Mrs. Johnson, a patient with a history of peptic ulcer disease, presents with signs of gastrointestinal bleeding and compensated shock. Which nursing intervention should be prioritized to prevent progression to hypovolemic shock in this patient?

C) Initiate intravenous fluid resuscitation with isotonic saline.

A) Administer intravenous proton pump inhibitor therapy.

B) Prepare the patient for an immediate blood transfusion.

C) Initiate intravenous fluid resuscitation with isotonic saline.

D) Monitor the patient's neurological status every hour.

Mrs. Johnson is admitted with a suspected upper gastrointestinal bleed and signs of hypovolemia. Which of the following nursing interventions should be prioritized to prevent further hemodynamic instability?

B) Administer isotonic intravenous fluids as ordered to restore circulating volume.

A) Place the patient in Trendelenburg position to increase cerebral perfusion.

B) Administer isotonic intravenous fluids as ordered to restore circulating volume.

C) Apply compression stockings to promote venous return and reduce dizziness.

D) Encourage oral fluid intake to maintain hydration and electrolyte balance.

Mrs. Johnson's sudden increase in abdominal pain and distension after initial stabilization suggests a complication from her condition. Which of the following actions should the nurse prioritize next in managing her care?

D) Notify the surgical team for emergent consultation

A) Administer additional pain medication

B) Prepare her for an urgent abdominal X-ray

C) Increase the rate of intravenous fluids

D) Notify the surgical team for emergent consultation

After identifying free air under the diaphragm in Mrs. Johnson's abdominal X-ray, what is the most appropriate immediate nursing action to prioritize while awaiting surgical intervention?

C) Ensure intravenous access is patent and administer prescribed IV fluids

A) Administer a high-flow oxygen mask to improve oxygenation

B) Position Mrs. Johnson in a semi-Fowler's position to reduce abdominal pressure

C) Ensure intravenous access is patent and administer prescribed IV fluids

D) Provide Mrs. Johnson with oral analgesics for pain management

Mrs. Johnson, a patient with a perforated peptic ulcer, is experiencing hemodynamic instability and has a hemoglobin level of 7.8 g/dL. After initiating a blood transfusion, which of the following actions should the nurse prioritize to ensure her stability and safety?

A) Monitor her vital signs and oxygen saturation frequently

B) Increase the rate of intravenous fluids to prevent hypotension

C) Administer additional sedatives to manage her anxiety

D) Prepare for immediate transport to the operating room

A nurse is caring for Mrs. Johnson, who is displaying signs of hemodynamic instability due to a perforated peptic ulcer. Despite fluid resuscitation, her blood pressure continues to drop, and her hemoglobin level is 7.8 g/dL. What is the most appropriate nursing intervention to prioritize at this time?

B) Initiate a blood transfusion to address her anemia and improve oxygen delivery.

A) Increase the rate of intravenous fluid administration to improve blood pressure.

B) Initiate a blood transfusion to address her anemia and improve oxygen delivery.

C) Administer vasopressors to maintain adequate blood pressure.

D) Provide high-flow oxygen to improve oxygen saturation levels.

Given Mrs. Johnson's current clinical presentation, which nursing intervention is the priority to address her hemodynamic instability?

B) Administer the prescribed vasopressors

A) Increase the rate of her intravenous fluid infusion

B) Administer the prescribed vasopressors

C) Reassess her pain and administer analgesics

D) Monitor her urine output every hour

A nurse is preparing Mrs. Johnson for surgery due to a suspected perforated peptic ulcer and potential septic shock. Which of the following interventions is the most critical to implement before she goes to the operating room?

A) Administer a bolus of intravenous fluids to improve hemodynamic stability.

B) Ensure the surgical team is aware of the patient's recent antibiotic administration.

C) Monitor and document the patient's urine output every hour.

D) Educate the patient and family about the surgical procedure and obtain informed consent.

A nurse is caring for Mrs. Johnson in the ICU following her surgery to repair a duodenal perforation. Her vitals include a blood pressure of 90/58 mmHg, heart rate of 115 bpm, and urine output of 30 mL/hr. Which of the following nursing interventions is the most appropriate to address her current condition?

A) Increase the rate of intravenous fluids to improve renal perfusion

B) Administer an additional dose of vasopressors to stabilize blood pressure

C) Encourage the patient to increase oral fluid intake

D) Monitor the patient for signs of fluid overload and adjust fluid management accordingly

A nurse is monitoring Mrs. Johnson in the ICU following her emergency surgery for a perforated duodenum. Given her current condition and recent surgical history, which of the following interventions should the nurse prioritize to prevent further complications?

