Victoria Holly, age 68, is newly admitted to the hospital due to anemia and severe dehydration. They have been prescribed an IV of D5 ½ NSS infusing into the right hand to address the dehydration. Mrs. Holly has a second IV access in her left arm to be used for blood administration only. She recently received 2 units of packed red blood cells in response to the anemia. There are prescribed interventions to draw a complete blood count (CBC) and a complete metabolic profile (CMP). Mrs. Holly also has an ileostomy, which she has managed for several years on her own. Upon your initial nursing assessment of Mrs. Holly, you find her vital signs are as follows: temperature, 97.2°F; pulse, 96 beats/min; respirations, 18 breaths/min; blood pressure, 88/50 mm Hg. Her skin is “tenting” and you are having difficulty palpating her peripheral pulses. Her lips are dry and cracked. The skin around her stoma site is bright red and open in areas. You notice that her ostomy pouch was cut much larger than the stoma site. She reports she is very tired and “lacks energy.” Her family informs you that she has always been a very independent person but in the last couple of months she just “hasn't been herself.”
Prescribed Interventions
- Intravenous fluids: D5 ½ NSS IV at 125 mL/hr
- Strict I&O
- Daily weights
- CBC and CMP stat
Developing Clinical Reasoning and Clinical Judgment
- Identify the equipment needed and appropriate sites to consider to obtain the blood samples.
- Describe how you would assess Mrs. Holly's peripheral circulation.
- What concerns you about Mrs. Holly's present condition in relationship to performing her activities of daily living (ADLs) independently?
- What is alarming about the assessment of her ileostomy? Identify possible explanations for the stoma's condition.
- What are measurable physical parameters you can use to determine whether the fluid replacement therapy and blood administration have had a therapeutic effect?
- Develop a discharge teaching plan for Mrs. Holly related to ostomy care.
Suggested Responses for Integrated Nursing Care
- You cannot obtain the specimen from above the IV in her right hand because the specimen will be diluted with the D5 ½ NSS solution and, thus, will be inaccurate. It is not considered best practice to draw laboratory specimens from an IV site unless absolutely necessary, according to facility policy. Also, you cannot draw blood specimens from a dedicated IV access such as the one Mrs. Holly has for blood administration. Collect Mrs. Holly's laboratory work from her left arm via venipuncture, avoiding the right arm due to the IV infusion (Chapter 18).
- When a patient has no peripheral pulses, you must investigate further (refer to Chapters 2 and 3). Never ignore the absence of pulses, as this could signal a life-threatening condition. Have another nurse check the pulses, or use a Doppler. Upon checking Mrs. Holly's pulses with a Doppler device, you were able to hear them and marked them with an “x” to facilitate future assessments. In your initial assessment, you were not surprised that Mrs. Holly's pulses were nonpalpable, as she has a very low circulating volume.
- Mrs. Holly's vital signs are disconcerting because her blood pressure is low. Because of her hypotension, ADLs may unduly tax her. Until you see a positive change in her vital signs, provide assistance with her ADLs (see Chapter 7). In addition, Mrs. Holly has an IV in each arm. It may be difficult for her to care for the ostomy and perform personal care when one or both of the access sites are used for infusions.
- Mrs. Holly's ileostomy site is very red and excoriated. You are alarmed, as this could place her at risk for infection. Do not assume that a health care provider has seen the excoriation around the ostomy site. If the patient came into the hospital with more pressing matters, such as decreased blood pressure, the health care provider may not have observed the ileostomy. Notify the health care team. Mrs. Holly may lack knowledge about the appropriate method for sizing and cutting her ostomy appliance. You suspect that she may be cutting the faceplate in such a way as to leave her skin exposed to the liquid stool, which is then causing the excoriation (see Chapter 13).
- One therapeutic outcome to anticipate with Mrs. Holly would be an increase in blood pressure. Other outcomes include palpable peripheral pulses and normal skin turgor. Subjectively, Mrs. Holly should report that her energy has increased. Her family may also comment that she is becoming more “like herself.” Sometimes health care workers make judgments about older adults, thinking that they are always tired. Since health care workers are often unfamiliar with their patients' normal conditions, comments made by family members can often be very helpful in determining progress. This is especially true if your patient cannot communicate. Objectively, one outcome would be that Mrs. Holly becomes more active in her own care.
- One area you should investigate is Mrs. Holly's ability to care for the ostomy before she came to the hospital. It is possible that her skin around the stoma site has looked like this for some time. Before her hospital discharge, evaluate her knowledge through return demonstration to ensure that she can care for the stoma and can identify possible family resources. She may benefit from a home health referral to ensure she is caring for her stoma properly.