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OUR LADY OF FATIMA UNIVERSITY COLLEGE OF NURSING

Nursing Management of Patient with Upper Gastrointestinal Bleeding

Submitted by: Fatima Mae D.L. Panganiban BSN 3Y3 -8D

Submitted to: Mrs. Eden Salazar, RN

Nursing Management of Patient with Upper Gastrointestinal Bleeding CLR, an 84 year old female with a medical history of nonerosive gastritis last July 2011, was diagnosed with upper gastrointestinal bleeding probably secondary to BPUB:

Cardiovascular infarct, left MCA distribution. The patient had therapeutic procedure that is colonoscopy with SNARE

polypectomy in November 16, 2011. Patient was admitted in November 6, 2011 at 3:18pm. Patients chief complaint was generalized body weaknesses and it is the reason for the patient to be admitted in AFPMC for the 4th time. The patient was a previous smoker 3 years ago.

Pathophysiology Acute gastrointestinal (GI) bleeding is a potentially lifethreatening abdominal emergency that remains a common cause of hospitalization. Upper gastrointestinal bleeding (UGIB) is defined as bleeding derived from a source proximal to the ligament of Treitz. The incidence of UGIB is approximately 100 cases per 100,000 populations per year. Bleeding from the upper GI tract is approximately 4 times as common as bleeding from the lower GI

tract and is a major cause of morbidity and mortality. Mortality rates from UGIB are 6-10% overall. The diagnosis of and therapy for nonvariceal upper gastrointestinal bleeding (UGIB) has evolved since the late 20th century from with passive medical diagnostic therapy until

esophagogastroduodenoscopy

surgical intervention was needed to active intervention with endoscopic techniques followed by angiographic and surgical approaches if endoscopic therapy fails. Variceal hemorrhage is not discussed in this article because the underlying mechanisms of bleeding are different and require different therapies. The underlying mechanisms of nonvariceal bleeding

involve either arterial hemorrhage, such as in ulcer disease and mucosal deep tears, or low-pressure venous hemorrhage, as in telangiectasias and angioectasias. In variceal hemorrhage, the underlying pathophysiology is due to elevated portal pressure transmitted to esophageal and gastric varices and resulting in portal gastropathy.

History Patients has a known case of non-erosive gastritis last July 2011 but was also admitted to the institution last April 2011 with a case of UGIB to BPUD and was then maintained on Esomeprazole 40mg/tab 1tab BID in 6 weeks and Refamide 100mg/tab 1tab TID. On her readmission last October 2011, patient went home against medical advice and was prescribed with Pantoprazole 40mg/tab 1tab ODBB for 4weeks. After the patients discharged, her meloma did not restore. No follow-up consult was done. 4days after discharge, she complained of generalized body weakness associated with loss of appetite. 4days prior to admission, patient had 4episodes of loss bowel movement, blackish in color amounting to 2 cup. Other associated signs and symptoms include occasional burning, epigastric pain and dizziness. No vomiting noted. Persistence of symptoms prompted consult hence admission.

Nursing Physical Assessment CLR was alert, conscious, oriented and coherent to person, place and time. She is not in cardio respiratory distress or in any alarming event. Her first vital signs upon admission were that her temperature was 36.7C, her pulse rate was 90bpm, her respiratory rate was 20cpm and her blood pressure was 110/70. Patients HEENT results had antistatic schlera, pink palpated conjunctivae, no neck vein engorgement. Chest exam results were symmetrical chest expansion, no retraction and with clean breath sound. In cardiovascular system has dynamic permission, has normal rate with regular rhythm and with no murmurs. In abdomen exam, the results were flabby, soft, no-tenders and no palpable mass. Extremities are full and with equal pulse, no edema. Rectal exam has positive dark stool upon examining with finger, has good sphincter with no mass. Active problem is melena. In her system review, she has no cough, chest pain, cold or difficulty in breathing. She is positive with hypertension but had maintained on Telmisartan. Also, she had no Diabetes Mellitus or allergy in medicines. Ionized calcium is higher than normal that is 1.15mmo/L upon receiving her laboratory test in November 19, 2011. Creatinine is normal. There is a decrease of

