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Tuesday 1630 (admission to emergency department [ED])

 

A 38-year-old female client experienced loss of consciousness while in the grocery store with her three young children. The client is currently awake and alert x3. Reports excess fatigue and cold sensitivity

 

Vital signs:

Heart rate: 130 beats/min; b
Blood pressure: 100/52 mm Hg
Respiratory rate: 28 breaths/min
Oxygen saturation: 92% on room air

Heart monitor indicates sinus tachycardia. Client appears visibly pale and anxious.

 

Cardiac: Tachycardic; no audible murmur; no noted shortness of breath. Slight hypotension with orthostatic hypotension noted.

 

Eyes: Recent reports of blurry vision. Negative for scleral icterus.

 

Gastrointestinal: Client reports that she does not feel hungry and that the inside of her mouth is sore. Oral cavity reveals smooth, beefy red tongue and pale mucous membranes.

 

Respiratory: Tachypnea. Lung sounds clear to auscultation.

 

Neurologic: Report headache. No noted injury from the loss of consciousness.

 

Urinary: Reports some burning with urination.

 

Obstetric history: Three term births; zero premature births; zero abortions; three living children

Youngest child is 3 months old, uncomplicated vaginal delivery; currently breast feeding. History of heavy menses and endometriosis.

 

Social: Lives in a home with spouse and three children. The client is currently off work because of the recent birth; works as a financial advisor. Spouse at the bedside currently.

The client received one unit of PRBCs at 2000 and the second unit at 2330. Ultrasound and transvaginal ultrasound completed. Currently in sinus rhythm with heart rate 88 beats/min. Blood pressure is 120/64 mm Hg while sitting. Menstrual bleeding has decreased.

 

Tuesday 1900:

The client was admitted to the medical monitoring unit from the emergency department. Client is awake and alert X 3. The client reports a headache, fatigue, and needs assistance to the restroom. The client reports bleeding through a menstrual pad every 30 to 45 minutes. While assisting the client in the bathroom, blood clots larger than the size of a quarter were noted. Client remains in sinus tachycardia with a heart rate of 144 beats/min.

 

Blood pressure (BP)

when lying down: 132/64 mm Hg
when sitting: 120/53 mm Hg
when standing: 108/50 mm Hg

The client remains pale and reports abdominal cramping.

 

Tuesday 1630 (admission to ED):

Complete blood count (CBC) with differential:

Laboratory Parameter

Result

Reference Range

Hemoglobin

7 g/dL

Females: 12-16 g/dL (7.4-9.9mmol/L)

Males: 14-18 g/dL (8.7-11.2 mmol/L)

Hematocrit

21%

Females: 37%-47% (0.37-0.47 volume fraction)

Males: 42%-52% (0.42-0.52 volume fraction)

Mean corpuscular volume (MCV)

64 fL

80-95 fL

Serum ferritin

9 mcg/L

Female: 10-150 mcg/L (10-150 ng/mL)

Male: 12-300 mcg/L (12-300 ng/mL)

Serum iron

38 mcg/dL

Female: 60-160 mcg/dL (11-29 μmol/L)

Male: 80-180 mcg/dL (14-32 μmol/L)

 

Metabolic panel:

Laboratory Parameter

Result

Reference Range

Glucose (fasting)

63 mg/dL

70-115 mg/dL (<6.4 mmol/L) Blood urea nitrogen (BUN) 18 mg/ dL 10-20 mg/dL (3.6-7.1 mmol/L) Glomerular filtration rate (GFR) 97 mL/min/1.73 m2 >60 mL/min/1.73 m2

Sodium

140 mEq/L

136-145 mEq/L (mmol/L)

Chloride

96 mEq/L

98-106 mEq/L (mmol/L)

Calcium

9.4 mg/dL

9.0-10.5 mg/dL (2.25-2.75 mmol/L)

Potassium

4.9 mEq/L

3.5-5.0 mEq/L (mmol/L)

Total Protein

6.9 g/dL

6.4-8.3 g/dL (64-83 g/L)

AST (SGOT)

20 units/L

0-35 units/L (0-0.58 μkat/L)

ALT (SGPT)

19 IU/L

4-36 IU/L (4-36 units/L)

 

Urinalysis:

Laboratory Parameter

Result

Reference Range

Color

Orange

Amber yellow

Clarity

Cloudy

Clear

Specific gravity

1.015

1.005-1.030

pH

5.2

4.6-8.0

Leukocytes

Positive

Negative

Nitrate

Positive

Negative

Protein

Negative

Negative

Glucose

Negative

Negative

Ketones

Trace

Negative

Urobilinogen

Normal

Normal

Bilirubin

Negative

Negative

Blood

Trace

Negative

 

Tuesday 1700:

Blood = AB+

 

Tuesday 2300:

Laboratory Value

Result

Reference Range

Hemoglobin

8.3 g/dL

Females: 12-16 g/dL (7.4-9.9mmol/L)

Males: 14-18 g/dL (8.7-11.2 mmol/L)

Hematocrit

24%

Females: 37%-47% (0.37-0.47 volume fraction)

Males: 42%-52% (0.42-0.52 volume fraction)

 

Wednesday 0800:

Laboratory Value

Result

Reference Range

Hemoglobin

9.5 g/dL

Females: 12-16 g/dL (7.4-9.9mmol/L)

Males: 14-18 g/dL (8.7-11.2 mmol/L)

Hematocrit

28%

Females: 37%-47% (0.37-0.47 volume fraction)

Males: 42%-52% (0.42-0.52 volume fraction)

Tuesday 1630:

Insert intravenous (IV) line; begin 0.9% normal saline at 100 ml/h.
Consult obstetrics/gynecology (OB/GYN) to evaluate for excessive menstrual bleeding.
Consult with gastrointestinal (GI) to evaluate for potential gastrointestinal source of bleeding.
Type and crossmatch for blood administration; obtain consent for blood administration.
Admit to medical monitoring floor.

 

Tuesday 1930:

Infuse 2 units of packed red blood cells (PRBCs)
Ultrasound of the abdomen and pelvis
Transvaginal ultrasound

 

Wednesday 0800:

Administer 200 mg of elemental iron PO
Administer ascorbic acid, 1 tablet BID
Repeat urinalysis
Administer nitrofurantoin 100 mg BID, PO

Tuesday 1630 (admission to ED)

Chest x-ray: normal with no evidence of infiltrates

 

Wednesday 0100:

Transvaginal ultrasound: appearance consistent with endometriosis; possible uterine fibroid

 

 

 

 

 

 

 

 

Which action would the nurse take at this time? Select all that apply.

 

 

 

Administer liquid iron undiluted.

 

Administer ascorbic acid with iron.

 

Encourage consumption of lean beef and chicken.

 

Teach client to avoid green leafy vegetables

 

Have the client sit upright for 30 minutes after taking iron.

 

Teach client that iron can cause diarrhea.

 

Teach client that iron supplements will cause the stool to appear tarry and dark red

 

Teach that the nitrofurantoin is used to treat a urinary tract infection.

 

Ask the client to ring for assistance to the bathroom.

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 366