What is the primary reason for keeping the patient NPO (nothing by mouth) at this time?

A) To ensure the patient does not become nauseated.

D) To allow the omeprazole to work more effectively.

Which vital sign finding indicates that the patient is currently hemodynamically stable?

C) Respiratory rate of 24 breaths per minute

What is the primary reason for maintaining the patient in an upright position while awaiting further evaluation for an upper GI bleed?

B) To reduce the risk of aspiration

C) To prevent orthostatic hypotension

D) To increase hemoglobin levels

What is the most appropriate initial nursing intervention for a patient experiencing orthostatic hypotension?

B) Instruct the patient to sit or lie down slowly

A) Encourage the patient to drink more fluids

B) Instruct the patient to sit or lie down slowly

C) Administer oxygen via nasal cannula

D) Provide the patient with a high-sodium snack

What is the most appropriate initial nursing intervention for a patient experiencing mild orthostatic hypotension?

A) Encourage increased fluid intake

C) Advise the patient to remain in bed

D) Notify the physician immediately

What is the primary purpose of administering intravenous fluids to a patient experiencing a slow, ongoing bleed?

B) To support hemodynamic stability

What is the primary reason for administering intravenous fluids to the patient in this scenario?

B) To support the patient's hemodynamic stability

A) To increase the patient's hemoglobin levels immediately

B) To support the patient's hemodynamic stability

C) To prevent orthostatic hypotension

D) To replace lost red blood cells

What is the most appropriate initial nursing action when a patient reports mild abdominal discomfort and an increase in nausea?

B) Conduct a focused abdominal assessment

A) Administer prescribed antiemetic medication

B) Conduct a focused abdominal assessment

C) Notify the physician immediately

D) Instruct the patient to avoid eating until symptoms subside

When a nurse observes mild abdominal discomfort and increased nausea in a patient, which immediate nursing action should be prioritized?

B) Conduct a focused abdominal assessment

A) Administer an antiemetic immediately without further assessment

B) Conduct a focused abdominal assessment

C) Notify the physician immediately without further assessment

D) Encourage the patient to ambulate to relieve discomfort

Upper GI bleed - Nursing Case Study

Pathophysiology

• Primary mechanism: Upper GI bleed often results from peptic ulcers, which occur when the stomach lining is eroded by stomach acid, leading to the exposure and bleeding of underlying blood vessels.

• Secondary mechanism: Esophageal varices, swollen veins in the esophagus due to increased pressure from liver disease, can rupture and cause significant bleeding if the vessel walls are weakened.

• Key complication: If not managed promptly, upper GI bleeding can lead to hypovolemic shock, where severe blood loss results in decreased blood volume and compromised organ function.

Patient Profile

Demographics:

45-year-old male, accountant

History:

• Key past medical history: Occasional gastritis, hypertension

• Current medications: Lisinopril 10 mg daily, omeprazole 20 mg daily

• Allergies: None

Current Presentation:

• Chief complaint: Mild hematemesis

• Key symptoms: Nausea, slight abdominal discomfort, fatigue

• Vital signs: Blood pressure 120/80 mmHg, heart rate 78 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F, SpO2 98% on room air

Section 1

Initial Assessment Findings:

Upon initial assessment, the patient is alert and oriented, with no signs of acute distress. His skin is warm and dry, with a normal capillary refill time of less than two seconds, indicating adequate peripheral perfusion. However, the patient reports feeling increasingly fatigued over the past week, which he initially attributed to work-related stress. On abdominal examination, there is mild epigastric tenderness on palpation, but no rebound tenderness or guarding. Bowel sounds are present and normal in all quadrants. The patient's mucous membranes appear slightly pale, which could suggest mild anemia, a common consequence of minor but persistent gastrointestinal bleeding.

The nurse notes that the patient's vital signs remain stable, with a blood pressure of 120/80 mmHg, a heart rate of 78 bpm, and a respiratory rate of 16 breaths per minute. SpO2 is 98% on room air, and his temperature is 98.6°F. These findings suggest that the patient is hemodynamically stable, despite the episode of hematemesis. The nurse also reviews the patient's medication history and notes compliance with omeprazole, which may have contributed to minimizing the severity of the gastric mucosal erosion.

The nurse prioritizes obtaining laboratory studies to assess the patient's hemoglobin and hematocrit levels, as well as coagulation profiles, to evaluate the extent of blood loss and clotting function. Additionally, the nurse anticipates an order for a type and screen in case blood transfusion becomes necessary if the patient’s condition changes. The patient is advised to remain NPO (nothing by mouth) to prepare for potential endoscopic evaluation and to minimize further irritation to the gastric lining. These steps ensure a comprehensive approach to assessing and managing the patient's condition while maintaining his current stable status.

Section 2

New Diagnostic Results:

The laboratory results return, providing valuable insights into the patient's condition. The complete blood count (CBC) reveals a hemoglobin level of 11 g/dL and a hematocrit of 33%, indicating mild anemia, likely due to the ongoing upper GI bleed. These values are slightly below the normal range but correlate with the patient's complaint of fatigue and pale mucous membranes. The patient's platelet count and coagulation profile, including PT/INR and aPTT, are within normal limits, suggesting that clotting function is not impaired, which is reassuring.

