Case Study: Bleeding

Group 3: Christine Dimaano, Amie Howard,

Christina Jue, Julia Nyznyk, Lindsay Umeda
Bruce G, aged 59 years, was admitted from the ED after he came
in with complaints of dizziness, dyspnea, and anxiety. He reported
a 2 day history of hematemesis with some bright red blood and
large amounts of coffee ground material. Mr. G denied any chronic
illnesses and did not remember any family history. He did admit to
drinking 6-8 alcoholic beverages a day almost every day for the
past 7 years. He also remembered that he had been told that he
had Hepatitis C, probably from a blood transfusion in the past.

Primary Diagnoses
! Upper Gastrointestinal Bleed
secondary to...
! Laennecs Cirrhosis
Pathophysiology
! Hx of hepatitis C & excessive alcohol consumption"
! Cirrhosis: fibrosis" obstruction of biliary and vascular
channels" increased pressures in portal vein
! Portal Hypertension!
o Gastroesophageal varices! bleeding!
Hypovolemic shock
o Ascites d/t decreased oncotic pressure
o Splenomegaly! anemia & thrombocytopenia
o Hepatic Encephalopathy! altered LOC
Bruce G, aged 59 years, was admitted from the ED after he came
in with complaints of dizziness, dyspnea, and anxiety. He
reported a 2 day history of hematemesis with some bright red
blood and large amounts of coffee ground material. Mr. G
denied any chronic illnesses and did not remember any family
history. He did admit to drinking 6-8 alcoholic beverages a day
almost every day for the past 7 years. He also remembered that he
had been told that he had Hepatitis C, probably from a blood
transfusion in the past.

Critical Assessments
Upon admission
! Dizziness, dyspnea, anxiety # bleeding and hypovolemia
! Two-day Hx of bloody emesis
o some bright red blood # esophageal bleed
o large amounts of coffee ground blood # gastric bleed
! Health Hx " predisposes patient to cirrhosis
o Hepatitis C
o 6-8 alcoholic drinks/day almost everyday for 7 years
Critical Assessments (cont.)
Physical examination
! Vitals: BP 92/60 LOW, 120/min HIGH,
RR 28/min HIGH, T 36.9
! Cool, clammy skin # low blood volume d/t bleed
! Abdomen distended with hypoactive bowel sounds #
ascites secondary to portal hypertension
! Spider angioma around umbilicus # poor hepatic
metabolism of estrogen ! elevated estrogen
! Multiple purpural areas on legs and arms #
thrombocytopenia and bleeding

Spider angioma
Purpura
Laboratory Findings
Patients Labs Normal Ranges Evaluation
Ammonia: 60 ug/dl
19-60 ug/dl Upper limit: poor liver detoxification of
ammonia from blood
Glucose: 87 mg/dl
60 - 110 mg/dl --
LDH: 500 units/L
140-280 units/L HIGH: liver tissue damage
AST: 950 units/L
8-20 units/L HIGH: liver tissue damage
ALT: 1000 units/L
10-40 units/L HIGH: liver tissue damage
ALP: 165 units/L
25-100 units/L HIGH: liver damage and/or biliary
obstruction
Laboratory Findings (cont.)
Patients Labs Normal Ranges Evaluation
Total Bili: 2.5 mg/dl
0.3-1.2 mg/dl HIGH: poor liver metabolism of bilirubin;
and/or increased hemolysis by spleen
Albumin: 2.5 g/dl
3.4-4.8 g/dl LOW: poor liver synthesis of albumin &
third spacing of plasma and albumin
PT, INR: 26 sec, 2.0
11-14 sec, 0.8-1.2 HIGH: delayed clot formation
PTT: 85 sec
25-35 sec HIGH: delayed clot formation
Hgb/Hct: 9/22% Male: 13.5-17.5 g/dl,
41-53%
LOW/LOW: bleeding and anemia
Medical Treatment Plan
Medical Orders Rationale
IV NS via 18G angiocath @ 125ml/hr Fluid resuscitation to restore blood volume
2 units PRBCs Treat anemia by restoring H&H
Foley catheter Closely monitor urine output
NGT to low suction, preceded by
saline lavage
Used to remove particulate matter and blood
clots in preparation for EGD
Schedule an EGD
(esophagogastroduodenoscopy)
Examine lining of esophagus, stomach, and
duodenum with possible biopsy; diagnosis
source of bleed
Esophageal Varices
Priority Nursing Care Issues
! Deficient fluid volume related to abnormal loss of fluid from trauma to
epithelial lining of upper GI system AEB hypotension, tachycardia, low
hemoglobin and hematocrit and signs of bleeding: hematemesis, purpura
on extremities and spider nevi on umbilicus

