A patient with acute blood loss anemia and signs of hemodynamic instability is receiving a blood transfusion and IV fluids. Despite these interventions, the patient reports increased abdominal pain and new onset nausea. What is the most appropriate nursing action to take next?

A) Reassess the patient's vital signs and notify the physician immediately.

B) Administer anti-nausea medication to manage the patient's symptoms.

C) Increase the rate of IV fluid administration to stabilize blood pressure.

D) Prepare the patient for immediate surgical intervention.

A patient with acute blood loss anemia is receiving a blood transfusion and IV fluids. The nurse notes increased abdominal pain and new onset of nausea in the patient. Which nursing intervention is most appropriate to address the potential complication indicated by these symptoms?

C) Monitor vital signs closely and prepare for urgent colonoscopy.

A) Encourage the patient to ambulate to alleviate abdominal discomfort.

B) Administer prescribed antiemetic medication to manage nausea.

C) Monitor vital signs closely and prepare for urgent colonoscopy.

D) Increase the rate of IV fluid infusion to stabilize blood pressure.

A patient with a suspected bowel ischemia following a lower GI bleed presents with an elevated heart rate and low blood pressure despite initial interventions. Considering the new findings and the current clinical picture, which of the following nursing actions is the priority?

C) Increase the frequency of vital signs monitoring to every 15 minutes.

A) Administer additional IV fluids to manage hypotension.

B) Prepare the patient for possible surgical intervention as ordered.

C) Increase the frequency of vital signs monitoring to every 15 minutes.

D) Educate the patient about the potential need for surgery to alleviate anxiety.

A patient with a suspected ischemic colitis following a lower GI bleed presents with persistent abdominal pain and elevated lactate levels. As the nurse, which of the following interventions should be prioritized to address the patient's current condition?

A) Increase intravenous fluid administration to improve perfusion.

B) Administer an anxiolytic to reduce the patient's anxiety.

C) Prepare the patient for immediate surgical intervention based on CT findings.

D) Encourage oral intake to enhance nutritional support and tissue repair.

A patient with suspected ischemic colitis is exhibiting signs of systemic inflammatory response and neurological changes. Which nursing intervention is most critical to prioritize before the patient's exploratory surgery?

A) Administering prescribed broad-spectrum antibiotics immediately.

B) Monitoring vital signs every 4 hours to assess for stability.

C) Encouraging oral intake to prevent dehydration.

D) Educating the patient about the surgical procedure to reduce anxiety.

A patient with a suspected ischemic colitis is being prepared for exploratory surgery. The nurse notes that the patient has a low-grade fever, tachycardia, hypotension, hypoactive bowel sounds, and an increasing lactate level. What is the nurse's priority intervention to address the patient's current condition while awaiting surgery?

C) Increase the rate of intravenous fluids to improve hemodynamic stability.

A) Administer an antipyretic to address the fever.

B) Initiate a blood transfusion to correct the low hemoglobin level.

C) Increase the rate of intravenous fluids to improve hemodynamic stability.

D) Apply warm blankets to the patient to promote comfort.

A nurse is caring for a patient with suspected bowel perforation and signs of septic shock. Which intervention should the nurse prioritize to address the patient's hemodynamic instability?

B) Initiating norepinephrine infusion as ordered

A) Administering intravenous broad-spectrum antibiotics

B) Initiating norepinephrine infusion as ordered

C) Preparing the patient for an immediate CT scan

D) Providing supplemental oxygen via nasal cannula

A patient with a suspected bowel perforation and systemic inflammatory response syndrome (SIRS) is showing signs of respiratory compromise and hemodynamic instability. What is the nurse's priority intervention after initiating norepinephrine infusion?

A) Increase the patient's oxygen supplementation

B) Prepare the patient for immediate transport to the operating room

C) Insert a nasogastric tube to decompress the stomach

D) Administer additional broad-spectrum antibiotics

A patient is admitted to the ICU post-emergency laparotomy with a temporary colostomy in place. The nurse notes that the patient's blood pressure remains low despite vasopressor support, and urine output is minimal. The patient is also receiving a blood transfusion. What should be the nurse's priority intervention to assess the effectiveness of the current treatment plan?

A) Measure the patient's central venous pressure (CVP) to evaluate fluid status

B) Increase the rate of norepinephrine infusion to improve blood pressure

C) Monitor the patient's hemoglobin levels after transfusion to assess for bleeding

D) Assess the patient's abdominal dressing for signs of infection

A postoperative patient in the ICU following an urgent laparotomy with bowel resection and colostomy for necrotic bowel is showing signs of persistent hypotension, tachycardia, and decreased urine output, despite vasopressor support. Which of the following nursing actions is most appropriate to prioritize at this time?

B) Administer a bolus of intravenous crystalloid fluids.

A) Increase the rate of the norepinephrine infusion.

