Medical Surgical GI bleed #4

Question

The nurse is caring for an elderly client with ulcerative colitis who experienced a gastrointestinal (GI) bleed and was treated for hypovolemia. Which of the data collected is most concerning?

Answers

  1. Bounding pulse, respiratory crackles, and pitting edema.
    • Rationale:

      This answer is correct because a client with a GI bleed is susceptible to a fluid volume deficit. Treatment for fluid volume deficit is volume resuscitation by IV fluids. An elderly client receiving this treatment should be carefully monitored for fluid volume overload. These assessment findings are signs of hypervolemia which is very concerning in the elderly client.

  2. Flattened jugular vein, elevated blood pressure, increased pulse.
    • Rationale:

      This answer is not correct because these assessment findings are not alarming. It is not unusual for an elderly client to have an elevated blood pressure or increased heart rate. Also, there is no jugular vein distention noted.

  3. Fever, chills, erythema at IV insertion site.
    • Rationale:

      This answer is not correct because these are signs of an infection. An infection at the IV insertion site is important, but not more important than respiratory crackles while receiving rapid IV infusion.

  4. Decreased urine output, pallor, clammy skin.
    • Rationale:

      This answer is not correct because these signs are indicative of hypovolemia, in which the client is being treated. These assessment findings are important, but not as important as the findings associated with hypervolemia.

Overview

The elderly client that has been treated for hypovolemia should be monitored for fluid volume overload. The elderly are most susceptible to hypervolemia due to age-related comorbidities and decline in organ function.

Explanation

Learning Outcomes

The elderly are most susceptible to hypervolemia due to age-related comorbidities and decline in organ function. For this reason, they should be monitored for fluid volume overload. Normally, fluid resuscitation elicits potassium to come out of cells to maintain a normal potassium level. It is not uncommon for elders to have chronically low potassium and not sustain enough potassium to maintain a normal serum level. As a result, fluid resuscitation can potentially cause electrolyte imbalances. Monitoring the cardiopulmonary response to rapid volume expansion in the elderly is imperative due to congestive heart failure and the potential for pulmonary edema. Bounding pulse, respiratory crackles, shortness of breath, jugular vein distention are just some of the assessment findings related to fluid volume overload.

Test Taking Tip

Key words such as “elderly” and “treated for hypovolemia” indicate the need for the nurse to monitor for fluid volume overload.

Video Rationale