11.16 Learning Activities

GI Case Study 1

Mrs. G.B. is a 38-year-old female who presents to the emergency department with complaints of severe abdominal pain. G.B reports that she has had similar pain intermittently over the past week; however, tonight her pain has become constant and unbearable. She reports that the pain usually starts on the upper right side of her abdomen and radiates to her back. The pain often occurs at night after eating dinner, particularly after eating fatty foods. She reports nausea but no vomiting and explains that she has taken ibuprofen and antacids but neither have helped her symptoms.

Physical Exam

Upon exam, G.B.’s vitals are found to be as follows:

HR: 106, RR: 16, BP: 148/95, Temp: 100.6 F, Pulse ox: 98%

G.B. appears uncomfortable and is sweating. G.B. reports it feels better for her to lie in bed and not move. When G.B. is assessed, the right side of her abdomen below her rib cage is palpated during inspiration. She reports increased pain to the point that she gently pushes the examiner’s hands away.

Abnormal Laboratory Values

• WBC – 15.4
• CRP – 18.3

Past Medical History

• Obesity, BMI of 31
• Mother of 2 children, ages 3 and 5 years
• Gestational diabetes with both pregnancies
• Hypertension, diagnosed 1 year ago, mild and not treated with medication at this time
• Cesarean section, age 35 and 33

Pertinent Family History

• Father alive and healthy age 71
• Mother with a history of obesity, hypertension, and gallstones, alive age 70
• Brother with a history of obesity, alive age 41
• Sister alive and healthy, age 36

Pertinent Social History

• Client works for a local hospital doing IT assistance, has worked there for 10 years
• Client’s hobbies include reading, knitting, and baking
• Client reports difficulty with attempts at weight loss, prefers to not go to the gym or be seen working out in public environment

After assessing the client, the health care provider states, “The client’s pain could be caused by cholecystitis.”

Answer the following questions:

1. Symptoms of gallbladder disease often resemble those of other GI diseases. Which group of symptoms suggests cholecystitis?

A) Pain in the right lower quadrant, leukocytosis, low-grade fever

B) Pain in the right upper quadrant, low-grade fever, bloody stools

C) Pain in the right upper quadrant that radiates to the right shoulder or back, positive Murphy’s sign, bloody stools

D) Pain in the right upper quadrant that radiates to the right shoulder or back, positive Murphy’s sign, low-grade fever

2. What diagnostic tests can be used to confirm a diagnosis of cholecystitis?
3. Why are G.B. symptoms triggered by eating and/or eating fatty foods?
4. Which best describes the role of the gallbladder?

A) Similar to the appendix, the gallbladder has little known physiologic function. Because of this, it can be removed without any consequence to the client.

B) The gallbladder synthesizes bile. It also stores and secretes bile, a yellow-green substance needed to digest lipids.

C) The gallbladder makes cholecystokinin (CCK). CCK stimulates the vagus nerve and facilitates movement of bile through the intestines.

D) The gallbladder stores, concentrates, and secretes bile.

5. G.B.’s family history reflects a maternal history of gallbladder disease. True or False: Family history is the ONLY risk factor for cholecystitis seen in G.B.’s case. If other risk factors are present, please list them.
6. What are some potential treatment options for G.B.?
7. The physician decides that the best course of action for G.B. is a laparoscopic cholecystectomy. What does this procedure entail? What kind of postoperative instructions will you give to G.B.?

GI Case Study 2

Samara Yang is a 33 year-old, second-generation Chinese American female who presents to the local hospital emergency department.  She is unmarried, and has no children.  She works as an account executive in a corporate accounting firm.  She states, “ I am sorry to bother you, but I have been so sick.  I had thought it must be the flu.  Everyone at work has it.  I am achy and tired.  I keep vomiting and have not been able to keep anything down for the past three days—not even ginger tea.  I am empty, and tonight, I vomited twice within three hours and it was red like blood.  I became frightened and came in.”

Vital signs:

• BP: 108/60
• HR: 88, regular
• R: 20
• Temp 100.5 F (38 C)

Skin is clammy and pale

Appears physically fatigued, but able to ambulate independently

Denies pain, however leaning forward slightly holding abdomen

Medications

• Ortho Tri-Cyclen once a day
• Advil (ibuprofen) 3-4 times a day for headaches and body ache.

Samara is admitted to the hospital for a probable upper GI bleed, and labwork and diagnostic testing has been ordered to further evaluate Samara’s condition.  Samara expresses concerns to the nurse regarding admission to the hospital. “ I hope I will not be here for very long.  I have been managing an important project for the past few months at my company.  My boss is understanding, but there is an important deadline coming up next week.  Being in the hospital for a long time could jeopardize the project and my future with the company.”

Lab result findings:

• WBC: 11,800 cells/mm3
• RBC: 3.31 million/uL
• Hgb: 11g/dL
• Hct: 34%
• Platelets: 150,000mm3
• K+: 3.6 mEq/L
• Na+: 138 mEq/L

Diagnostic Tests: 

• EKG: normal sinus rhythm
• KUB abdominal x-ray: nonspecific gas pattern with moderate stool through the colon.  No acute abnormality noted.
• EGD: normal duodenum with no vascular anomalies.  Gastric mucosa is inflamed.  Small erosive changes noted, and one ulceration clearly visible.

Additional inpatient physician orders:

• Normal saline 100ml/hr
• Pantoprazole continuous IV drip
• Prochlorperazine  5 mg IV push  q 3-4 hours prn for nausea and vomiting
• Strict I&O q 2 h
• Bedrest, up with assist
• VS q 2hrs
• Test every BM for occult blood
• Re-check CBC in six hours (@1400)

1. What are the signs and symptoms of peptic ulcer disease?
2. What risk factors does Samara present with?
3. What other MAJOR complications can occur with peptic ulcer disease?
4. What is the patient management if these major complications occur?
5. Should the nurse suggest to the healthcare provider that that these two home medications should be added to her admission orders? Why or why not?

Ortho Tri-cyclen Lo

NSAIDS

6. Which lab results are abnormal and what is the significance of the abnormal results?

7. What are the nursing responsibilities after Samara has the EGD?

8. After returning to the nursing unit from diagnostic testing, Samara asks to try some saltine crackers and ginger ale.  How should the nurse respond to Samara’s request?

9. Identify three nursing diagnoses appropriate on admission for Samara. Prioritize each nursing diagnosis and provide the rationales for each selected nursing diagnoses and its priority number.

10. Samara is diagnosed with a peptic ulcer. The plan of care is for Melia to be discharged tomorrow morning.  Discharge medications and instructions include the following:

• omeprazole 40mg one time per day every am for 4-6 weeks
• calcium carbonate 1-3 tablets following meals as needed
• general diet as tolerated—minimize caffeine consumption
• take acetaminophen as needed for headache—hold ibuprofen use for 4-6 weeks
• follow up with primary health care provider in 3 weeks

Develop a teaching plan for these medications and explain to Melia rationales for diet and health care follow-up.