Students will be working through complex case studies in class. In preparation for these exercises, students must complete the questions and charting noted in the attached instructions, using the asso
CJM-Table
| Recognize Cues What cues need follow up? What findings are of most concern? | Analyze Cues Based on your identified cues, what possible disease processes exist? Group your findings that support these disease processes | Prioritize Hypotheses What are the priority concerns or highest risk/complication? Support with your evidence—why? | Generate Solutions What potential interventions are needed for this patient? What are the contradictions if any? | Take Action What interventions need to be performed immediately? Think about 2-3 to do right away. | Evaluate Outcomes What findings would indicate an improvement or decline? How will you measure this? |
| -78-year-old female with a history of osteoarthritis, was found on the floor by her daughter covered in bright red vomit. -Was recently admitted with abdominal pain and tarry stools. At that time, endoscopy confirmed a duodenal ulcer. -Religion: Jehovah Witness Abnormal assessment: -A&Ox3, appears drowsy and generalized weakness -S1S2, pulses equal +1, cap refill 4 seconds, patient pale, skin dry -mild increase work of breathing -hyperactive bowel sounds, abdomen tender in all 4 | -Low blood pressure, 80/48 -elevated heart rate, 118 -Elevated respiration rate, 28 -low O2 sat, 90% while on 2L NC -low temp, 96.9 F Endoscopy confirmed duodenal ulcer, the use of high dose Ibuprofen and the symptoms of vomiting bright red and having black tarry stools imply that the bleeding is related to the ulcer. Mild increase work of breathing, generalized weakness, pale, rapid breathing, low temp, low blood pressure and elevated pulse could be signs of hypovolemic shock due to GI bleed. | The patient is actively bleeding (due to bright red emesis) and is at risk for hemorrhage and hypovolemic shock, potentially fatal. Hgb: 5.0 Hct: 30 Bright red emesis Black tarry stools Symptoms: Mild increase work of breathing, generalized weakness, pale, rapid breathing, low temp, low blood pressure and elevated pulse | -IVF to maintain hemodynamic stability and compensate for fluid loss owing to hemorrhage. -Blood transfusion to replace the blood lost, restore the blood’s oxygen-carrying capacity. However, since the patient is Jehovah Witness, it may be challenging to carry out this intervention. Alternatives may need to be explored if patient refuses blood transfusion such as erythropoiesis stimulating agents, iron treatments, or blood clotting factor agents. -Acid suppression and ulcer healing medications including PPI and H2 blockers. -Keep patient NPO to help with healing and | -Intravenous fluid resuscitation need to be initiated immediately for treatment of hypovolemia, maintenance of blood pressure and improvement of tissue perfusion. -Oxygen and place in semi fowlers position to improve tissue perfusion -Discuss alternative options for blood replacement if patient refuses blood transfusion due to religion -Start PPI to promoting healing of ulcers and erosions as well as stabilizing thrombi and decreasing bleeding. | Improving: -VS WNL, BP baseline (120/80), HR 60-100, Temp 97-99 F, O2 sat >94% - bright red emesis resolved -Black tarry stool has ceased -Normoactive bowel sounds, non-distended and non-tender -Skin dry and warm -Capillary refill <3 seconds -regular respirations, between 12-18 -Hgb improved and between 13.5-16.5 -Hct improved and between 41-50 Declining: -worsening H/H -bright red emesis and black tarry stools intensify -gray or bluish tinge to lips or fingernails |
| quadrants, black tarry bowel movement VS: -Low blood pressure, 80/48 -elevated heart rate, 118 -Elevated respiration rate, 28 -low O2 sat, 90% while on 2L NC -low temp, 96.9 F Risk Factors: -Taking Ibuprofen 600mg Q8hrs -Taking aspirin 325mg daily Labs: -Hgb: 5.0 -Hct: 30 -Osmolality: 320 -Mg:3 |
| avoid further GI system aggravation. | -Vital signs to monitor for deterioration or improvement. | -dysrhythmia -dizziness -Hypovolemic shock -Altered mental status -Unconsciousness -SOB, hypoxia -cardiac arrest, death |
