Case Study 10: Hypovolemic Shock; The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at 0430. (answered)

June 11,

2021

Case Study 10: Hypovolemic Shock

Scenario

The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at

0430. She told the ED triage nurse that he had diarrhea for the past 2 days and that

last night he had a lot of “dark red” diarrhea. When he became very dizzy, disoriented,

and weak this morning, she decided to bring him to the hospital. C.W.’s vital signs (VS)

in the ED were 70/− (systolic blood pressure [SBP] 70, diastolic blood pressure [DBP]

inaudible), pulse rate 110, respiratory rate 22, oral temperature 99.1 ° F (37.3 ° C). A

16-gauge IV catheter was inserted and a lactated Ringer’s infusion was started. The

triage nurse learned C.W. has had idiopathic dilated cardiomyopathy for several years.

The onset was insidious, but the cardiomyopathy is now severe. His last cardiac

catheterization showed an ejection fraction of 13%. He has frequent problems with

heart failure (HF) because of the cardiomyopathy. Two years ago, he had a cardiac

arrest that was attributed to hypokalemia. He has a long history of hypertension and

arthritis. He had atrial fibrillation in the past, but it has been under control recently.

Fifteen years ago he had a peptic ulcer.

Endoscopy showed a 25- × 15-mm duodenal ulcer with adherent clot. The ulcer was

cauterized, and

C.W. was admitted to the medical intensive care unit (MICU) for treatment of his

volume deficit. You are his admitting nurse. As you are making him comfortable, Mrs.

W. gives you a paper sack filled with the bottles of medications he has been taking:

enalapril (Vasotec) 5 mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin (Lanoxin)

0.125 mg/day PO, potassium chloride 20 mEq PO bid, and diclofenac (Voltaren) 50 mg

PO tid. As you connect him to the cardiac monitor, you note he is in sinus tachycardia.

Doing a quick assessment, you find a pale man who is sleepy but arousable and

slightly disoriented. He states he is still dizzy and feels weak and anxious overall. His

BP is 98/52, pulse is 118, and respiratory rate 26. You hear S3 and S4 heart sounds and

a grade II/VI systolic murmur. Peripheral pulses are all 2+, and trace pedal edema is

present. Capillary refill is slightly prolonged. Lungs are clear. Bowel sounds are present,

mid-epigastric tenderness is noted, and the liver margin is 4 cm below the costal

margin. Has not yet voided since admission. Rates his pain level as “2.” A Swan-Ganz

pulmonary artery catheter and a peripheral arterial line are inserted.

1. What may have precipitated C.W.’s gastrointestinal (GI) bleeding?

25× 15-mm duodenal ulcer with adherent clot caused the gastrointestinal bleeding

that was present in dark red diarrhea.

2. From his history and assessment, identify 5 signs and symptoms of GI bleeding and

loss of blood volume, and explain the pathophysiology for each one listed.

1. “dark red diarrhea”- duodenal ulcer caused gastrointestinal bleeding

resulting in dark red diarrhea

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