Med-Surg+Case+Study+3

[|side effects of Omeprazole] UPPER GI BLEED CASE STUDY NUR 154 Mr Ulcer is a 76 y/o male admitted to the med/surg unit with c/o vomiting coffee brown emesis x 2 days. Pt is NPO, IV D5W1/2NS at 125mL/hr. Pt is A&Ox3. V/S 142/76 T97.9 P 72 R 20. BR with BRP. HX: -alcohol intake of 2-3 drinks a day for 20 years -smoking ½ - 1 pack day -HTN -cholecystectomy -GERD X -5 years -NSAID usage

Mr Ulcer asks the nurse what can cause gastric bleeding.
 * 1) What would the nurse tell him? What risk factors does Mr Ulcer have? The bleeding is most likety due to chronic esophagitis that is caused by GERD, the ingestion of drugs irritating to mucosa, alcohol, and smoking cigarretes.(Diana z) Other common causes of Upper Gi Bleeds are, peptic ulcer and gastritis.
 * 2) When the emesis is bright red or red, where is the bleeding occurring in the GI track? The bright red color indicates that the blood has not been in contact c the stomach's gastric secretions. it occurs in the lower esophagus.? (Diana z)
 * 3) When the emesis is coffee ground or there is melena, where is the bleeding occurring? Melena indicates slow bleeding from the upper GI source. it occurs through the intestines due to the breakdown of hemoglobin and the release of iron . (Diana z) The bleeding can also be coming from the stomach depending on the contact time in the stomach the digestive processes which changes the hemoglobin to a brown pigment. (ADRIA)

Mr Ulcer asks you why the use of Motrin can cause GI bleeding.
 * 1) What would you tell him? What other medications can irritate the gastric mucosa and cause bleeding? Aspirin, NSAID, and corticosteroids can cause irritation and disruption of the gastric mucosal barrier. OTC preparation contain aspirin, such as alka-seltzer, bufferin, and excedrin. (Diana z)

Two days later Mr Ulcer rings his call light and when you go in the room you not a large amount of bright red emesis (approx 500mL). Mr Ulcer is pale and diaphoretic, he is very apprehensive.

First priority would be fluid volume loss, pt. is already has IV site but I would switch to an infusion normal saline or a lactate ringer. V/S drop in B/P can occur, rapid weak pulse indiction of shock Assess abdomen for distension, guarding and peristalisis Cap Refill, notes circulatory problems Urine Output / if urine appears concetrated could indicate Low Blood volume Assess neck vein for distension or lack there of Assess respiratory status, and maintain open airway (aspiration oof blood) All vital signs should be taken every 15 min until stable Urine output monitor hourly urine (Adria)
 * 1) What would be your first priority? What other nursing assessment would you complete and why?

Upon assessment Mr Ulcer complains of pain in his abdomen. Upon assessment, his abd is rigid and tense. He has absent bowel sounds.

Perforation of an ulcer. This occurs when the ulcer penetrates the serosal sruface, and spills either gastric or duodenal contents into the peritoneal cavity. s/s includes rapid onset of pain that spreads throughout the abdomen, shallow and rapid respiration, and absent bowel sounds (Nekita).
 * 1) What do you think is going on with Mr Ulcer?


 * 1) The provider orders the following labs:


 * CBC**
 * BUN**
 * Serum electrolytes**
 * Blood glucose**
 * Prothrombin time** **Liver enzymes**
 * ABGs**
 * Type/cross-match for possible blood transfusions**

CBC: Assess the level of Blood Loss BUN: If elevated it can indicate blood in the upper intestine Prothrombin Time assess for continued bleeding/ underlying coagulopathy. And Elevated Liver Funtion Test, Serum Electrolytes for any imbalances, ABG's Decrease Oxygen and increase PO2 indicate poor oxygen in the blood also Respiratory Acidosis can occur (Adria) The provider orders stools for occult blood x3.
 * 1) What is the purpose of these tests?

This test finds blood in the stool by placing a small sample of stool on a chemically treated card, pad, or cloth wipe. Then a special chemical solution is put on top of the sample. If the card, pad, or cloth turns blue, there is blood in the stool sample. Purpose is to find any hidden blood that can't be seen with the naked eye. ( Rachel )
 * 1) What is the purpose of the occult blood test?

The provider orders 2 units PRBC. You are going to transfuse them on your shift.

