Transcript A case study/presentation on a patient with

UPPER GASTROINTESTINAL
BLEEDING
Case
no.
Name:
Age:
Sex:
Nationality:
Marital Status:
Date of Admission:
Date of Discharge:
195***
Patient X
72 y.o
Male
Syrian
Married
February 4,2013
February 7,2013
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GCS:
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VITAL SIGNS:
GRBS:
 WT:
 SKIN:
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EYES:
15/15
E: Opens eyes spontaneously
V: Oriented and converses normally
M:Obeys commands
Dizziness and nausea upon assessment
BP:100/70MMHG
T: 37 c
HR: 125CPM
RR: 25BPM
SpO2:91%
190mg/dl
116kgs
Light complexion, Warm to touch,smooth,
hair evenly distributed
slightly sunken eyeballs,no redness, no
discharges, pupils reactive to light and
accommodation
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MOUTH:
 THORAX:
oral cavity is pale in color,
buccal mucosa is dry but no
ulcers,lips are pale and dry
thorax is symmetric, slight
retraction of theIntercostal
muscles during inspiration
 MUSCULOSKELETAL:generalized
weakness with
residual Left SidedWeakness
 GASTROINTESTINAL:moderate-severe epigastic
pain (PS:8/10)
Passage of soft, black stool
WBC
NEUT
RBC
HGB
PLT
PT
APTT
UREA
CREATININE
SODIUM
POTASSIUM
CHLORIDE
RESULT
REFERENCE
21.63
76.6
2.68
8.2
238
16.3
30
23.2
121
141
5.1
114
4.23-9.07
34-67.9
4.63-6.08
13.7-17.5 g/dl
163-337
10.9-16.3 SECS
27-39 SECS
3.2-7.1 mmol/L
46-110 mmol/L
137-145 mmol/L
3.5-5.1 mmol/L
98-107 mmol/L
3 months prior to consult, the patient experienced left sided weakness
and had hypertension recorded a 190/100mmhg BP, sought consult and
was diagnosed of CVA, treated medically started medications of Valsartan
(Diovan) 160 mg OD to control elevation of his BP, Aspirin 80 mg OD,
Plavix 75 mg OD, Simvastatin 20 mg OD and Piracetam 800mg OD. Also
the patient has a long diagnosed type 2 DM (non insulin dependent
diabetes mellitus) and continuously taking Glimipride 1mg BID. Long been
diagnosed of degenerative arthritis and chronically took Diclofenac 50 mg
BID since many years ago. Same incident of suspected GI
bleeding,wherein the patient passed soft blak stool,happened 10 years
ago as stated by the relative but endoscopy was not done.Only
prescribed with medications. He is a known smoker and consumes
caffeine containing drinks on a regular basis.
Patient was brought to the Emergency Department, presenting with symptoms of dizziness, body
weakness and epigastric pain for 2 days, passed black colored loose stool 3-4 times. Patient
was conscious and oriented but with obvious body weakness. Upon interview, reveals that
morning prior to consult, he had passage of black loose stool moderate to large amount as
observed. In the emergency department, patient was immediately given IV Infusion of NSS 500
ml, and given Omeprazole 80 mg TIV STAT as ordered by the treating physician. Blood sample
was collected, sent to laboratory, reveals a low HGB level of 8.2. ECG was done and noted sinus
tachycardia. Also Chest xray done no significant finding as explained by the physician.
Gastroenterology consult was done and advised for admission for monitoring and correction of
blood loss. Patient was admitted in Surgery Ward. Started omeprazole infusion 8 mg/hr and
continuous IV fluid infusion and was put on NPO. Then after a series of investigations, later that
day, was shifted to ICU (4/2/13)due to rapid decrease of blood pressure to 60/ 40 regardless of
continuous fluid replacement, Voluven infusion given and was scheduled for an urgent Upper GI
Endoscopy on OR , alongside blood transfusion of PRBC was done. Endoscopy shows duodenal
ulcer on the anterior wall of the bulb and a large amount of black material (digested blood)
inside the stomach cavity. 15 ml of Adrenaline was injected around the ulcer to control
bleeding. Patient was monitored in ICU w/ regular checking of RBS and CBC.Oral anticoagulants
and other medications are withheld. After stabilization and a total of 4 units PRBC transfusion
was transferred back to ward (5/2/13). Omeprazole infusion was then shifted to Omperazole 40
mg TIV BID, started soft diabetic diet.Patient was discharged last 7/2/13 with home medications
of Nexium, Amoxicillin, Clarithromycin, Amlor, Simvastatin and Panadol. Instructed to avoid
aspirins and NSAIDs.
