Assignment:

GI Procedure Case Study

Your patient is a 55-year-old male with bleeding from the rectum (melena) for the last month. He is very anxious on pre-procedural assessment and has a history of Congestive Heart Failure with an irregular heartbeat treated with medications: Digoxin, Lasix, and Coumadin. He also has rheumatoid arthritis with severe knee pain relieved by non-steroidal anti-inflammatory medicines for the last ten years. Family has dropped him off and left with a promise to return in four hours. Your patient tells you the prep was hard to perform and the enemas never did come back clear.

Intra-procedure Care

The patient is now ready for his IV push dose of Versed and Fentanyl. He is less anxious due to pre-procedural Valium 5 mg and has no peripheral edema; but has a slight inspiratory wheeze and a pulse oxymetry baseline of 95% SaO2. As you put on the nasal oxygen at 2L, he tells you he snores loudly at night and the wheezes and snoring gets worse if he is flat. More of the medication will be given if groaning is noted or hand signals indicate discomfort. The patient is positioned with the HOB elevated 30 degrees and comfort measures for knee support-all pulses are checked for presence and are 2+ in all extremities. His blood pressure rises and falls 10 mm during the procedure and pulse ox remains within the safe range for this patient.

Post-Procedure Nursing Care

The patient is now in the recovery area after the colonoscopy and use of procedural/moderate sedation. He is groggy at one hour after Narcan and Flumazenil, narcotic antagonists, were given due to pre-procedural Valium 5 mg. You see his pulse ox drops to 90% SaO2 and use a shake-up / wake-up routine to stimulate him and his pulse ox returns to 95% SaO2. He continues to have a slight inspiratory wheeze and you have suctioned his upper airway with a Yankauer two times for poor secretion control. The MD asks for post-procedural Hgb and PT. The EKG now shows Premature Ventricular Contractions (PVC`s) at 4-6 a minute.

Question 1: What electrolyte lab might you ask the MD to order?

Question 2: As you put the nasal O2 back on at 2L, his family returns and asks for the results of the tests for cancer of the colon. How would you answer this question?

Question 3: He awakens with a start as he hears his son`s voice and the PVC`s on the EKG have become more frequent. How will you handle the needs of the patient and family with a therapeutic comment?

Question 4: The Hgb returns with results of 8.8 and a normal PT of 13 seconds and the arrhythmias are slowing but you are concerned still about cardiac ischemia due to severe cardiac history. What might you ask the MD to order to rule out this concern for ischemic heart damage?

Question 5: You process the physician`s referral for the patient to a rheumatologist and send information on the NSAID problem. You forward the procedural note to the consulting cardiologist for consideration of clotting profiles and EKG and post-procedural monitoring. The family wants to take the patient home now.

What must the patient show you what discharge criteria need to be met to feel safe that the procedural/moderate sedation effects are gone and the patient is safe for discharge?