bowtie

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Gastrointestinal Disorders

E. P. Wieber | NDSU | 12/24

Instructions:

Review the entire case study (parts 1-3), then complete a bowtie concept map for Mr. Thompson based on your assigned priority

problem and the case presented.

Part 1: Review Case 1. Review the entire case study.

2. Choose two priority concepts from the table below; ONE from each grouping. a. Concepts can relate to any part of the case or primary medical diagnosis (PMD) - part 1, 2, or 3. Focus on one

part when completing the concept map.

Concept Options:

Options for Patient Problems (Choose one per bowtie)

Choose ONE from this group. Choose ONE from this group.

Teaching/Learning

Psychosocial

Fluid/Electrolyte balance

Elimination (bowel or bladder)

Nutrition

Neurologic Function

Infection

Part 2: Complete Two (2) Bowtie Concept Maps 1. Patient Problem (Blue box):

a. Add priority problems chosen above to the blue box at the center of

each concept map

b. Add “related factors” (r/t) – Physiologic factors related to the patient problem

c. Add “secondary factors” (s/t) - Medical diagnosis (the PMD noted in ONE part

of the case study) i. Focus on one pathophysiologic process/PMD in each bowtie; don’t add in multiple secondary factors.

2. Cues (Yellow Boxes): a. Add 6 cues (3-4 signs/symptoms/lab findings and 2-3 risk factors) relevant to the “patient problem” and/or

related/secondary factors (blue box).

i. Cues should come directly from ONE PART of the case study, but may be presumed based on knowledge of

pathophysiology and nursing care related to PMD. ii. Risk factors (i.e. patient history) may be taken from any previous part of the case study.

3. Actions (Green boxes): a. Add 5 different nursing actions/interventions related to the “patient problem” (blue box).

i. Include rationale for each action/intervention.

ii. Actions/interventions should be presumed, based on knowledge of pathophysiology and nursing care related to

the PMD.

iii. Provider orders may be used to guide actions, but actions should be within nursing scope of practice.

4. Evaluate Outcomes (Red Box): a. Add relevant cues (signs/symptoms, lab findings, etc.) that would indicate to the nurse that the patient problem

(blue box) is resolving or improving: i. Signs/symptoms/lab values indicative of improved status.

ii. Signs/symptoms/lab values that indicate a complication of the PMD has not occurred.

Oxygenation

r/t bronchoconstriction and

increased mucous production

s/t COPD exacerbation

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Gastrointestinal Disorders

E. P. Wieber | NDSU | 12/24

Introduction: Each part of this case study follows Ryan Howard, a male patient with a history of intravenous drug use and alcoholism.

Part 1: Hepatitis Diagnosis

Provider Note – Interval Update

Chief Complaint: "I've been feeling really tired and have some yellowing of my skin. Also, my stomach hurts a lot."

History of Present Illness:

Ryan Howard, a 34-year-old male with a history of IV drug use and binge drinking, presents to the was admitted to a medical-surgical unit 3 days ago with complaints of fatigue, yellowing of the skin and eyes, abdominal pain in the upper right quadrant, and dark urine. He reports that the symptoms have progressively worsened over the last few weeks. He also notes some nausea and loss of appetite.

Both an HCV antibody test and HCV RNA PCR have come back as positive and indicative of HCV infection. Ryan is unsure of when he might have contracted hepatitis C but admits to sharing needles and participating in high-risk sexual behavior in the past. Ryan has a history of alcohol use disorder, and although he’s been sober for about 6 months, he relapsed a few weeks ago. He denies any prior diagnoses of liver disease.

Key Labs: Liver Function Tests: • AST: 245 U/L (normal: 10-40 U/L)

• ALT: 305 U/L (normal: 7-56 U/L)

• Alkaline phosphatase (ALP): 120 U/L (44 - 147 U/L)

• Bilirubin (total): 5.6 mg/dL (normal: 0.3-1.2 mg/dL)

• Albumin: 2.8 g/dL (normal: 3.5-5.0 g/dL)

Hepatitis C Screening: • Hepatitis C antibodies: Positive

• HCV RNA PCR: 1,200,000 IU/mL (indicating active infection)

Complete Blood Count (CBC): • WBC: 8000/mm³ (normal: 4,500-11,000/mm³)

• Hemoglobin: 12.5 g/dL (normal: 13-18 g/dL)

• Platelets: 98,000/mm³ (normal: 150,000- 450,000/mm³)

Physical Exam:

General: Mildly jaundiced skin and sclerae Abdomen: Tenderness in the right upper quadrant, hepatomegaly, no signs of peritoneal irritation Extremities: No edema, but slight bruising noted on forearms

Vital Signs: Temperature: 99.2°F (oral) Heart Rate: 88 bpm Respiratory Rate: 16 breaths/min

Blood Pressure: 130/84 mmHg Oxygen Saturation: 96% on room air Weight: 74 kg

Orders

1. Diagnostics: a. HCV Genotype b. Liver biopsy c. Liver ultrasound d. Liver function tests (daily)

2. Medications:

a. Hepatitis C treatment: i. Sofosbuvir 400 mg PO daily (direct-acting antiviral) ii. Ledipasvir 90 mg PO daily (combined with Sofosbuvir)

b. Vitamin K 10 mg IV once

3. Consults: Gastroenterology & infectious disease (for HCV management). Case management. Psychiatry.

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Gastrointestinal Disorders

E. P. Wieber | NDSU | 12/24

Part 2: Acute Pancreatitis & Alcohol Use

Admission Note

Chief Complaint: "Severe upper abdominal pain that radiates to my back. I’ve been drinking a lot again."