Digested blood
Ulcer
Gastrointestinal bleeding is not just a gastroduodenal disorder but may occur
anywhere along the alimentary tract. Bleeding is a symptom of an upper or lower GI
disorder. It may be obvious in emesis or stool or it may be occult or hidden.Upper
gastrointestinal (GI) bleeding refers to hemorrhage in the gastrointestinal
tract.Patients with upper GI hemorrhage often present with hematemesis,coffee
ground vomiting, and melena. The presentation of bleeding depends on the amount
and location of hemorrhage. Melena refers to the black, "tarry" feces that are
associated with gastrointestinal hemorrhage. The black color is caused by oxidation
of the iron in hemoglobin during its passage through the ileum and colon. Bleeding
may be caused by a lot of factors. One of which is a peptic ulcer which is an erosion
in the gastronintestinal lining wherein lining is exposed to acid secretion causing
inflammation, it may be seen as a small, red crater on the inside lining of the gut.
Peptic ulcer is classified according to its origin It may be classified as gastric
wherein ulcer develops in the stomach lining and duodenal if it arise on the
duodenum. In this case the duodenum which is the most common site of peptic ulcer.
Peptic ulcer is the end result of an imbalance between digestive fluids in the
stomach and duodenum.. It is estimated that between 5% and 10% of adults globally
are affected by peptic ulcers at least once in their lifetimes.
Upper gastrointestinal tract The
upper gastrointestinal tract
extend from the
mouth,esophagus, stomach, until
the duodenum.The exact
demarcation between "upper" and
"lower" can vary.
The mouth leads to the oral cavity, which has a
vestibule lying between the lips, the cheeks and
gums (gingivae), and the teeth. The main oral
cavity also lies between the hard and soft palate
above, the tongue below, and the alveoli and
teeth. The oral cavity leads to the pharynx
through the fauces, which contain pharyngeal
tonsils (adenoids) and palatine tonsils. Salivary
glands (parotid, submandibular, and sublingual)
open into the oral cavity.
The pharynx extends from the base of the skull
above to the cricoid cartilage (at the level of
C6) below. It has 3 parts: the nasopharynx (from
the base of the skull above to the soft palate
below), the oropharynx (from the soft palate
above to the hyoid bone below), and the
laryngopharynx (from the hyoid bone above to
the cricoid cartilage below). The nasal cavity,
oral cavity, and larynx open into the
nasopharynx, oropharynx, and laryngopharynx,
respectively. The laryngopharynx also has a
piriform fossa on either side.
The esophagus (gullet) is one of the
few organs traversing 3 regions of
the body--namely, the neck, thorax,
and abdomen. Accordingly, it is
divided into 3 parts: cervical,
thoracic, and abdominal. The
esophagus is a 25-cm-long vertical
muscular tube that which normally
remains collapsed and that runs from
the laryngopharynx (throat or
hypopharynx) in the neck through
the thorax (chest) to the stomach in
the abdomen.
The stomach is a muscular, hollow,
dilated part of the digestion system
located between the esophagus and the
small intestine. It secretes proteindigesting enzymes called protease and
strong acids to aid in food digestion,
(sent to it via esophageal peristalsis)
through smooth muscular contortions
(called segmentation) before sending
partially digested food (chyme) to the
small intestines.
The duodenum is the first section of
the small intestine and is the
shortest part of the small intestine,
where most chemical digestion takes
place. The duodenum is largely
responsible for the breakdown of
food in the small intestine, using
enzymes. The duodenum also
regulates the rate of emptying of the
stomach via hormonal pathways
The lower gastrointestinal tract
includes most of the small
intestine and all of the large
intestine. According to some
sources, it also includes the anus.
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Duodenum: Here the digestive juices from the
pancreas (digestive enzymes) and hormones and
the gall bladder (bile) mix. The digestive enzymes
break down proteins and bile and emulsify fats
into micelles. The duodenum contains Brunner's
glands which produce bicarbonate. In combination
with bicarbonate from pancreatic juice, this
neutralizes HCl of the stomach.
Jejunum: This is the midsection of the intestine,
connecting the duodenum to the ileum. It contains
the plicae circulares, and villi to increase the
surface area of that part of the GI Tract. Products
of digestion (sugars, amino acids, fatty acids) are
absorbed into the bloodstream.
Ileum: Has villi and absorbs mainly vitamin B12
and bile acids, as well as any other remaining
nutrients.
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Caecum: The Vermiform appendix
is attached to the caecum.