B) Administer a bolus of intravenous crystalloid fluids.

C) Monitor the patient closely for signs of infection.

D) Request a repeat hemoglobin level and consider transfusion.

Lower GI Bleed - Nursing Case Study

Pathophysiology

• Primary mechanism: Diverticulosis - Outpouchings in the colon wall, known as diverticula, can erode blood vessels. When these vessels rupture, they cause acute bleeding, often presenting as painless hematochezia (bright red blood per rectum).

• Secondary mechanism: Angiodysplasia - Abnormal, fragile blood vessels in the GI tract, particularly the cecum and right colon, are prone to rupture due to increased pressure or wall stress, leading to episodic bleeding.

• Key complication: Hemodynamic instability - Significant blood loss can lead to hypovolemia, resulting in hypotension, tachycardia, and potential shock if not promptly managed.

Patient Profile

Demographics:

65-year-old male, retired construction worker

History:

• Key past medical history: Hypertension, diverticulosis, and coronary artery disease

• Current medications: Lisinopril, aspirin, and atorvastatin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Blood in stool and dizziness

• Key symptoms: Melena, fatigue, and abdominal cramping

• Vital signs: Blood pressure 98/60 mmHg, heart rate 115 bpm, respiratory rate 22 breaths per minute, temperature 99.1°F

Section 1

As the nursing team continues to monitor the patient, his condition begins to evolve. During a routine check, new lab results reveal a hemoglobin level of 8.2 g/dL, significantly lower than the normal range and indicating the severity of the ongoing bleed. The patient also starts to exhibit signs of orthostatic hypotension, fainting briefly when attempting to sit up. His blood pressure drops to 85/55 mmHg, and his heart rate escalates to 125 bpm, signaling worsening hemodynamic instability. The combination of these findings points towards acute blood loss anemia and the need for immediate intervention to prevent further complications.

In response to these alarming changes, the healthcare team initiates a blood transfusion protocol to stabilize his hemoglobin levels and improve oxygen carrying capacity. Simultaneously, IV fluids are administered to address hypovolemia and support blood pressure. Despite these interventions, the patient reports increased abdominal pain and a new onset of nausea, raising concerns about potential bowel ischemia due to prolonged hypotension. The nursing team promptly communicates these developments to the attending physician, who orders an urgent colonoscopy to identify the exact source of the bleed and assess for any ischemic damage in the bowel.

These developments prompt the healthcare team to prioritize a multidisciplinary approach, involving gastroenterology and potentially surgical consultation, to manage the lower GI bleed effectively. The clinical reasoning process now focuses on balancing the need for rapid intervention to control bleeding while preventing further complications such as ischemia or shock. The patient's response to the transfusion and fluid resuscitation will be crucial in determining the next steps, guiding the team towards potential endoscopic or surgical interventions if the bleeding source proves elusive or refractory to medical management.

Section 2

As the healthcare team continues to monitor the patient, they observe a change in his status following the initial interventions. Despite receiving a blood transfusion and IV fluids, the patient's heart rate remains elevated at 118 bpm, and his blood pressure stabilizes only slightly at 92/60 mmHg. He continues to experience dizziness and reports persistent fatigue, indicating that while there is some stabilization, the interventions have not fully resolved his hemodynamic instability. The patient’s abdominal pain persists, and he becomes increasingly anxious, which could further complicate his condition by increasing his heart rate and potentially exacerbating his bleeding.

In the wake of these developments, the team receives new lab results showing a marginal improvement in hemoglobin levels to 9.0 g/dL, yet his lactate levels have increased to 3.2 mmol/L, suggesting ongoing tissue hypoperfusion and a risk of lactic acidosis. Concerned about possible bowel ischemia, the attending physician orders an abdominal CT scan with contrast to better visualize any ischemic areas and to assess the extent of the bleed. The CT scan reveals thickening of the bowel wall in a segment of the descending colon, consistent with potential ischemic colitis. This finding prompts the team to involve a surgical consult to evaluate whether surgical intervention might be necessary.

These findings lead the healthcare team to re-evaluate their management strategy, emphasizing the importance of continuous monitoring and reassessment. The possibility of surgical intervention looms closer as the team prepares for potential escalation of care. Meanwhile, they ensure the patient is kept hydrated and comfortable, adjusting fluids and analgesics as needed while maintaining close observation for any signs of deterioration or further complications. This stage of the patient's journey highlights the critical role of timely diagnostics and interdisciplinary collaboration in managing complex cases of lower GI bleed with potential ischemic involvement.

Section 3

As the healthcare team continues to navigate the complexities of this case, the patient's condition takes a concerning turn. During the evening rounds, the nurse notices that the patient has developed a low-grade fever of 100.4°F (38°C) and his heart rate has increased further to 124 bpm. His blood pressure, however, remains relatively unchanged at 90/58 mmHg despite ongoing fluid resuscitation. On auscultation, his bowel sounds are hypoactive, and he reports increased abdominal pain, now rated at 8/10, which is more diffuse than before. Additionally, the patient appears more lethargic and intermittently confused, raising concerns about his neurological status.

