health teachings whenever the nurse is
taking care of patient with cancer ?
G. What possible diagnostic exams and management were given to him when he was
suffering PUD?
 PART II
During your interview with the wife of MJ, he is also taking Aldactone, Lactulose. At
times he has been disoriented and had memory problems. You noticed ascites, some edema on
his lower extremities. Additional tests were done like serum enzyme tests, serum Bilirubin.,
total protein A/G ratio, PT.

H. What can cause MJ’s liver cirrhosis?

I. Cite the complications of Liver cirrhosis that already exist with his presenting signs
and symptoms?
J. Give the rationale of the above management and diagnostic assessments for his
cirrhosis..

During the 4th week of MJ’s confinement, the nurse observed the patient to be restless
and suddenly he vomited fresh blood.

K. What would be your immediate management at this time?

L. What could have caused the vomiting of fresh blood? What are your other parameters
of assessment with these advancing liver condition?

For the succeeding days, MJ became comatose, ascites and edema worsening and was
hooked to dopamine for his dropping blood pressure and was confined in ICU with decreasing
GCS everyday.. The physician explained the irreversible effects of his advanced liver disease
and later on the family and relatives signed for DNR .

M. What ethical concepts are related to issues at end of life happening to MJ.
N. With what members of the interdisciplinary team does the nurse collaborate when
caring for the dying patient and providing support for the family.?
O. Give signs and symptoms related to the end of life.
P. Discuss the ethical and legal obligations of the nurse with regard to end of life care.
Maryam Ahmarinejad April 2020
4NUR2 CA 2 –
MS
CASE 4
Neuro, Endocrine, Urinary

PART I
S.B. is a 62-year-old married woman with a past medical history of seizure disorder
controlled with Tegretol (last seizure was 5 years ago), underwent Total Thyroidectomy for
Toxic Nodular Goiter three years ago and presently receiving Synthyroid. She has a history of
HTN for the past 10 years and is receiving Enalapril for it. She has been diagnosed with DM
Type 2 since age 40 years old and being managed with Oral antidiabetic agents. She is obese
and the family admits to her being non-compliant to her diabetic control regimen. She sought
consult at the doctor’s clinic last September 2016 for her non-healing 2-cm wound with sero-
purulent drainage at her right foot. She reports that her latest blood tests two months ago reveal
an elevated glycosylated hemoglobin, BUN & creatinine levels. The daughter states that the
patient has been advised to undergo further tests for her kidneys to determine the extent of her
Diabetic Nephropathy. After the consult visit, the doctor advised admission for treatment of the
foot ulcer and further evaluation of her diabetic condition.

1. What relevant assessment data will you need related each of your patient’s medical
condition? Give the rationale for each assessment data.
2. Identify predisposing factors to each of her medical problems that you need to check
out with S.B.
3. Illustrate using a flow chart the pathophysiology of each of the medical problems of
S.B. and their possible complications .
4. Using another flow chart, indicate the pathophysiologic relationship of the medical
problems of S.B. How do these conditions relate to each other, if they do?
5. Prior to the thyroid surgery of your patient,
5.1. What manifestations would you have seen for a toxic nodular goiter
5.2. What medications were ordered to SB to help manage her condition? Give
their rationale.
6. Following total thyroidectomy,
6.1. What complications can possibly occur and why? Give their nursing and
collaborative preventive interventions.
6.2. Why is the patient being given Synthyroid? What specifc health teachings
need to be given regarding this drug.
7. What criteria is used for the establishment of a definite diagnosis of DM?
8. What health teachings can be given to the family members of S.B. to keep them from
developing DM?
9. What 2 acute complications of DM2 should be watched out for in S.B.? Give their
manifestations, preventive and therapeutic interventions.
10. Can the patient develop a DKA? Support your answer.
11. How do you recognize the difference between a Somogyi effect & the Dawn
phenomenon?
12. Discuss briefly the management strategies for DM and their rationale.
13. Make a nutritional health teaching plan for S.B.
14. What are the different types of oral antihyperglycemic agents that can be given? Make
a table to include: Type of drug; examples; therapeutic action; onset, peak & duration
of action; side effects

S.B’s non-healing wound is debrided and treated further with oral antibiotics.

15. The patient asks, “When will this wound heal? Why is it taking so long? What other
bad thing can I have because of this?” What would be your response to these
queries?
16. What relevant teaching can you provide at this time?
17. Should the patient’s foot condition further deteriorate, when would amputation be
indicated? What major concerns related to care would you have?

The doctor evaluates for other possible effects of her poorly managed DM.

18. What tests would you expect to be ordered? What would their findings be to indicate
the presence of complications?

The lab test results return confirming previous results with elevated BUN & creatinine.
S.B. appears worried & states, “My mother had DM and had dialysis for several years before
she died because of chronic Renal failure. I don’t want to have the same thing happen to me.”

19. How will you address this concern?

20. When does the nephrologist generally decide to perform dialysis on a patient? What is
the purpose of this procedure?

S.B. is eventually sent home after a week’s stay in the hospital with take home regimen
for her medical problems.
 PART II
Last December 26, 2016 during an outing this Christmas season in Tagaytay Highlands
with her family, she slipped while walking around the zoo park and landed on the back of her
head. She experienced loss of consciousness at the scene. She was taken to a nearby medical
center where a CT scan revealed a Left subdural hematoma. The family wanting more
experienced management transferred the patient to USTH 2 days later. At USTH, she was given
the diagnosis of Acute subdural hematoma.

1. What assessment parameters are important upon admission? Why is each of them
important?
2. What diagnostics do you expect to be ordered? Give the rationale for each and expected
findings.
3. What major concerns/problems exist upon admission related to her diagnosis?
a. What immediate interventions do you expect to be done for each major concern.
Give the rationale for these interventions.
4. Using a flow chart, illustrate the pathophysiologic responses resulting from acute
subdural hematoma.
5. Can S.B’s other medical conditions have any effect or influence on her medical
diagnosis? Support your answer and briefly discuss how.
6. What parameters would you use to monitor for any neurological change? Give the
pathophysiologic basis of significant findings that could be encountered.
7. What is the best position for the client and why?

S.B. is also placed on seizure precautions.

8. Why is there a need for seizure precautions? Why is it especially important to make
sure that her Tegretol is given and that she has a therapeutic serum level?

A repeat CT scan is done and the doctor writes the order for craniotomy in the morning.

9. What is the primary indication for a craniotomy to be done on S.B.?

10. You are the primary nurse of S.B. What would be your priority concerns in your pre-
operative care?

S.B. undergoes craniotomy.

11. What 4 priority objectives do you have for your post-op care for her. For each
objective, give the relevant nursing and collaborative interventions and their rationale.
12. If S.B’s LOC started to decrease, what information would you give the neurosurgeon
when you call?
13. How would you provide support to S.B’s family?
14. What positive parameters will you observe to say that the patient’s condition is
improving?

S.B’s condition improves and the doctor tells you to prepare the patient for a possible discharge
in 2 days.

15. Outline your comprehensive discharge teaching plan for your patient.