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Cirrhosis Case Study (45 min)

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Mr. Garcia is a 43 year old male who presented to the ED complaining of nausea and vomiting x 3 days. The nurse notes a large, distended abdomen and yellowing of the patient’s skin and eyes.  The patient reports a history of alcoholic cirrhosis.

Critical Thinking Check
Bloom's Taxonomy: Application

What initial nursing assessments should be performed?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What diagnostic testing do you anticipate for Mr. Garcia?

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Mr. Garcia’s vitals are stable, BP 100/58, bowel sounds are active but distant, and the nurse notes a positive fluid wave test on his abdomen.  The patient denies itching, but is constantly scratching at his chest. He is oriented to person only and his brother at the bedside reports he hasn’t been himself today.  He keeps trying to get out of bed

Critical Thinking Check
Bloom's Taxonomy: Analysis

Which finding is most concerning and needs to be reported to the provider? Why?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What further diagnostic and lab tests should be ordered to determine Mr. Garcia’s priority problems?

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The provider places orders for the following:

Keep SpO2 > 92%

Keep HOB > 30 degrees

Insert 2 large bore PIV’s

500 mL NS IV bolus STAT

100 mL/hr NS IV continuous infusion

Hydrocodone/Acetaminophen 5-500 mg 1-2 tabs q4h PRN moderate to severe pain

Diphenhydramine 25 mg PO q8h PRN itching

Ondansetron 4 mg IV q6h PRN nausea

Lactulose 20 mg PO q6h

Mr. Garcia’s LFT’s and Ammonia level are elevated. He is extremely confused and agitated and appears somewhat short of breath. The patient’s current vital signs are as follows:

HR 82 RR 22

BP 94/56 SpO2 93%

Temp 98.9°F

Critical Thinking Check
Bloom's Taxonomy: Analysis

Which order should be implemented first? Why?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

Which order should be questioned? Why?

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The order is changed to Fentanyl 25 mcg IV q4h PRN moderate to severe pain. The provider notes somewhat shallow breathing and severe ascites and requests for you to set up for paracentesis. At this time, you express your concern that the patient is extremely confused and agitated and trying to get out of bed. You do not feel that he will be still enough for the procedure.  The provider agrees and plans to postpone the paracentesis for now, but orders for you to report any signs of respiratory depression or hypoxia.

Critical Thinking Check
Bloom's Taxonomy: Analysis

Why is Mr. Garcia so confused and agitated?

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Critical Thinking Check
Bloom's Taxonomy: Analysis

What is the rationale for performing a paracentesis for Mr. Garcia?

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After 6 doses of lactulose, Mr. Garcia is much more calm and cooperative. He is oriented times 2-3 most times. The provider performs the paracentesis and is able to remove 1.5 L of fluid. The patient’s shortness of breath is relieved and his breathing is less shallow.  Ultrasound of the liver showed severe scarring on the liver. Mr. Garcia’s condition continues to improve and the plan is to discharge him home tomorrow.

Critical Thinking Check
Bloom's Taxonomy: Application

What discharge teaching should be included for Mr. Garcia, including nutrition?

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