A patient with a history of peptic ulcer disease and suspected portal hypertension is admitted with signs of hypovolemic shock due to a bleeding gastric ulcer. Despite initial fluid resuscitation, his condition is only marginally improved. What is the most appropriate nursing intervention to prioritize after initiating blood transfusion?

C) Assess the patient's oxygen saturation and administer supplemental oxygen if needed.

A) Monitor the patient's vital signs every hour.

B) Prepare the patient for an urgent surgical consult.

C) Assess the patient's oxygen saturation and administer supplemental oxygen if needed.

D) Educate the patient about dietary changes to prevent future ulcers.

A patient is admitted with signs of hypovolemic shock and is found to have a bleeding gastric ulcer with esophageal varices. After initial stabilization with IV fluids and a blood transfusion, which nursing intervention is most critical to prioritize in managing this patient's condition and preventing further complications?

B) Administer prescribed proton pump inhibitor to reduce gastric acid secretion.

A) Monitor vital signs every 4 hours to assess for stability.

B) Administer prescribed proton pump inhibitor to reduce gastric acid secretion.

C) Prepare the patient for a repeat endoscopy to monitor for re-bleeding.

D) Educate the patient on the importance of avoiding NSAIDs to prevent ulcer exacerbation.

A patient who recently underwent an endoscopic intervention is now experiencing increasing abdominal distension, tenderness, and respiratory distress. Which nursing intervention should be prioritized to address the patient's current symptoms?

B) Prepare the patient for therapeutic paracentesis to relieve abdominal pressure

A) Administer supplemental oxygen to maintain saturation above 94%

B) Prepare the patient for therapeutic paracentesis to relieve abdominal pressure

C) Educate the patient on dietary modifications to manage ascites

D) Initiate a fluid restriction protocol to prevent further ascites accumulation

A patient with confirmed ascites and suspected portal hypertension is experiencing increased abdominal distension and respiratory distress. As the nurse, what is your priority intervention to address the patient's respiratory compromise?

B) Prepare the patient for therapeutic paracentesis as ordered by the healthcare provider

A) Administer supplemental oxygen to maintain oxygen saturation above 94%

B) Prepare the patient for therapeutic paracentesis as ordered by the healthcare provider

C) Position the patient in high Fowler's position to facilitate lung expansion

D) Educate the patient about the importance of a low-sodium diet to manage ascites

A patient with suspected cirrhosis who recently underwent therapeutic paracentesis is now experiencing new-onset confusion and disorientation. Which nursing intervention is the priority to address the suspected hepatic encephalopathy?

B) Initiating lactulose therapy to reduce serum ammonia levels

A) Administering intravenous fluids to prevent dehydration

B) Initiating lactulose therapy to reduce serum ammonia levels

C) Preparing the patient for an immediate liver biopsy

D) Encouraging high-protein meals to support liver function

A patient with suspected cirrhosis has undergone therapeutic paracentesis and is now experiencing new-onset confusion and disorientation. The serum ammonia level is elevated, and lactulose therapy has been initiated. As the nurse, what is the most important assessment to prioritize in order to ensure the efficacy and safety of the lactulose treatment?

A) Monitor the patient's bowel movement frequency and consistency.

B) Measure the patient's blood pressure and heart rate regularly.

C) Assess the patient's skin for signs of jaundice.

D) Evaluate the patient's dietary intake for protein content.

A patient with a history of cirrhosis presents with hematemesis, hypotension, and tachycardia. The healthcare team initiates fluid resuscitation and plans for endoscopic intervention. Which nursing intervention should be prioritized to stabilize the patient's condition while awaiting endoscopic procedure?

C) Administer intravenous proton pump inhibitors as prescribed.

A) Administer oral antacids to neutralize stomach acid.

B) Position the patient in a high Fowler's position to facilitate breathing.

C) Administer intravenous proton pump inhibitors as prescribed.

D) Encourage the patient to drink clear fluids to maintain hydration.

A patient with cirrhosis is experiencing hematemesis and signs of hemodynamic instability. After initial resuscitative measures, which nursing action should be prioritized to effectively manage the patient's condition?

B) Prepare the patient for an urgent endoscopy to identify and control the bleeding source.

A) Increase the rate of isotonic saline infusion to improve blood pressure.

B) Prepare the patient for an urgent endoscopy to identify and control the bleeding source.

D) Monitor the patient for signs of transfusion reaction after blood transfusion.

A patient with advanced liver disease underwent endoscopic variceal ligation for bleeding esophageal varices. Post-procedure, the patient exhibits hemodynamic instability, low hemoglobin levels, and signs of altered mental status. Which nursing action is the priority in managing this patient's condition?

A) Administer lactulose to address potential hepatic encephalopathy.

B) Prepare the patient for a balloon tamponade procedure.

C) Monitor the patient's neurological status closely.