Hematocrit and Hemoglobin and increase in WBC. CK-total is higher than normal and sodium level is low. Related Treatment The patient had her radiologic test on November 6, 2011 and in her results, there are 3 defined opacities seen in the left upper lung. Her heart is not enlarged. Aorta is calcified. Her right hemidiaphragm is elevated while the left hemidiaphragm and sulci are intact. There are degenerative changes seen on the visualized osseous structures. The impression is that she has PTB. Atheromators aorta and elevated right hemidiaphragm considerations are: liver pathology, phrenic nerve paralysis, eventration and degenerative osteoarthritis. On her CT-scan of the whole abdomen shows that she has multiple contrast-enhanced axial images reveal a normal-sized liver with a well defined non-contrast enhancing oyst in segment 5 measuring 2 x 1.3 cm and without intrinsic mass or calcifications. The hepatic surface is smooth. There is segmental gaseous dilatation of the small intestine and colon due to a dyanamic ileus. The pancreas, spleen, adrenal, kidneys, ureters, urinary bladder and stomach as well as the lymph nodes and peritoneum are unremarkable save for few benign left renal cortical cysts. No lytic bone lesion is seen. Impressions are

hepatic cyst, dynamic ileus and no intra-abdominal mass or enlarged lymph nodes. Medicines that are prescribed are given at the exact time of medication. Cefepime 1g/IV q12 anti-infective/cepholosporin Erythropoietin B5000 (once a week with BP precaution) immunomodulators/ biological response modifiers Esomeprazole 40mg/tab 1tab ODBB antiulcer drug Rebamepide 100mg/tab 1tab TID antacid drug Simvastatin 40mg/tab 1tab ODHS antilipemic drug Trifusal 300mg/cap 1cap TID antiplatelet agent drug

Nursing Care Plan CLRs nursing diagnosis is intolerance related to generalize weakness as manifested by discomfort, fatigue and dizziness. Patient feels discomfort, fatigue, dizziness. She has a

temperature of 36.7C, pulse rate of 90bpm, respiratory of 20cpm, and a blood pressure of 110/70. Patient verbalized that she her body weakens. The nursing goal to the patient is that in short term: after 30 to 60 minutes of nursing intervention, the patient will be able to: Participate in necessary physical activity with appropriate increases in blood pressure and monitor patterns with in normal

limits. Identify activities or anxiety. To producing situations that may contribute to activity intolerance. While on long term: after 2 to 4hours of nursing intervention, the patient will be able to: Balances activity and rest. Perform home maintenance

management with some help. Verbalize understanding of need for medications that may increase tolerance for activities. The nursing interventions to the patient in independent are, note client reports of weakness, difficulty in accomplishing task. The rationale behind this is symptoms may be result or contribute to intolerance of activity. Assess nutritional status. The rationale behind this is adequate energy reserves are requirements for activity. Provide positive atmosphere, while acknowledging difficulty of the situation for the client. The rationale behind this is it helps to minimize frustration and rechannel energy. In dependent interventions are Adjust activities to prevent overexertion. The rationale behind this is to reduce intensity level or discontinues activity that causes undesired physiological changes. Monitor response to supplemental

medication and changes in regimen. The rationale behind this is to monitor the effect of the medications that were given. Note treatment-related factors, such as side effects/interaction

of medication. The rationale behind this is to monitor the effect of the medications that were given. Provide referrals to other

disciplines such as exercise physiologist, recreational/leisure specialist, as indicated. The rationale behind this is to develop individually appropriate therapeutic regimens. On short term intervention, after 30to 60 minutes of nursing intervention, the patient was able to: Participate in necessary physical activity with appropriate increases in blood pressure and monitor patters with in normal limits. Identify activities or anxiety-producing situations that may contribute to activity intolerance. While on long term intervention, after 2 to 4hours of nursing intervention, the patient was able: Balances activity and rest. Perform home maintenance management with some help Verbalize understanding of need for medications that may increase tolerance for activities.

Recommendation The patient should follow up with her physician regarding to her condition, medications and therapy. The patient should also follow up her nutritionist about her dietary needs. Her diet must include low-cholesterol, low-fat diet. Also, she must maintain her prevention to smoking. She must also live a healthier lifestyle, have lesser stress activities and thing that can exhaust the patient rapidly. The patient must also take her

maintenance and supplemental medicines to lessen the risk of being ill again. The nurse must orient the patient about her condition and the risk factors that she may encounter once outside the hospital ground. Advice and teach her the importance of weekly check-up to her physician. The nurse must also orient the relatives about the condition of the patient and help the patient to feel better upon leaving the hospital care.

Reference

http://emedicine.medscape.com/article/187857-overview http://www.scribd.com/