! Ineffective breathing pattern related to poor perfusion and decreased
diaphragmatic excursions and pressure on diaphragm from ascites AEB
distended abdomen, dyspnea and tachypnea

! Decreased cardiac output related to decreased blood volume and
ventricular filling AEB cool, clammy skin and hypotension with tachycardia

Diagnosis Interventions
Outcomes
Deficient
fluid volume
! Monitor VS Q15 min until stable
! Weigh patient daily
! Ensure patency of IV and fluids
! Monitor I&O
! Urine output of $ 30/ml/hr
! Normotensive BP and HR of 100
! No weight loss greater than 5%
Ineffective
breathing
pattern
! Auscultate breath sounds
! Be prepared for paracentesis
! Encourage position changes
! HOB elevated
! Monitor RR, depth and effort
! Teach deep breathing exercises
! Maintain soothing/calm and quiet
environment
! Maintain effective respiratory pattern
! Be free of dyspnea
! ABGs within acceptable range
! Lungs clear to auscultation
Decreased
cardiac
output
! Assess pulses, skin color and
temperature
! Restrict activity
! Cluster care
! Provide calm environment
! Monitor effects of IV fluids
! HR within patients normal range
! Demonstrate an increase in activity
tolerance
! Patient maintains BP within normal limits
! Warm, dry skin
! Equal peripheral pulses.
! Anxiety related to situational crisis and initial alcohol withdrawal AEB
subjective report of anxiety and chronic alcohol abuse
% Interventions: Identify and explain anxiety & withdrawal referrals,
reorient patient, explain care and provide choices when available.
% Outcomes: reduction of anxiety, sense of regaining some control of
situation/life, demonstrate problem-solving skills and use resources
effectively

Nursing Care
Nursing Care
! Imbalanced nutrition: less than body requirements related to inability
to ingest and digest food due to biologic factors AEB by albumin lab result
of 2.5 g/dl
% Interventions: Monitor and record percentage of meals eaten, offer
high protein, high calorie snacks often, request diet consult, provide
oral hygiene before meals.
% Outcomes: Weight within normal range for client, normal BUN and
serum albumin, Hct, Hb, no further decline in strength and activity
tolerance, healthy oral mucous membrane.
Nursing Care
! Chronic confusion related to neurological effects of chronic alcohol intake
AEB ammonia lab value of 60ug/dl and unclear self-reporting of medical
history
o Interventions: Assess mental status,neuro check, orient patient to
person, place & time, monitor for s/s of delirium, evaluate and suggest
medications for hepatic encephalopathy
o Outcomes: AxOx3 each shift, demonstrate appropriate motor behavior
at each VS check, ammonia level within acceptable range by end of
stay
Addl Nursing Care Issues
! Pain
! Risk for injury
! Immobility
! Fatigue
! Dysfunctional family processes
! Knowledge deficit
! Disturbed body image
! Sensory-perceptual alterations
! Risk for violence d/t withdrawal
! Altered health maintenance
! Ineffective coping
! At risk for aspiration
Anticipate withdrawal and CIWA
Literature Review
! The American College of Surgeons recommends crystalloids for fluid
replacement, the most commonly used crystalloid being normal saline at
0.9% concentration.

! Crystalloid solutions help expand intravascular volume and maintain
adequate blood pressure without altering cellular fluid shifts (Moranville,
Mieure & Santayana, 2011).

This patients normal saline is being given at a rate of 125 ml/hr.

! Kilic, Konan & Kaynaroglu (2011) support this controlled rate, asserting that
patients who have a variceal bleed should be more conservatively
resuscitated to avoid a rebound increase in portal pressure, which may
exacerbate bleeding.



Literature Review



! Administration of packed red blood cells is a standard in GI bleed care, as
approximately 70% of patients admitted to ICU for GI bleeding and 85% of
patient with bleeding varices receive a blood transfusion(Kilic, Konan, &
Kaynaroglu, 2011).

Questions?