A patient with advanced liver disease has undergone endoscopic variceal ligation due to active esophageal variceal bleeding. Post-procedure, the patient remains hemodynamically unstable and shows signs of altered mental status. Which nursing intervention is the priority to address the potential complication of hepatic encephalopathy?

A) Administer lactulose as prescribed to reduce ammonia levels.

B) Increase the IV fluid rate to correct hypotension.

C) Position the patient in a semi-Fowler's position to improve breathing.

D) Prepare for immediate endotracheal intubation to secure the airway.

GI bleed - Nursing Case Study

Pathophysiology

• Primary mechanism: Ulceration in the gastrointestinal tract, often due to peptic ulcer disease, leads to erosion of blood vessels, causing bleeding. Acidic gastric secretions can exacerbate this erosion, leading to more significant blood loss.

• Secondary mechanism: Portal hypertension, commonly resulting from liver cirrhosis, can cause varices (enlarged veins) in the esophagus and stomach. Increased pressure in these fragile vessels can lead to rupture and significant hemorrhage.

• Key complication: Hemodynamic instability due to acute blood loss can result in hypovolemic shock, requiring prompt fluid resuscitation and blood transfusion to restore circulatory volume and maintain organ perfusion.

Patient Profile

Demographics:

65-year-old male, retired construction worker

History:

• Key past medical history: Hypertension, peptic ulcer disease, Type 2 diabetes

• Current medications: Lisinopril, Metformin, Omeprazole

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Dark, tarry stools for 3 days

• Key symptoms: Abdominal pain, fatigue, dizziness, nausea

• Vital signs: Blood pressure 100/60 mmHg, heart rate 112 bpm, respiratory rate 22 breaths per minute, temperature 98.6°F, oxygen saturation 94% on room air

Section 1

As the clinical team continues to assess the patient, they note a further decline in his hemodynamic status. His blood pressure has dropped to 90/55 mmHg, and his heart rate has increased to 120 bpm, indicating worsening hypovolemia. The patient's skin appears cool and clammy, and he reports feeling increasingly lightheaded, particularly when attempting to sit up. This change in vital signs, combined with symptoms of weakness and dizziness, suggests progression towards hypovolemic shock. The team promptly initiates intravenous fluid resuscitation with crystalloids to stabilize his blood pressure and improve circulation. Despite these efforts, the patient shows only marginal improvement, necessitating further intervention.

New diagnostic results from a complete blood count reveal a significant drop in hemoglobin levels to 7.5 g/dL, confirming substantial blood loss. The patient's hematocrit is also decreased, reinforcing the need for a blood transfusion to address anemia and restore oxygen-carrying capacity. In addition, liver function tests indicate elevated liver enzymes, raising concern for potential liver involvement or exacerbation of existing liver pathology, which may contribute to portal hypertension. Given these findings, the healthcare team orders a stat crossmatch for packed red blood cells and arranges for an urgent endoscopy to locate and treat the source of the bleeding.

The endoscopic procedure reveals a large, actively bleeding gastric ulcer, which is managed with endoscopic intervention to control the hemorrhage. However, during the procedure, the team observes signs of esophageal varices, suggesting possible underlying portal hypertension. This discovery prompts a reassessment of the patient's condition, as the coexistence of peptic ulcer disease and portal hypertension could lead to further complications. As the team plans the next steps, they consider the need for ongoing monitoring, potential surgical consultation, and adjustments to the patient's medication regimen to prevent future episodes and manage his complex gastrointestinal and hepatic conditions.

Section 2

Following the endoscopic intervention, the patient's condition initially stabilizes, but within a few hours, new complications arise. The patient begins to exhibit increasing abdominal distension and tenderness, accompanied by a gradual rise in his respiratory rate to 28 breaths per minute and a decrease in oxygen saturation to 92% on room air. These changes suggest the development of secondary complications, possibly related to the intervention or underlying conditions. A repeat abdominal examination reveals a shifting dullness, indicating the accumulation of fluid in the abdominal cavity, likely ascites, which could be secondary to portal hypertension or acute inflammatory processes.

Further diagnostic evaluations are promptly ordered, including an abdominal ultrasound, which confirms the presence of significant ascites and reveals dilated portal and splenic veins, reinforcing the suspicion of portal hypertension complications. Additionally, repeat blood work shows a further drop in platelet count to 80,000/mm³, raising concerns about coagulopathy and increased bleeding risk, possibly due to liver dysfunction or hypersplenism. This finding necessitates a careful review of the patient's coagulation profile and consideration for platelet transfusions or other interventions to prevent hemorrhagic complications.

The healthcare team decides to initiate therapeutic paracentesis to relieve the abdominal pressure and improve respiratory function. They also consult with a hepatologist to assess the need for long-term management strategies, such as beta-blockers for portal hypertension and potential liver biopsy to evaluate underlying cirrhosis. These steps aim to address both the immediate and chronic aspects of the patient's condition, balancing the acute stabilization with preventive measures to mitigate future risks. As the patient's journey continues, the team remains vigilant in monitoring for signs of hepatic encephalopathy or further decompensation, anticipating the need for additional interventions.

