ACUTE AND LONG TERM HEALTH CHALLENGES
Jean Jones: Age 83, works with her husband on their farm
Situation:
• You visit White Horse Farm to give William Jones his fortnightly depot injection of Zuclopenthixol Decanoate 200mg
• While you are there his mother collapses and starts vomiting approximately 500 mls of coffee ground liquid.
• You call an ambulance and she is taken in to the ED.
• She was admitted to the ward with a provisional diagnosis of bleeding peptic ulcer.
• She is to remain nil by mouth, continue with IV fluids and newly prescribed proton pump
inhibitor (IV), please monitor 4 hourly and review.
Background:
• Jean is still very active and works on the farm 3 days a week.
• Has had Type II diabetes for 40 years
• Medication:
o Metformin 500 mgs twice a day (35 years)
o Glipizide 2.5 mg orally once a day 30 mins before breakfast (20 years) o Aspirin 75 mg/day (15 years)
o Simvastatin 10 mg at night (15 years)
Assessment on admission to the ward: Airway:
• Airway is clear but Jean still feels nauseated and would like a vomit bowl near her.
Breathing:
• R 25/ minute
• Shallow respirations, regular
• SaO2: 94%
• 2l nasal O2 prescribed to maintain SpO2 above 94%
Circulation:
• Skin Pale and cool
• P 90/minute
• Sinus rhythm
• BP 110/70 mmHg
• Na: 136 mmol/L
• K: 4.0 mmol/L
• Creatinine: 115 micro mol/L
• WCC: 6.2 109/l
• Hb: 9.4 g/dl
• CXR: a clear lung field
• Nauseated but no further vomiting
• Estimated fluid loss from vomiting was 500 mls
• Has not passed urine since admission
• Jean was commenced on an infusion of 0.9% saline at a rate of 125 mls/hr
• A proton pump inhibitor was prescribed, and Jean remained nothing by mouth.
• Weight 60 Kg
Disability:
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ACUTE AND LONG TERM HEALTH CHALLENGES
• Patient very anxious and distressed after vomiting.
• Wants to go home
• Pain assessment: 2/5, dull abdominal pain. Her pain is better than it has been all week – she
admitted.
• Blood glucose: 16.7 mmol/l, Jean admits that hasn’t felt like eating very much and so hasn’t
taken her “diabetic” drugs
Exposure:
• There is no sign of injury following her collapse.
• T: 36.0°C
• Pale mucus membranes
Initial management:
The primary cause of the fluid loss was judged to be a bleeding peptic ulcer. An endoscopy was planned for the following morning.
Blood was taken for:
• Full blood count
• Clotting
• Blood group and cross match
• Urea and electrolytes
• Liver function tests
Jean gradually began to feel better after being visited by her Husband and Son and settled to sleep at 23.00 hrs.
However at 00.30 Hrs Jean awoke feeling nauseated.
• Within minutes she had vomited 500 mls of coffee ground liquid that tested positive to blood
• She felt she wanted her bowels open and requested a bedpan and passed 400 mls of liquid
melaena stool (tested positive to blood).
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Following an ABCDE assessment:
ACUTE AND LONG TERM HEALTH CHALLENGES
Airway:
• Clear
Breathing:
• R: 28/min
• Breathless
• SaO2 90%
• 2L O2 given by nasal specs as prescribed
• Skin pale, peripherally cyanosed and cold to touch
• On palpation the chest feels clear
• The lung fields on auscultation are audible in the 4 quadrants.
• ABGs
o pH:7.40
o PaO2:9.3kPa
o PaCO2:4.2kPa
o HCO3:22.0mmol/l o Lactate:1.7mmol/l
Circulation:
• P: 110/min and regular/ pulse thready
• BP 90/58 mmHg
• Skin cool and pale
• Urine output: 150 mls since admission 5.5 hours ago
• Haematology results
o Na:135mmol/l
o K:3.7mmol/l
o Creatinine:150μmol/L
o WCC:14.2109/l
o Hb:7.9g/dl
o Clotting screen is in the normal range
• IV fluids continue at 125 mls/hour
• Feeling cold and thirsty
• T: 37.5
Disability:
• ACVPU: Alert but agitated and appears frightened
• Glucose: 18.4 mmol/l Exposure:
• T37.5
• Pale peripheries
• Some abdominal distension but no guarding of the abdomen
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ACUTE AND LONG TERM HEALTH CHALLENGES
Essay Question:
Please use the resources in this module to analyse and interpret Jean’s story.
Part A) With reference to Jean Jones’ scenario critically discuss her long-term health challenges (40%)
Part B) Critically discuss the risk assessment and management of Jean Jones from 00.45 – 02.00 hours (60%)
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