Additionally, the basic metabolic panel indicates normal levels of electrolytes and renal function, with a blood urea nitrogen (BUN) to creatinine ratio of 15:1. This finding is important because an elevated BUN-to-creatinine ratio could suggest significant blood loss into the gastrointestinal tract, but in this case, it remains normal, supporting the notion of a minor bleed. The nurse updates the physician with these results, emphasizing the need for continued monitoring and consideration of endoscopy to identify the source of bleeding and determine appropriate interventions.

As the patient remains NPO and awaits further evaluation, the nurse educates him on the importance of reporting any changes in symptoms, such as increased abdominal pain or additional episodes of hematemesis. The nurse also reinforces the need to maintain an upright position to reduce the risk of aspiration and to facilitate breathing, given his stable SpO2 levels. These steps ensure the patient's comfort and safety while awaiting the next phase of diagnosis and treatment, promoting a stable clinical course with minimal complications.

Section 3

Change in Patient Status:

A few hours into the patient's observation, the nurse notes a subtle change in his condition. The patient, previously stable, now reports feeling slightly dizzy upon standing, and his skin appears more pallid than before. Upon reassessment, his vital signs show a mild orthostatic hypotension, with blood pressure readings dropping from 120/80 mmHg while supine to 105/70 mmHg when standing. His heart rate has increased from 80 beats per minute to 95 beats per minute, indicating a compensatory response likely due to decreased circulating blood volume.

The nurse promptly informs the physician of these findings, highlighting the potential need for closer monitoring of the patient's hemodynamic status. Despite the normal platelet count and coagulation profile, these changes suggest that the bleeding may be more significant than initially assessed, or it may be continuing at a slow rate. To address this, the physician orders a repeat CBC to evaluate any further drop in hemoglobin and hematocrit levels.

In the interim, the nurse advises the patient to avoid sudden movements and to call for assistance when needing to change positions, ensuring he remains safe and reduces the risk of falls or further dizziness. The patient is also encouraged to report any new symptoms immediately. These measures, alongside the planned repeat lab tests, aim to maintain stability while awaiting more definitive diagnostic procedures, such as endoscopy, to identify and manage the source of the upper GI bleed effectively.

Section 4

Response to Interventions:

Following the implementation of safety measures and communication with the physician, the nurse continues to monitor the patient closely. Over the next couple of hours, the patient's symptoms of dizziness slightly improve with rest and positioning adjustments, suggesting that the interventions are helping to stabilize his current condition. The repeat CBC results indicate a slight decrease in hemoglobin from 13.5 g/dL to 12.8 g/dL and a hematocrit drop from 40% to 38%, signifying a minor but manageable decline in red blood cell volume. These findings support the nurse's initial assessment of a slow, ongoing bleed.

The nurse also administers intravenous fluids as per the physician's order to support the patient's hemodynamic stability. The patient's heart rate gradually returns to 85 beats per minute, and his blood pressure stabilizes at 115/75 mmHg while supine, demonstrating a positive response to the fluid therapy. The patient is instructed to remain in bed with the head of the bed slightly elevated to promote comfort and reduce orthostatic changes.

The nurse educates the patient on the importance of maintaining an open dialogue about any new or worsening symptoms and emphasizes the need for continual monitoring. This interaction not only reinforces patient safety but also encourages patient engagement in his care plan. The interdisciplinary team readies for the scheduled endoscopy, prepared to address potential findings with a clear strategy for managing the upper GI bleed, reflecting a systematic and proactive approach to patient care.

Section 5

As the day progresses, the nurse observes a change in the patient's status, requiring further assessment and adjustment of the care plan. The patient begins to report mild abdominal discomfort and an increase in nausea, which prompts the nurse to conduct a focused abdominal assessment. The nurse notes that the patient's abdomen is soft but slightly tender to palpation, with no distension or guarding. Bowel sounds are present and normal in all four quadrants, suggesting that there is no acute abdominal process but indicating the need for continued observation.

The nurse promptly communicates these findings to the physician, who orders a repeat CBC and electrolyte panel to monitor the patient's ongoing status. The new laboratory results show a hemoglobin level of 12.5 g/dL and hematocrit of 37%, indicating a slight continued decline. Electrolytes reveal mild hypokalemia, with a potassium level of 3.4 mEq/L, likely related to the ongoing fluid therapy and the patient's nausea, which may have affected his oral intake. In response, the physician orders the administration of potassium supplements to correct the electrolyte imbalance and prevent further complications.

To address the patient's nausea, an antiemetic is administered as prescribed, which provides relief and allows the patient to tolerate clear fluids orally, enhancing his hydration status. The nurse educates the patient about the importance of reporting any increase in abdominal pain or changes in symptoms, reinforcing the need for vigilance as the team prepares for the endoscopy. This seamless communication and coordinated care exemplify the nurse's role in managing potential complications while supporting the patient through the diagnostic process. As the care plan unfolds, the focus remains on maintaining stability and preparing for further evaluation to guide treatment decisions.