Colon: Includes the ascending
colon, transverse colon,
descending colon and sigmoid
Flexure: The main function of the
Colon is to absorb water, but it
also contains bacteria that
produce beneficial vitamins like
vitamin K.
Rectum
The major processes occurring in the GI system are that of motility, secretion,
regulation, digestion and circulation. The function and coordination of each of these
actions is vital in maintaining GI health, and thus the digestion of nutrients for the
entire body.
In the uppermost portion, the teeth begin the process of digestion by grinding food
into small fragments. The esophagus delivers the food to the stomach where strong
acid further breaks up and degrades the swallowed material. Small amounts of the
liquified food called chyme are then delivered in spurts from the stomach into the
duodenum where they are mixed with bile from the liver (via the bile ducts) and
pancreatic juice (via the pancreatic duct). Bile aids in the breakdown and digestion
of fat, while the pancreatic enzyme amylase fragments starches into smaller
molecules. The pancreas also releases a fluid into the duodenum, which neutralizes
the acidic stomach contents. This neutral bile/amylase/fragmented food substance
passes to the upper small intestine for the next phase of digestion. It is moved along
by peristalsis, worm-like contractions of the intestine.
The small intestine is so named because its calibre is small, about one inch in
diameter. The term small creates some confusion because, in terms of length, it is not
small at all. In fact, it normally measures nearly 23 feet in length! The small intestine's
job is absorption of food. The body gains access to the food that we consume by means
of absorption of microscopic particles of food through the wall of the small intestine.
Vitamins and minerals and large amounts of fluid are also absorbed by the small intestine
and pass into the bloodstream for distribution to the rest of the body.
Small amounts of the liquified food called chyme are then delivered in spurts from
the stomach into the duodenum where they are mixed with bile from the liver (via the
bile ducts) and pancreatic juice (via the pancreatic duct). Bile aids in the breakdown
and digestion of fat, while the pancreatic enzyme amylase fragments starches into
smaller molecules. The pancreas also releases a fluid into the duodenum, which
neutralizes the acidic stomach contents. This neutral bile/amylase/fragmented food
substance passes to the upper small intestine for the next phase of digestion. It is moved
along by peristalsis, worm-like contractions of the intestine.
By the time the intestinal contents reach the large intestine, most of its nutritional
value has been extracted, leaving a watery waste product. The role of the large
intestine is fluid absorption from the remaining waste and compaction and storage of
what is left. Expulsion of the waste (feces, stool) is generally under voluntary control
and is undertaken when socially convenient
There are many possible causes of bleeding, Causes are
usually anatomically divided into their location in the upper
gastrointestinal tract. It may be a result of trauma anywhere
along the GI tract, rupture of an enlarged vein such as a
varicosity (esophageal or gastric varices),inflammation such as
esophagitis,gastritis,inflammatory bowel disease and bacterial
infection. Alcohol and drugs (aspirin-containing
compounds,NSAIDS, anticoagulants,corticosteroids), cancers, or
even anal disorders, and erosions and ulcers.
DRUG
CLASSIFICATION
ACTION
ADVERSE REACTIONS
Aspirin/Acetylsalicylic
acid/ASA
NSAID
Produces analgesia and exert anti
inflammatory effect by inhibiting
prostaglandin and other substance
that sensitize pain receptor.
Interferes with clotting by keeping
a platelet-aggregating substance
from forming.
GI: nausea, GI bleeding, GI distress
Hematologic: prolonged bleeding
time
Clopidogrel bisulfate/Plavix
Antiplatelet
Reduces thrombotic events in
patient with atherosclerosis,
documented by recent stroke or
MI
GI: hemorrhage,abdominal pain,
ulcers
Diclofenac
NSAID
Inhibits prostaglandin synthesis to
produce anti inflammatory,
analgesic and antipyretic effects
GI: abdominal distention, abdominal
pain, bleeding,peptic ulceration
Bleeding may be classified as:
-massive: it may be acute, wherein there is bright red hematemesis
or large amount of
melena with clots in the stool, rapid
pulse,drop in BP, hyppovolemia and shock
-subacute:intermittent melena or coffe ground
emesis,hypotension,weakness and dizziness
-chronic:intermittent appearance of bleed,increased
weakness,paleness or shortness of breath,occult blood and iron
deficiency anemia.
Upper gastrointestinal bleeding is a result of the ulceration of the
mucosal lining of the stomach. This is due to infection with a
bacterium (germ) called H. pylori or chronic use of Antiinflammatory medicines used to treat various medical conditions. The
diagnosis of upper GI bleeding is assumed when there is the presence
of at least two factors among: black stool, age > 50 years, and high
blood urea nitrogen/creatinine ratio.