Section 3

As the healthcare team proceeds with the therapeutic paracentesis, they note an initial improvement in the patient's respiratory status, with the respiratory rate decreasing to 22 breaths per minute and oxygen saturation improving to 95% on room air. The patient reports feeling less abdominal discomfort, and the abdominal distension visibly decreases post-procedure. However, during the follow-up assessment, the nurse observes new-onset confusion and disorientation, raising concerns about hepatic encephalopathy, a potential complication given the suspected underlying liver dysfunction.

The team promptly orders a serum ammonia level, which returns elevated at 85 µmol/L, confirming the suspicion of hepatic encephalopathy. This finding necessitates immediate intervention to manage the patient's altered mental status. Lactulose is initiated to reduce ammonia levels, with careful dosing to balance efficacy with the risk of diarrhea, which could exacerbate the patient's fluid and electrolyte imbalances. The healthcare team also considers the potential need for rifaximin as an adjunct therapy if the patient's mental status does not improve with lactulose alone.

Meanwhile, repeat liver function tests reveal worsening liver parameters, with an increase in bilirubin to 3.5 mg/dL and a further decline in albumin to 2.8 g/dL. These results, coupled with the ongoing thrombocytopenia and signs of portal hypertension, suggest significant liver impairment, likely cirrhosis. The hepatologist recommends a liver biopsy to confirm the diagnosis and guide future management. As the team prepares for this next step, they remain vigilant for signs of further deterioration, such as worsening encephalopathy or new bleeding episodes, ensuring that the patient receives comprehensive care at this critical juncture.

Section 4

As the clinical team continues to monitor the patient's condition, they note a new development during the next assessment. The patient begins to exhibit signs of hematemesis, with fresh blood noted in the vomitus. This alarming symptom prompts immediate concern for an active upper gastrointestinal (GI) bleed, which could be a complication related to portal hypertension and variceal hemorrhage due to cirrhosis. The patient's vital signs reveal tachycardia with a heart rate of 110 beats per minute, a drop in blood pressure to 90/60 mmHg, and a decrease in hemoglobin from 8.5 to 7.2 g/dL, suggesting significant blood loss and necessitating urgent intervention.

The healthcare team swiftly initiates resuscitative measures, including fluid replacement with isotonic saline and cross-matching of blood for transfusion. An urgent endoscopy is ordered to identify the bleeding source, with a focus on assessing for esophageal varices. In the interim, the patient is started on intravenous proton pump inhibitors and octreotide to manage the bleeding and reduce portal pressure. The team also collaborates with the gastroenterology service to plan for potential endoscopic variceal ligation, should varices be confirmed as the bleeding source.

Despite these efforts, the patient shows signs of hemodynamic instability, with persistent hypotension and a further drop in hemoglobin levels, raising concerns about the effectiveness of current interventions. This situation requires careful clinical reasoning to prioritize interventions, monitor for transfusion reactions, and reassess the need for additional diagnostic and therapeutic procedures. The unfolding scenario underscores the complexities associated with managing a multifaceted case of liver dysfunction and GI bleeding, necessitating a coordinated, multidisciplinary approach to optimize patient outcomes.

Section 5

As the clinical team continues to address the patient's condition, they receive new diagnostic results from the urgent endoscopy conducted earlier. The endoscopy reveals large esophageal varices with active bleeding, confirming the suspected source of the gastrointestinal hemorrhage. The gastroenterology team quickly performs endoscopic variceal ligation to control the bleeding. Despite successful banding of the varices, the procedure is complicated by the patient's ongoing coagulopathy, a common issue in those with advanced liver disease, as evidenced by a prolonged INR of 2.5.

Following the procedure, the patient's vital signs continue to reflect hemodynamic instability, with blood pressure remaining low at 85/55 mmHg and heart rate elevated at 115 beats per minute. The hemoglobin level has further decreased to 6.8 g/dL, indicating continued blood loss or ineffective hemostasis. The team decides to administer additional units of packed red blood cells and fresh frozen plasma to address both anemia and coagulopathy. Meanwhile, the patient exhibits signs of altered mental status, raising concerns about hepatic encephalopathy, a potential complication arising from the buildup of toxins due to impaired liver function.

These developments necessitate a reassessment of the treatment plan. The team considers the need for further interventions such as balloon tamponade or transjugular intrahepatic portosystemic shunt (TIPS) if bleeding persists or recurs. The nursing staff is tasked with closely monitoring the patient's neurological status, fluid balance, and potential signs of transfusion reactions. This complex situation requires ongoing collaboration among the multidisciplinary team to manage the interlinked complications of variceal bleeding, liver failure, and the risk of further deterioration.