Critical Thinking Exercise

Case Study 1

INSTRUCTIONS: All questions apply to this case study. Your responses should be brief and to
the point. When asked to provide several answers, list them in order of priority or significance.
Do not assume information that is not provided. Please print or write clearly. If your response is
not legible, it will be marked as ? and you will need to rewrite it.

Gastrointestinal Disorders
Scenario
T.H., a 57-year-old stockbroker, has come to the gastroenterologist for treatment of recurrent
mild to severe cramping in his abdomen and blood-streaked stool. You are the registered nurse
doing his initial workup. Your findings include a mildly obese man who demonstrates moderate
guarding of his abdomen with both direct and rebound tenderness, especially in the left lower
quadrant (LLQ). His vital signs are 168/98, 110, 24, 100.4° F (38° C), and he is slightly
diaphoretic. T.H. reports that he has periodic constipation. He has had previous episodes of
abdominal cramping, but this time the pain is getting worse.
Past medical history reveals that T.H. has a “sedentary job with lots of emotional moments,” he
has smoked a pack of cigarettes a day for 30 years, and he has had “2 or 3 mixed drinks in the
evening” until 2 months ago. He states, “I haven't had anything to drink in two months.” He
denies having regular exercise: “just no time.” His diet consists mostly of “white bread, meat,
potatoes, and ice cream with fruit and nuts over it.” He denies having a history of cardiac or
pulmonary problems and no personal history of cancer, although his father and older brother died
of colon cancer. He takes no medications and denies the use of any other drugs or herbal
products.
1. Identify four general health risk problems that T.H. exhibits.
2. Identify a key factor in his family history that might have profound implications for his
health and present state of mind.
3. Identify three key findings on his physical exam, and indicate their significance.

CASE STUDY PROGRESS

The physician ordered a KUB (x-ray of the kidneys, ureters, and bladder), CBC, and complete
metabolic profile. Based on x-ray and lab findings, physical examination, and history, the
physician diagnoses T.H. as having acute diverticulitis and discusses an outpatient treatment plan
with him.
4. What is diverticulitis? What are the consequences of untreated diverticulitis?
5. While the patient is experiencing the severe crampy pain of acute diverticulitis, what
interventions would you perform to help him feel more comfortable?
6. What is the rationale for ordering bed rest?
CASE STUDY PROGRESS
T.H. is being sent home with prescriptions for metronidazole (Flagyl) 500 mg PO q6h,
ciprofloxacin (Cipro) 500 mg PO q12h, and dicyclomine (Bentyl) 20 mg qid PO × 5 days.
7. For each medication, state the drug class and the purpose for T.H.
8. Given his history, what questions must you ask T.H. before he takes the initial dose of
metronidazole? State your rationale.
9. What is a disulfiram reaction?
10. When teaching T.H. about the metronidazole prescription, which instructions need to be
included? (Select all that apply.)
a. Avoid all alcohol-containing products while on this medication.
b. If his urine turns reddish brown, notify his doctor immediately.
c. Take the medication exactly as scheduled, without skipping doses.
d. He might feel some tingling or numbness in his hands, which is an expected effect.
e. Take the medication with or after meals.
f. This medication might cause a metallic taste.

11. What specific information would you want to know before T.H. starts the antibiotics?
12. What are the signs and symptoms of an allergic reaction?
13. T.H. asks you if he can take a laxative for his occasional constipation. What is your answer?
14. T.H. asks you about his diet. “I'm confused. I was always told that I needed to be eating a
high-fiber diet, which is difficult for me. But the doctor just told me that I need to be on
a low-fiber diet for now, so now I'm confused. Which is it supposed to be?” How will you
answer his question?

CASE STUDY PROGRESS

To help T.H. work through his dietary concerns, you obtain a referral to a registered dietitian.
15. What measures do you think the dietitian will discuss with T.H. to avoid recurrent
diverticulitis once his acute symptoms are resolved?

CASE STUDY OUTCOME

T.H. returns for a checkup 14 days later; all signs and symptoms of diverticulitis are gone. He is
working on his lifestyle changes and reports he is walking 30 minutes every day.
Case Study 2:

INSTRUCTIONS: All questions apply to this case study. Your responses should be brief and to
the point. When asked to provide several answers, list them in order of priority or significance.
Do not assume information that is not provided. Please print or write clearly. If your response is
not legible, it will be marked as ? and you will need to rewrite it.
Scenario:
M.R. is a 56-year-old general contractor who is admitted to your telemetry unit directly from his
internist's office with a diagnosis of chest pain. On report, you are informed that he has an
intermittent 2-month history of chest tightness with substernal burning that radiates through to
the mid-back intermittently, in a stabbing fashion. Symptoms occur after a large meal; with
heavy lifting at the construction site; and in the middle of the night when he awakens from sleep
with coughing, shortness of breath, and a foul, bitter taste in his mouth. Recently, he has
developed nausea, without emesis, that is worse in the morning or after skipping meals. He
complains of “heartburn” three or four times a day. When this happens, he takes a couple of
Rolaids or Tums. He keeps a bottle at home, at the office, and in his truck. Vital signs (VS)
at his physician's office were 130/80 lying, 120/72 standing, 100, 20, 98.6° F (37° C), SpO2 92%
on room air.
A 12-lead ECG showed normal sinus rhythm with a rare premature ventricular contraction
(PVC).
1. What are some common causes of chest pain?
2. What mnemonic can you use to help you better evaluate his pain?
3. What other history is important?
CASE STUDY PROGRESS
M.R. indicates that usually the chest pain is relieved with his antacids, but this time they had no
effect.
A “GI cocktail” consisting of Mylanta and viscous lidocaine given at his physician's office
briefly helped decrease symptoms.