History of Present Illness:

Ryan Howard, a 35-year-old male, presents to the emergency department with severe abdominal pain that radiates to his back, nausea, and vomiting. He reports drinking heavily over the past weekend and has experienced similar episodes of abdominal discomfort in the past.

Ryan states that the pain started approximately 24 hours ago after a binge drinking session. The pain has worsened and is constant, rated 8/10, with nausea and vomiting. He denies recent changes in diet or medications but admits to consuming alcohol excessively over the past few years. He has a history of binge drinking, particularly on weekends, and has been hospitalized twice in the past for alcohol-related issues. His most recent hospitalization was for a head injury due to a fall while intoxicated.

Key Labs: Pancreatic Enzymes: • Amylase: 1,210 U/L (normal: 30-110 U/L)

• Lipase: 2,500 U/L (normal: 20-180 U/L)

Liver Function Tests: • AST: 135 U/L

• ALT: 168 U/L

• Bilirubin: 3.8 mg/dL

• Albumin: 3.0 g/dL

CBC: • WBC: 12,000/mm³ (normal: 4,500-11,000/mm³)

• Hemoglobin: 13.2 g/dL

• Platelets: 130,000/mm³

Blood alcohol level: 0.18% (elevated)

Physical Exam:

General: Diaphoretic, lying in a fetal position due to pain Abdomen: Tender to palpation in the epigastric region, guarding present, no rebound tenderness Extremities: No edema or cyanosis

Vital Signs: Temperature: 100.1°F (oral) Heart Rate: 104 bpm (bradycardic) Respiratory Rate: 22 breaths/min

Blood Pressure: 115/72 mmHg Oxygen Saturation: 98% on room air Weight: 78 kg (172 lbs)

Orders

1. Medications: a. Normal saline 1 L bolus, then 100 mL/hr for maintenance b. Morphine sulfate 4 mg IV every 4 hours as needed for pain c. Ondansetron 4 mg IV every 8 hours as needed for nausea d. Thiamine 100 mg IV/IM daily e. Folic acid 1 mg PO daily

2. Labs/Diagnostics:

a. Monitor serum electrolytes: Potassium, magnesium, calcium, sodium (daily) b. Liver function tests and pancreatic enzyme levels (every 8 hours) c. Abdominal ultrasound to assess for complications like pseudocysts or biliary stones.

3. Alcohol withdrawal protocol:

a. Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar): Hourly until CIWA less than 20. Continue until 3 consecutive scores less than 8.

i. CIWA 8-15: Chlordiazepoxide 25–50 mg PO every 4–6 hours ii. CIWA > 15: Chlordiazepoxide 50–100 mg PO every 2–4 hours until symptoms improve

b. VS: Hourly x4, then q 4 hrs if stable

4. Consults: Gastroenterology. Case Management. Psychiatry. Dietitian.

NURS 307: Concepts of Adult Health Nursing

Unfolding Case Study: Gastrointestinal Disorders

E. P. Wieber | NDSU | 12/24

Part 3: Cirrhosis Complications

Admission Note

Chief Complaint: Ryan Howard, a 42-year-old male, presents with confusion, lethargy, and difficulty concentrating over the past few days. His family reports he has been increasingly irritable and has had difficulty remembering recent events.

History of Present Illness:

Ryan has a long history of alcohol use disorder and Hepatitis C, which eventually led to cirrhosis. He underwent a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure 6 months ago due to worsening portal hypertension and variceal bleeding. His family brought him into the clinic today due to increased confusion and disorientation with episodes of agitation.

Though Ryan has been sober for the past 5 years since attending Alcoholic Anonymous (AA) meetings, his family reports that he inconsistently takes his medications.

Key Labs: Liver Function Tests: • AST: 199 U/L

• ALT: 122 U/L

• Bilirubin (total): 3.5 mg/dL

• Albumin: 2.8 g/dL

Coagulation Studies: • Prothrombin Time (PT): 18 seconds (prolonged)

Complete Blood Count (CBC): • WBC: 7000/mm³

• Hemoglobin: 10.0 g/dL

• Platelets: 78,000/mm³

Physical Exam:

General: Confused, disoriented, asterixis (flapping tremor of hands) Abdomen: Distended, with a palpable liver edge, ascites present, no tenderness Extremities: 2+ edema in bilateral lower extremities

Vital Signs: Temperature: 97.8°F (oral) Heart Rate: 99 bpm Respiratory Rate: 20 breaths/min

Blood Pressure: 98/62 mmHg Oxygen Saturation: 98% on room air Weight: 85 kg

Orders

1. Medications: a. 1 L normal saline over 4 hours b. Lactulose 30 g PO every 8 hours c. Rifaximin 550 mg PO every 12 hours d. IV albumin 25% 100 mL once, followed by 50 mL daily

2. Labs/Diagnostics:

a. Monitor serum ammonia levels (every 12 hours)

3. Procedures: Abdominal paracentesis to assess for ascitic fluid infection or bleeding

4. Consults: Liver Transplant team for consideration of liver transplantation if indicated. Case management.