B) Monitor arterial blood gas results closely and adjust ventilator settings as needed to manage metabolic acidosis

A) Increase the infusion rate of intravenous fluids to maintain a urine output of at least 50 mL/hr

B) Monitor arterial blood gas results closely and adjust ventilator settings as needed to manage metabolic acidosis

C) Administer an additional dose of broad-spectrum antibiotics to prevent further infection

D) Implement strict bed rest to reduce metabolic demand and prevent respiratory failure

GI Bleed - Nursing Case Study

Pathophysiology

• Primary mechanism: Mucosal erosion or ulceration, often due to peptic ulcer disease or NSAID use, leads to the breakdown of the protective lining of the gastrointestinal tract, exposing blood vessels and causing bleeding.

• Secondary mechanism: Variceal bleeding caused by portal hypertension, typically from liver cirrhosis, increases pressure in the portal venous system, causing engorged veins (varices) that can rupture and bleed.

• Key complication: Massive blood loss from these mechanisms can lead to hypovolemic shock, requiring urgent fluid resuscitation and stabilization to prevent organ failure and ensure patient survival.

Patient Profile

Demographics:

68-year-old female, retired teacher

History:

• Key past medical history: Hypertension, Osteoarthritis, Peptic Ulcer Disease

• Current medications: Lisinopril, Naproxen, Omeprazole

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Black, tarry stools for the past two days

• Key symptoms: Fatigue, dizziness, abdominal pain, nausea

• Vital signs: Blood pressure 100/60 mmHg, heart rate 110 bpm, respiratory rate 22 breaths/min, temperature 98.6°F, oxygen saturation 94% on room air

Section 1

As the nursing team initiates the initial assessment, they note that the patient, Mrs. Johnson, is visibly pale and demonstrates signs of orthostatic hypotension, as she becomes more dizzy when attempting to sit up. Her abdomen is tender upon palpation, particularly in the epigastric region, consistent with her history of peptic ulcer disease. Auscultation reveals hyperactive bowel sounds, which could indicate gastrointestinal irritation and bleeding. Her vital signs suggest a state of compensated shock, with tachycardia (heart rate of 110 bpm) and hypotension (blood pressure of 100/60 mmHg), alongside an elevated respiratory rate of 22 breaths per minute. Given these findings, the primary concern is the risk of progression to hypovolemic shock due to ongoing gastrointestinal bleeding.

The decision is made to perform a complete blood count (CBC) and comprehensive metabolic panel to evaluate the extent of blood loss and organ function. Results reveal a hemoglobin level of 8.5 g/dL, indicating significant anemia likely due to the GI bleed. Her hematocrit is low at 26%, and there is a mild elevation in blood urea nitrogen (BUN), suggesting upper GI bleeding. Furthermore, the patient's creatinine level is slightly elevated, pointing towards pre-renal azotemia, a possible consequence of decreased perfusion due to hypovolemia. Electrolyte imbalances, such as mild hyponatremia, are also noted, which could exacerbate her symptoms of dizziness and fatigue.

In response to these findings, the team initiates intravenous fluid resuscitation with isotonic saline to maintain perfusion and prevent further deterioration of her hemodynamic status. A proton pump inhibitor (PPI) is administered intravenously to reduce gastric acid secretion and promote ulcer healing. The team prepares for potential endoscopic evaluation to identify and manage the bleeding source, but they remain vigilant for any signs of worsening respiratory status or further drops in blood pressure, which would necessitate more aggressive interventions, such as blood transfusions or vasopressor support. The nursing team's ongoing monitoring and timely interventions are crucial in stabilizing Mrs. Johnson and preventing progression to more severe complications.

Section 2

As Mrs. Johnson's treatment progresses, the nursing team closely monitors her response to the interventions. After administering the intravenous fluids and PPI, there is an initial stabilization in her vital signs. Her blood pressure slightly improves to 110/65 mmHg, and her heart rate decreases to 100 bpm, suggesting a positive response to the fluid resuscitation. However, despite these improvements, Mrs. Johnson begins to complain of increasing abdominal pain and distension. On reassessment, her abdomen appears more rigid, and there is a noticeable decrease in bowel sounds compared to the initial hyperactivity, raising concerns for potential complications such as perforation or peritonitis.

To further evaluate her condition, an urgent abdominal X-ray is ordered. The results reveal free air under the diaphragm, indicative of a perforated peptic ulcer. This finding necessitates an emergent surgical consultation to address the perforation and prevent further deterioration. The nursing team promptly coordinates with the surgical team to prepare Mrs. Johnson for transfer to the operating room, while continuing supportive care measures. This includes maintaining her fluid status and ensuring she remains stable until surgical intervention can be performed.

The sudden change in Mrs. Johnson's condition emphasizes the need for vigilant monitoring and quick adaptation to evolving clinical scenarios. The nursing team's ability to recognize the signs of a perforated ulcer and initiate timely diagnostic imaging showcases critical clinical reasoning skills. As Mrs. Johnson is prepped for surgery, the focus shifts to stabilizing her hemodynamically and preventing potential complications, such as sepsis, which can arise from the perforation if not addressed promptly. This pivotal moment in her care highlights the importance of comprehensive assessment and swift decision-making in managing complex cases of gastrointestinal bleeding.

