Mr. Garcia is a 43-year-old male who presented to the ED complaining of nausea and vomiting x 3 days. The nurse notes a large, distended abdomen and yellowing of the patient’s skin and eyes. The patient reports a history of alcoholic cirrhosis.
Critical Thinking Check
Bloom's Taxonomy: Application
What initial nursing assessments should be performed?
Mr. Garcia’s vitals are stable, BP 100/58, bowel sounds are active but distant, and the nurse notes a positive fluid wave test on his abdomen. The patient denies itching but is constantly scratching at his chest. He is oriented to person only and his brother at the bedside reports he hasn’t been himself today. He keeps trying to get out of bed
Critical Thinking Check
Bloom's Taxonomy: Analysis
Which finding is most concerning and needs to be reported to the provider? Why?
Abdominal X-ray and/or Abdominal ultrasound to visualize liver and whether the distended abdomen is related to ascites or other sources
Ammonia level to determine if hepatic encephalopathy is the source of Mr. Garcia’s altered mental status.
The provider places orders for the following:
Keep SpO2 > 92%
Keep HOB > 30 degrees
Insert 2 large bore PIV’s
500 mL NS IV bolus STAT
100 mL/hr NS IV continuous infusion
Hydrocodone/Acetaminophen 5-500 mg 1-2 tabs q4h PRN moderate to severe pain
Diphenhydramine 25 mg PO q8h PRN itching
Ondansetron 4 mg IV q6h PRN nausea
Lactulose 20 mg PO q6h
Mr. Garcia’s LFT’s and Ammonia level are elevated. He is extremely confused and agitated and appears somewhat short of breath. The patient’s current vital signs are as follows:
Insert two large-bore IV’s. The patient requires IV fluids and has other IV meds ordered and will likely need labs drawn. This needs to be a priority.
You could also say elevate the HOB to 30 degrees or higher, if there was indication that he was lying flat
His SpO2 is >92%, so no intervention is required there.
Lactulose should be the next priority intervention – to get the ammonia levels down – but it may take a bit for pharmacy to profile it, send it to the unit, etc.
Hydrocodone/Acetaminophen – Acetaminophen can be toxic for patients with liver disease. The way this order is written, this patient could receive anywhere from 3 g – 6 g of Acetaminophen in a 24-hour period. The max for a healthy person is 4 g, but for liver patients, it is 2 g max.
Either the dose and frequency should be lowered significantly, or the medication should be changed altogether
The order is changed to Fentanyl 25 mcg IV q4h PRN moderate to severe pain. The provider notes somewhat shallow breathing and severe ascites and requests for you to set up for paracentesis. At this time, you express your concern that the patient is extremely confused and agitated and trying to get out of bed. You do not feel that he will be still enough for the procedure. The provider agrees and plans to postpone the paracentesis for now, but orders for you to report any signs of respiratory depression or hypoxia.
The excess fluid in Mr. Garcia’s belly is compressing his thoracic cavity, causing him to feel short of breath and to only take shallow breaths. Draining this fluid will not only relieve some discomfort, but it can also help improve Mr. Garcia’s breathing
After 6 doses of lactulose, Mr. Garcia is much more calm and cooperative. He is oriented times 2-3 most times. The provider performs the paracentesis and is able to remove 1.5 L of fluid. The patient’s shortness of breath is relieved, and his breathing is less shallow. Ultrasound of the liver showed severe scarring on the liver. Mr. Garcia’s condition continues to improve, and the plan is to discharge him home tomorrow.
Critical Thinking Check
Bloom's Taxonomy: Application
What discharge teaching should be included for Mr. Garcia, including nutrition?
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 