In light of these changes, the team decides to perform repeat laboratory tests. The results reveal a further drop in hemoglobin to 8.5 g/dL and an increase in lactate levels to 4.0 mmol/L, indicating worsening tissue hypoperfusion. His white blood cell count has also risen to 15,000 cells/mm³, suggesting a possible inflammatory or infectious process. The combination of fever, leukocytosis, and abdominal pain heightens the suspicion of ischemic colitis progressing to bowel necrosis or perforation, which could explain the systemic inflammatory response and neurological changes.

Recognizing the urgency of the situation, the surgical team is consulted again, and a decision is made to prepare the patient for exploratory surgery. The goal is to assess the viability of the affected bowel segment, address potential areas of necrosis, and prevent further complications such as peritonitis or septic shock. Meanwhile, the medical team focuses on optimizing the patient's hemodynamic status, administering broad-spectrum antibiotics, and continuing supportive care to stabilize him as much as possible before the surgical intervention. This critical juncture underscores the importance of dynamic clinical assessment and timely decision-making in the management of complex lower GI bleed cases with suspected ischemic involvement.

Section 4

As preparations for the exploratory surgery continue, the healthcare team remains vigilant in monitoring the patient's response to interventions. Despite the administration of broad-spectrum antibiotics and aggressive fluid resuscitation, the patient's condition becomes increasingly precarious. Over the next hour, his heart rate climbs to 132 bpm, and his blood pressure dips further to 86/52 mmHg, indicating worsening hemodynamic instability. His respiratory rate increases to 28 breaths per minute, and his oxygen saturation begins to drop to 92% on room air, suggesting the onset of respiratory compromise possibly linked to systemic inflammatory response syndrome (SIRS).

The surgical team conducts a focused reassessment, noting increased abdominal distension and guarding, which could signal the progression of bowel ischemia to potential perforation. In response, the team escalates the patient's care, initiating a norepinephrine infusion to support blood pressure and improve perfusion. Concurrently, they order a STAT abdominal CT scan with contrast to better delineate the extent of bowel involvement and identify any signs of perforation that might necessitate an urgent operative approach.

As the CT results come through, they reveal significant wall thickening and pneumatosis intestinalis in the descending colon, along with free air under the diaphragm, confirming the presence of bowel perforation. This critical finding shifts the surgical plan from exploratory assessment to an immediate laparotomy to resect the necrotic segment and manage any contamination. The patient is swiftly transferred to the operating room, illustrating the need for prompt and decisive action in the face of rapidly evolving complications. The healthcare team remains focused on stabilizing the patient and mitigating the risk of septic shock, emphasizing the complexities inherent in managing advanced lower GI bleed cases with ischemic complications.

Section 5

As the surgical team prepares for the urgent laparotomy, the patient's condition continues to evolve, prompting a reassessment of his clinical status. During preoperative evaluation, the nurse notes that the patient's heart rate has increased further to 140 bpm, and his blood pressure remains low at 82/50 mmHg, despite the norepinephrine infusion. His respiratory rate is now at 30 breaths per minute, and oxygen saturation has decreased to 89% on 3 liters of oxygen via nasal cannula. His skin is cool and clammy, suggestive of peripheral vasoconstriction, and there is a notable decrease in urine output to 15 mL/hour over the last two hours, indicating potential acute kidney injury secondary to hypoperfusion.

Laboratory results return with a significant leukocytosis at 18,000/mm³, elevated lactate levels at 4.5 mmol/L, and a drop in hemoglobin to 7.2 g/dL, reflecting ongoing bleeding and metabolic stress. The elevated lactate is particularly concerning, as it indicates widespread tissue hypoxia, compounding the risk of septic shock. The team recognizes the need to transfuse red blood cells urgently to address the anemia and improve oxygen-carrying capacity. Additionally, the elevated white blood cell count and the presence of free air in the abdominal cavity heighten the suspicion of an evolving septic process, further complicating the clinical picture.

In the operating room, the surgical team proceeds with the laparotomy, discovering extensive necrosis in the descending colon with significant purulent contamination of the peritoneal cavity. The decision is made to resect the necrotic bowel segment and perform a temporary colostomy to divert fecal matter and facilitate healing. Throughout the procedure, the anesthesiologist diligently monitors hemodynamics, adjusting vasopressor support as necessary to maintain adequate perfusion. The intraoperative findings confirm the severity of the patient's condition, underscoring the importance of swift surgical intervention to prevent further deterioration. As the surgical team works to stabilize the patient, the focus shifts to postoperative management, aiming to control infection, restore hemodynamic stability, and support recovery in the intensive care unit.