4. What tests can be done to determine the source of his problems?

CASE STUDY PROGRESS
M.R. has smoked one pack of cigarettes a day for the past 35 years, drinks two or three beers on
most nights, and has noticed a 20-pound weight gain over the past 10 years. He feels “so tired
and old now.”
M.R. has dark circles under his eyes and complains of constant daytime fatigue. His wife is even
sleeping in another bedroom because he is snoring so loudly. He also reinjured his lower back a
month ago at work, lifting a pile of boards, so his physician prescribed ibuprofen (Motrin) 800
mg bid or tid for 4 weeks.

5. Which factors in M.R.'s life are likely contributing to his chest pain and nausea? Explain how.
CASE STUDY PROGRESS
M.R. explains that 6 months ago his physician prescribed famotidine (Pepcid) 20 mg PO at
bedtime for heartburn, and that it helped a little, but that it never really “did the job.” Now he
keeps a bottle of Tums or Rolaids in his truck and at his bedside, in addition to the ranitidine,
“because I always seem to need them.”
6. Why do you think the famotidine did not help M.R.?
CASE STUDY PROGRESS
M.R.'s 12-lead ECG was normal, and the first set of cardiac enzymes was normal. CBC showed
WBC 6000/mm3, Hgb 15.0 g/dL, Hct 47%, platelets 220,000/mm3. Complete metabolic panel
(CMP) revealed Na 140 mEq/L, K 3.7 mEq/L, BUN 20 mg/dL, creatinine 1.0 mg/dL, lipase 20
units/L, amylase 18 units/L, PT 12.0 sec, INR 1.0. The H. pylori antibody test came back as 20
units/mL. The chest x-ray showed no abnormalities. Room air SpO2 is 94%, and breathing is
unlabored. Suddenly, M.R. begins to complain of nausea; as you hand him the emesis basin, he
promptly vomits coffee-ground emesis with specks of bright red blood. VS remain stable.
7. What concerns do you have about the coffee-ground emesis?
8. What is the significance of the H. pylori antibody test result?
CASE STUDY PROGRESS
You ask the charge nurse to contact the gastrointestinal (GI) consulting doctor to explain the
recent events while you stay with M.R. The gastroenterologist gives several orders and states he
will be there in 45 minutes. The orders are as follows:
9. List the previous orders in order of priority.
10. Explain the rationale for each of the preceding orders.

4 Gastrointestinal
CASE STUDY PROGRESS
The gastroenterologist finds erosive esophagitis LA Class B, a moderately sized hiatal hernia,
diffuse erosive gastritis, and an ulcer in the antrum of the stomach that is oozing blood. The
duodenal bulb yielded a normal endoscopic appearance. During the EGD, the bleeding was
stopped with cautery. Biopsies were obtained of the gastric mucosa, and the biopsies are negative
for H. pylori bacteria; his bleeding ulcer is attributed to the NSAIDs (i.e., ibuprofen). He is kept
NPO until the next morning to allow good hemostasis of the cauterized site. Clear liquids are
allowed at breakfast. His hematocrit (Hct) dropped to 32%, but he remained asymptomatic from
the mild anemia; the drop was believed, in part, to reflect that he was dehydrated on admission,
and the decrease reflected the dilution of the blood from the IV fluids added. Thus, he did not
receive a transfusion of blood.
M.R. tolerated the liquid diet without any nausea and vomiting and is discharged to home the
next day with the following instructions:

11. Why does the patient need to take the pantoprazole first thing in the morning?
12. After discussing lifestyle modifications for controlling acid reflux with M.R., which
statement
by M.R. indicates a further need for teaching?
a. “I will try to stop smoking.”
b. “I will wait thirty minutes before lying down or sitting in my recliner after meals.”
c. “I will avoid fatty foods, caffeine, and chocolate.”
d. “I will avoid eating two to three hours before my bedtime.”
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11. Why does the patient need to take the pantoprazole first thing in the morning?
12. After discussing lifestyle modifications for controlling acid reflux with M.R., which statement
by M.R. indicates a further need for teaching?
a. “I will try to stop smoking.”
b. “I will wait thirty minutes before lying down or sitting in my recliner after meals.”
c. “I will avoid fatty foods, caffeine, and chocolate.”
d. “I will avoid eating two to three ho