Section 3

As Mrs. Johnson is being prepared for surgery, the nursing team continues to provide critical supportive care. Despite the initial stabilization, her condition begins to fluctuate. Her blood pressure shows a downward trend again, dropping to 95/58 mmHg, and her heart rate increases to 115 bpm, indicating potential hemodynamic instability. The team promptly reassesses her fluid status, ensuring adequate intravenous fluid administration to support her circulation. Laboratory results return, revealing a hemoglobin level that has decreased to 7.8 g/dL, suggesting ongoing blood loss or dilutional effects from the resuscitation efforts.

In response to these findings, the decision is made to initiate a blood transfusion to address her anemia and further stabilize her hemodynamically. The nursing team carefully monitors Mrs. Johnson for any transfusion reactions, while also continuing to manage her pain and anxiety through appropriate medication administration. Her oxygen saturation remains stable at 95% on supplemental oxygen, but the team remains vigilant for any signs of respiratory compromise given her overall condition.

This phase of care underscores the complexity of managing a patient with a perforated peptic ulcer. The need to balance fluid resuscitation, maintain adequate perfusion, and address the underlying cause through surgical intervention requires coordinated efforts and clear communication among healthcare providers. The nursing team’s focus on comprehensive monitoring and timely interventions plays a critical role in optimizing Mrs. Johnson's clinical outcomes as she awaits surgery. The next steps in her care will seek to mitigate the risks of sepsis and other complications associated with gastrointestinal perforation, ensuring she receives the best possible care as she transitions to the operating room.

Section 4

As Mrs. Johnson is continually monitored, a change in her status prompts immediate attention. Despite the transfusion, her blood pressure fluctuates further, now reading 88/54 mmHg, and her heart rate has increased to 120 bpm, suggesting persistent hemodynamic instability. Her skin appears cool and clammy, and she reports increased abdominal discomfort. These findings raise concerns about the progression of her condition, possibly indicating the onset of septic shock due to the perforated peptic ulcer. The nursing team swiftly reassesses her fluid balance and ensures that she is receiving the appropriate amount of intravenous fluids. Meanwhile, her urine output is carefully monitored, as it has decreased to 20 mL/hr, a sign that her renal perfusion may be compromised.

Laboratory results return with a further drop in her hemoglobin to 7.2 g/dL and an elevated lactate level of 4.2 mmol/L, reinforcing the suspicion of tissue hypoperfusion and possibly worsening sepsis. In light of these developments, the medical team decides to escalate her care by initiating broad-spectrum antibiotics to combat any underlying infection and administer vasopressors to support her blood pressure and improve perfusion. The nurses continually assess her response to these interventions, paying close attention to her mental status, which remains alert but increasingly anxious.

As Mrs. Johnson is prepared for the operating room, the nursing team updates the surgical team on her condition, emphasizing the importance of rapid surgical intervention to address the source of bleeding and perforation. Throughout this critical period, the nursing staff maintains vigilant monitoring and communication, ensuring that all team members are aware of Mrs. Johnson's evolving clinical picture. This coordinated effort is essential to manage the complexities of her case, aiming to stabilize her condition and prevent further deterioration as she undergoes surgery.

Section 5

As Mrs. Johnson is wheeled into the operating room, the surgical team receives her with urgency, aware of the potential complications stemming from her deteriorating condition. During the initial surgical assessment, the surgeons identify a significant perforation in the posterior wall of the duodenum, which has resulted in an extensive intra-abdominal contamination. This finding correlates with her elevated lactate levels and abdominal discomfort, confirming the suspected septic process. The team quickly works to repair the perforation and thoroughly irrigate the abdominal cavity to minimize the risk of ongoing infection.

Meanwhile, the anesthesia team closely monitors Mrs. Johnson's hemodynamics. Despite the administration of vasopressors, her blood pressure remains labile, hovering around 90/58 mmHg, and her heart rate remains elevated at 115 bpm. Her skin continues to be cool and clammy, suggesting that her peripheral circulation is still compromised. Intraoperative blood gas analysis reveals a pH of 7.29, indicating a metabolic acidosis likely due to both lactic acidosis and the ongoing effects of the GI bleed. This prompts the anesthesia team to adjust the ventilator settings and administer sodium bicarbonate to correct the acid-base imbalance.

Post-operatively, Mrs. Johnson is transferred to the intensive care unit for close monitoring. The nursing team meticulously tracks her vital signs, fluid status, and mental alertness. Her urine output improves slightly to 30 mL/hr, suggesting some improvement in renal perfusion, but she remains at risk for acute kidney injury due to sustained hypotension. The team continues her broad-spectrum antibiotics and adjusts her fluid management in response to dynamic changes in her condition. As Mrs. Johnson stabilizes, the focus shifts to preventing further complications, such as respiratory failure or multi-organ dysfunction, by ensuring comprehensive supportive care and vigilant monitoring.