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emphasized items are those noted in the patient)
fatigue, weakness, or lack of energy
Lightheadedness may occur if a person stands too quickly, since the body isn't able to
pump oxygen-carrying red blood cells fast enough to the brain
abdominal pain/burning pain, classically epigastric strongly correlated to
mealtimes. In case of duodenal ulcers the pain appears about three hours after
taking a meal;
bloating and abdominal fullness;
nausea, and copious vomiting;
loss of appetite and weight loss;
hematemesis (vomiting of blood); this can occur due to bleeding directly from a
gastric ulcer, or from damage to the esophagus from severe/continuing vomiting
melena (tarry, foul-smelling feces due to oxidized iron from hemoglobin);
Pallor of oral and nasal mucosa due to blood loss
Low blood hemoglobin level (8.6)
Breathing difficulties and low O2 saturation
Decreased Blood pressure
Tachycardia
PREDISPOSING FACTORS:
Medications(aspirin,NSAIDs,anticoagulants)
Cigarette smoking
Alcohol and caffeine consumption
Stress
H. Pylori infection
DAMAGED MUCOSAL BARRIER
Dec function of mucosal cells
Dec quality of mucus
back diffusion of acid into gastric mucosa
Formation and liberation of
antihistamine
Increased acid production
Further mucosal erosion-uleration
Acute, massive GI bleeding
Blood volume depletion
Dec cardiac output –hypotension
and tachycardia
Compensatory constriction of
peripheral arteries-pallor of skin
and nail beds
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The initial focus is on resuscitation beginning with airway management and fluid resuscitation
using either intravenous fluids and or blood transfusion. Based on evidence from people with
other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer
bleeding.
Bowel rest: Bed rest and clear fluids with no food at all for a few days. This gives the ulcer a
chance to start healing without being irritated.
Also endoscopy is the priority management, both a diagnostic and a treatment for GI bleeding,
wherein after seeing the area where bleeding is originating, adrenalin can be injected to
control the bleeding.
Acid suppressing medication following a 4-8 week course of a medicine that greatly reduces
the amount of acid that your stomach makes is usually advised. The most commonly used
medicine is a proton pump inhibitor (PPI). These are a class (group) of medicines that work on
the cells that line the stomach, reducing the production of acid. Proton pump inhibitors may
reduce mortality in those with severe disease as well as the risk of re-bleeding and the need
for surgery. They include: esomeprazole, lansoprazole, omeprazole, pantoprazole and
rabeprazole, and come in various brand names.
Sometimes another class of medicines called H2 blockers is used. They are also called
histamine H2-receptor antagonists but are commonly called H2 blockers. H2 blockers work in a
different way on the cells that line the stomach, reducing the production of acid. They
include: cimetidine, famotidine, nizatidine and ranitidine, and come in various brand names.
As the amount of acid is greatly reduced, the ulcer usually heals.
Surgical Interventions may also be indicated for hemorrhage caused by ulcer.
Upper endoscopy is a procedure that
enables the examiner (usually a
gastroenterologist) to examine the
esophagus (swallowing tube), stomach,
and duodenum (first portion of small
bowel) using a thin, flexible tube
through which the lining of the
esophagus, stomach, and duodenum can
be viewed using a TV monitor
 Prolonged
bleeding detectable in a microscopic study can lead to the loss of
iron in the individual. This can cause anemia. Red blood cells contain a protein
called hemoglobin. It is required to carry oxygen to the tissues of the body. A
lack of hemoglobin and a lack of red blood cells can occur during constant GI
bleeding, causing anemia. Symptoms of anemia include chest pain, dizziness,
fatigue, weakness, headaches, shortness of breath and lack of mental clarity.
 Hypovolemia may occur as a complication of GI bleeding. Due to a severe loss
of blood and fluid in acute GI bleeding, the heart finds it difficult to pump
enough blood to the body. It is a life-threatening condition since it can cause
the body's organs to stop working. Symptoms of this condition include cool,
clammy skin; confusion; agitation; decreased urine output; weakness; pale
skin; quick breathing; and loss of consciousness.
 Acute and massive bleeding from the gastrointestinal tract can lead to a lack
of blood flow to the body. This can damage the different organs of the body,
causing organ failure. Shock is an emergency condition and if it is not treated
immediately, it can worsen quickly, causing irreversible damage to the organs
or even death. Symptoms of shock include an extremely low blood pressure,
bluish lips and fingernails, chest pain, confusion, dizziness, anxiety, pale skin,
decreased or no urine output, racing but weak pulse rate, shallow breathing,
and unconsciousness.