A blood specimen is drawn from the patient, so that the blood bank can type, match, and prepare the appropriate blood product. In most settings an armband is placed on the patient's wrist at the time of the blood draw with a number and name that will later match the blood product label. A physician or nurse will explain the procedure to the patient and obtain a signed informed consent for the transfusion. A physician or nurse will insert either a peripheral or central IV line and connect it to a normal saline drip with appropriate blood tubing and filters in place. If the patient has a PICC, it is better to start another peripheral IV to deliver blood because a PICC line has such a long narrow tubing that blood flows slowly through it and has a tendency to clog the line. Blood will flow most easily through a large bore (#18 or #19) needle or catheter. A blood pump, pressure bag, or blood warmer should be obtained if necessary. Blood warmers are most often used in the surgical or neonatal setting. Most IV pumps will pump blood without damaging the cells, but the medical center's policy should be checked for using blood pumps. The nurse should take and record a set of base-line vital signs, including the patient's bp, temperature,pulse, and respirations prior to transfusion. The patient should be placed in a comfortable position in bed during a transfusion to enhance relaxation and decrease resistance to the blood flow. ( Rachel )
 * 1) What would you need to prepare before infusing the PRBC? (IV, IV solution, etc). How would you infuse the PRBC?

Mr Ulcer receives his 2 units PRBC. The provider orders an endoscopy. Before the endoscopy the provider wants Mr Ulcer’s gastric area lavage.

This is most commonly done by placing a pt on suctioning. Ensure that the tube is in the stomach by checking pH, listening to whooshing sound of air after pushing 10mm. ( Rachel )
 * 1) How would you perform this?

Mr Ulcer returns to the floor with an unsuccessful endoscopy. The provider orders an angiography. Mr Ulcer is asking you what an angiography consist of.

What are other tests that can be performed for diagnostic purposes? Blood tests, endoscopy (as previously performed), PH monitoring, blood occult, stool tests, NG tube, gastroscopy, ECG. --Brandi
 * 1) What would you tell him? An angiography, aka “arteriography” is a medical test performed to visualize the inside of blood vessels and organs of the human body. This test plays close attention to the arteries, veins and chambers of the heart. Typically, this is done by injection of a contrast agent into the blood vessels and an x-ray imaging is used. It is used to diagnose bleeding and/or, in some cases, obstructions, within the vessels. --Brandi

> During his diagnostic tests, the provider notices a mod active bleed and performs an endoscopic hemostasis procedure and Pitressin IV. He returns to your unit. The provider orders Protonix 40mg IV daily. He is NPO. > What nursing assessment would you perform when Mr Ulcer returns from the above procedures? The patient had an endoscopic hemostasis This procedure is performed to control of bleeding, specifically to the patients GI tract, performed through the channel of the endoscope. Specific techniques are used and include: heat probes, local injection, lasers and bipolar electrocoagulation. Endoscopic hemostasis is commonly used to treat bleeding esophageal and gastrointestinal varices and ulcers. Pitressin, “Vasopressin”, is used to control the bleeding.--Brandi Assessments: Pain, Abd assessment, Bowel sounds/flatus, nausea and vomiting, assess stool, medications/allergies, LOC, airway, oral cavity--Brandi What are potential complications? What nursing interventions would you do for these complications? Uncontrolled pain:medicate PRN, proper body positioning…..Nausea/Vomiting-administer antiemetics-if unresolved call physician-assess the vomiting for color, characteristics, amount, consistency….Provide proper oral care to patient since oral cavity may become dry…..Patient may become constipated or have diarrhea-assess the stool for color, amount, consistency, odor-if orders for a stool softener are written, administer to patient-if unresolved or diarrhea persists call physican. Monitor patients airway at all times and provide the opportunity to facilitate oxygenation-if any difficulties should arise, treat patient and notify position. Endoscopic hemostasis may be unsuccessful and increase bleeding (small percentage)-assess bleeding from vomiting or stool and call physician.--Brandi Three days later Mr Ulcer has not active GI bleed, taking regular diet and is a planned discharge. You are the nurse assigned to him. > pt should be taught stress reduction techniques as relaxation helps decrease acid production and pain reduction. encourage the need to eliminate alcohol ingestion. pt should avoid smoking as it may promote the development of ulcers and delay ulcer healing. pt should avoid foods that cause epigastric distress such as spicy food, black pepper, and acidic foods. eating small frequent meals is better than large ones. pt should not take any OTC medications without consulting with physician. pt should not interchange antacids without consult physician. this practice can cause harmful side effects. pt should take all medication as prescribed. failure to do so may result in relapse. pt should report any nausea, vomiting, epigastric pain, bloody vomit, or tarry stools. encourage pt and family members to talk about their concerns about the required lifestyle changes when living with a chronic illness (Nekita)
 * 1) What health promotion discharge teaching would you do related to his GI bleed and ways to prevent?

Mr Ulcer is placed on ASA due to his newly diagnosed CAD and risk for clot formation.

Take ASA as prescribed. Take ASA with food to avoid irritation of the GI tract. Take a coated caplet to avoid gastric irritation. Notify provider if the following symptoms occur : black, bloody, or tarry stools, and coughing up blood or vomit that looks like coffee grounds. Ty to avoid drinking Alcohol which increases the risk of stomach bleed. (Adria) Mr Ulcer is discharge and controls his gastric secretions with no further episodes of bleeding.
 * 1) What are you going to tell him in relation to taking the ASA?