bloody poop - Nursing Case Study

Pathophysiology

• Primary mechanism: Gastrointestinal bleeding, which can occur due to ulcers, diverticulosis, or cancer. These conditions cause damage to the lining of the digestive tract, resulting in bleeding that can mix with stool.

• Secondary mechanism: Hemorrhoids and anal fissures. Swollen blood vessels in the rectum or anus (hemorrhoids) can bleed during bowel movements. Anal fissures (small tears) can also cause bleeding.

• Key complication: Iron deficiency anemia. Chronic blood loss can lead to a decrease in red blood cells, causing fatigue, weakness, and other symptoms of anemia.

Patient Profile

Demographics:

53, Male, Construction Worker

History:

• Key past medical history: Hypertension, Peptic Ulcer Disease

• Current medications: Lisinopril, Omeprazole

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Bloody stools for the past week

• Key symptoms: Abdominal pain, fatigue, lightheadedness, black tarry stools

• Vital signs: Blood Pressure 160/95 mmHg, Pulse 105 bpm, Temperature 98.6 F, Respiratory rate 18 breaths per minute

Section 1

New Diagnostic Results:

The physician ordered a complete blood count (CBC), liver function tests, and stool guaiac test. The CBC results revealed a hemoglobin level of 9.2 g/dL, suggesting mild anemia. The mean corpuscular volume (MCV) was 78 fL, indicating that the red blood cells were smaller than normal - a characteristic of iron deficiency anemia. The liver function tests were within normal limits, which was reassuring as it ruled out liver disease as a potential cause of the bleeding. However, the stool guaiac test was positive for occult blood, confirming gastrointestinal bleeding.

Change in Patient Status:

Mr. Smith's symptoms appeared to progressively worsen. He reported feeling increasingly lightheaded, weak, and his fatigue was intensifying. His pulse increased to 115 bpm and blood pressure dropped to 140/85 mmHg. The paleness of his skin and mucous membranes was noticeable, indicating reduced oxygen delivery to his tissues due to anemia. The continued presence of black, tarry stools suggested ongoing slow gastrointestinal bleeding.

This change in status necessitated a reevaluation of Mr. Smith's condition and a need for immediate interventions. The challenge was to identify the source of the bleeding and manage it promptly while stabilizing the patient's condition. The clinical data suggested an exacerbation of his peptic ulcer disease, possibly due to an interaction between his hypertension medication and the omeprazole, or due to other risk factors such as stress or alcohol consumption. It was crucial to control his blood pressure and heart rate, manage his anemia, and address the underlying cause of his gastrointestinal bleeding.

Section 2

New Diagnostic Results:

The physician ordered an esophagogastroduodenoscopy (EGD) to identify the source of the gastrointestinal bleeding. The EGD revealed a bleeding peptic ulcer in the duodenum, confirming the suspicion. A Helicobacter pylori breath test was also conducted, which came back positive, suggesting that an H.pylori infection might have contributed to the peptic ulcer.

Response to Interventions:

Following the diagnostic results, the physician started Mr. Smith on a triple therapy regimen to eradicate the H.pylori infection, consisting of a proton pump inhibitor (PPI), clarithromycin, and amoxicillin. Additionally, an intravenous iron supplement was administered to address the iron deficiency anemia. His blood pressure and heart rate were stabilized with a beta-blocker. His response to the interventions was monitored with regular check-ins.

After two days of therapy, Mr. Smith reported a slight decrease in fatigue and lightheadedness, and his heart rate reduced to 100 bpm. His blood pressure remained stable at 140/85 mmHg. However, his stools still appeared tarry, indicating continued slow gastrointestinal bleeding. The clinical team needed to reassess the management plan and consider additional interventions, possibly including an endoscopic procedure to stop the bleeding from the ulcer. The challenge was to manage the ongoing bleeding while dealing with the potential side effects of the triple therapy, including nausea, diarrhea, and possible allergic reactions.

Section 3

New Complications:

On the third day of therapy, Mr. Smith began to report abdominal pain and frequent bouts of diarrhea. On examination, his abdomen was distended and tender in the epigastric region. His temperature was slightly elevated at 38.2°C, and his heart rate increased again to 110 bpm. These symptoms raised concerns about a possible perforation of the peptic ulcer or an adverse reaction to the triple therapy regimen.

As part of the clinical reasoning process, the team ordered a repeat EGD, a complete blood count (CBC), and a stool test to differentiate between the two possibilities. The EGD would confirm or rule out a perforation, while an increase in the white blood cell count in the CBC might indicate an infection or inflammation. The stool test could identify undigested medications or changes in gut flora, which would suggest an adverse reaction to the triple therapy. The team also considered discontinuing the current regimen and switching to a different antibiotic to manage the H.pylori infection if the patient was indeed experiencing adverse effects from the medication.

Section 4

New Diagnostic Results:

The results from the diagnostics came back revealing significant findings. The EGD showed no signs of perforation, ruling out a perforation of the peptic ulcer. However, the CBC results showed an elevated white blood cell count of 15,000 per microliter, suggestive of inflammation or infection. Furthermore, the stool test indicated a presence of Clostridium difficile (C. diff), a bacteria that can cause symptoms ranging from diarrhea to life-threatening inflammation of the colon. This result brought into consideration the possibility of antibiotic-associated diarrhea, a common side effect of many antibiotics, including those in the triple therapy regimen.

These findings necessitated further clinical reasoning to manage Mr. Smith's condition. The team needs to decide whether to continue with the current antibiotics and manage the diarrhea with probiotics or other medications, or to switch to another antibiotic and risk the recurrence of H. pylori infection. It also highlighted the importance of monitoring the patient's clinical signs closely, as a worsening of the diarrhea or a further increase in the white blood cell count could indicate a severe C. diff infection that might require more aggressive treatment.

Section 5

Further monitoring of Mr. Smith's condition revealed a new complication: his diarrhea had become more frequent and severe, accompanied by abdominal cramping. His vital signs remained stable with a blood pressure of 130/80 mmHg, a heart rate of 85 beats per minute, a respiratory rate of 16 breaths per minute, and a temperature of 37.8°C. However, his intestinal discomfort was clearly escalating, disrupting his sleep and increasing his anxiety levels.

Emphasizing the need for clinical reasoning, the team had to consider the possibility that the C. diff infection was progressing, potentially towards a more severe condition such as pseudomembranous colitis. The increase in frequency and severity of diarrhea, despite the administration of probiotics and hydration efforts, supported this possibility. The team decided to order a repeat stool test and a CT scan of the abdomen to ascertain the extent of the C. diff infection and any possible bowel inflammation. The choice of continuing the current antibiotics, which might be exacerbating the C. diff infection, or switching to a different antibiotic regimen would depend on the results of these tests. This situation underscored the need for a careful balance in managing Mr. Smith's H. pylori infection and the emerging C. diff infection.