NGN: Gastrointestinal EAQ Case Study
Guide.
Gastrointestinal - Patient 1
H&P
Emergency department (ED)
0800:
55-year-old client, who lives alone, admitted to ED with an acute abdomen. Client experiencing
acute abdominal pain, distended abdomen. Reports vomiting and abdominal pain for 3 days....
H&P
Emergency department (ED)
0800:
55-year-old client, who lives alone, admitted to ED with an acute abdomen. Client experiencing
acute abdominal pain, distended abdomen. Reports vomiting and abdominal pain for 3 days.
States, "I think I have the flu." Foul-smelling, black stools began yesterday.
0815:
States no routine medications, but takes ibuprofen for arthritis, especially since the weather has
been so bad this winter. Arthritic changes noted to bilatera - answer✔✔
The nurse reviews the electronic health record and reevaluates client.
Complete the diagram by dragging from the choices area to specify what one potential condition
the client is most likely experiencing, two actions the nurse should take to address that condition,
and two parameters the nurse should monitor to assess the client's progress.
POTENTIAL CONDITIONS
Risk for aspiration
Fluid and electrolyte imbalance
Obstructed nasogastric (NG) tube
Upper gastrointestinal hemorrhage
ACTIONS TO T - answer✔✔POTENTIAL CONDITIONS:
Upper gastrointestinal hemorrhage
ACTIONS TO TAKE:
Open intravenous (IV) fluids wide open; send for typed and cross-matched blood
Initiate a rapid response per protocol
PARAMETERS TO MONITOR:
Vital signs every 15 minutes; hourly intake and output (I&O)
NG secretion's color and volume secondary to gastric lavage
Rationale:
The client was stable until 1045 when client vomited 150 mL of coffee ground-like fluid around
NG tube, became pale, cold, clammy, and vital signs deteriorated. Clinical cues indicate upper
gastrointestinal hemorrhage leading to hypovolemic shock. The risk for aspiration, fluid and
electrolyte imbalance, and obstructed NG tube are actual or potential conditions; but the
emergent condition supported by the client cues is hemorrhage leading to hemodynamic
instability. The priority action for the nurse to take is to administer the IV fluids "wide open" (as
rapidly as possible), request the typed and cross-matched blood, and activate the
Gastrointestinal - Patient 2
H&P
0200: An unidentified male received in the emergency department (ED) after local police found
client lying in an alley, unresponsive, and smelling of alcohol. Police report client is a member of
the homeless community downtown and responds to the name of "Joe." Approximate age is 65
years. Client difficult to arouse. Examination and radiographs negative for trauma/injury. Rule
out hepatic encephalopathy secondary to chronic liver disease.
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