 Acute
pain related to inflammation of gastric mucosa
 Fluid volume deficit related to active bleeding or fluid loss
 Decreased cardiac output due to active bleeding
 Fatigue related to decreased oxygen in blood
 Knowledge Deficit related to lifestyle modification and drug
regimen
ASSESMENT
NURSING DIAGNOSIS
Subjective:
“I have abdominal
pain”
Objective:
 Pain score: 8/10
 facial grimace
 assuming fetal
postion to
compress
stomach
 guarding position
 irritable
Acute Pain related
to epigastric
distress secondary
to mucosal
erosion.
PLANNING
INTERVENTION
RATIONALE
° Provided patient. optimal pain relief with
Each client has a right to expect
maximum pain relief. Optimal pain
relief using analgesics includes
determining the preferred route, drug,
dosage, and frequency for each
individual. Proton pump medications
reduce acid levels and allow the ulcer to
heal
° Positioned patient comfortably on bed
Proper positioning during times of pain
may give comfort to the patient
° Instructed patient to be on NPO
Limits gastric acid production thus
inhibiting irritation to the ulcer
After 15-30 mins of nursing
prescribed analgesics or proton pump
interventions, the patient will
inhibitors like Risek 80 mg TIV STAT and
experience relief from pain
Scopinal 20mg TIV STAT
as evidenced by a pain score
of 8/10 decreased to at least
5/10, a relaxed postion, and
absence of facial grimace.
° Taught the use
of nonpharmacologic techniques (e.g.,
relaxation,guided imagery, music therapy,
distraction, and massage)
The use of noninvasive pain relief
measures can increase the re- lease of
endorphins and enhance the
therapeutic effects of pain relief
medications
EVALUATION
Goal partially met:
After 30 mis of
nursing interventions,
the patient manifested
a slight relief of pain as
evidenced by a pain
score of 6/10 but still
uncomfortable.
ASSESMENT
NURSING DIAGNOSIS
Subjective:
Fluid volume deficit related to
“I am passing bloody stool”
blood loss due to active
Objective:
bleeding.
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(+) melena
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low HGb count of 8.6
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Pale and dry oral mucosa
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Tachyardia 125 bpm
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shortness of breath
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Hypotension 100/70mmhg
PLANNING
INTERVENTION
After 12 hours of nursing
•Administered fluid
interventions, the patient will be replacement through
able to regain fluid volume and intravenous fluids as ordered
minimize further blood loss.
• Administered properly typed
and crossmatched blood
products as ordered
RATIONALE
To provide replacement for the
amount of fluid loss
Urgently replaces blood loss
• Administered oxygen
inhalation by face mask
To compensate for the low
levels of oxygen in the blood to
facilitate breathing and
ventilation
• Witheld medications that can
aggravate bleeding like aspirin
Prevents exacerbation of
situation, prevents irritation and
inflammation of ulcers that
causes bleeding
• maintained pt on bed
rest,limit activity
To prevent further fluid loss and
minimize energy consumption
•Monitored Intake and Output
To monitor amount of fluid loss
for replacement
EVALUATION
Goal partially met.
After 12 hours of nursing
intervention, the patient
maintained fluid volume at an
acceptable level, as evidenced
by normal breathing and a
warm, moist skin and mucosa
and increased HGb level of
13.7-17.5 g/dl
Prevention of recurrence of bleeding due to duodenal ulcer is the
priority health teaching by:
 Instructing patient in taking gastric irritating medications on full
stomach
 Advising to limit or quit smoking
 Having a well balanced diet with meals at regular intervals and
avoiding dietary irritants.
 Religiously following medication regimen for duodenal ulcer
 Avoiding aspirins and NSAIDs instead using Paracetamol for pain
 Taking adequate amount of rest to prevent stress
 Advise to drink alcohol only in moderation, or avoid drinking
alcohol. Limit alcohol to 2 drinks a day for men and 1 drink a day
for women. Drinking too much alcohol and other caffeine
containing beverages may make an ulcer heal more slowly and may
make your symptoms worse.
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Early detection is important in the management of any disease.
In this case, the patient developed a complication of his past
medical condition which is CVA due to his medication treatment
and other causes. The Upper Gastrointestinal Bleeding was
already a complication of the duodenal ulcer which may be
caused by the medication he took and his lifestyle and started
months prior to hospitalization. And this case when not
prompted early may cause death. Improvement was seen upon
discharge as evidenced by laboratory results and the patients
overall condition. But it is possible that the condition may recur
if the patient will follow dietary and health regimens advised.
Maria Beverly A. Centeno,RN
Emergency Department staff