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Integrated Nursing Practice – Session 9 

Case Scenario 1 – GI Bleeding

HISTORY OF PRESENT ILLNFSS: The patient. Helen, is a 68-year-old woman who complains of a significant change in bowel movements during the past 6 weeks. She describes her bowel movements as being regular, once per day, up until 6 weeks ago. For the past 6 weeks she experienced 3-4 day periods of constipation alternating with non-bloody diarrhea.

 Although most bowel movements resulted in formed stools which were brown and of normal caliber, three days ago she passed a stool with streaks of bright red blood on the surface. The patient, however, was not alarmed because she occasionally suffers from bleeding hemorrhoids. Now her stools are sticky, black and she states they “smell bad”.

During periods of constipation she feels bloated and senses a mild discomfort or pain in the abdomen. The pain is always generalized and seems to be relieved with defecation. She lost “a couple of pounds” recently but decreased her dietary intake to “keep my weight down.” Even though she tires easily on some days, her health is good. She denies nausea, vomiting, vaginal bleeding, dysuria, hematuria or frequency. She does complain of easy fatigability. 

The patient is 16 years post menopausal. Her gestational history is gravida 1, para 1. She was treated for dysmenorrhea as a younger woman. She is under the care of a physician for Type II diabetes, osteoarthritis and glaucoma. She has suffered from anxiety and depression and takes escitalopram 10 mg once a day.  She was advised to take Tylenol for her arthritis pain but finds it does not work well so she has been taking Advil 400 mg 3 or 4 times a day.

 PHYSICAL EXAMINATION: The patient is a moderately obese woman who is alert and in no acute distress. Vital signs are as follows: Blood Pressure 152/82mmHg; Apical Heart Rate 92/minute and regular; Respiratory Rate 16/minute; Temperature 36.8. wt. 86 kg., ht 140 cm.

Conjunctivae are pale. The auditory canals are packed with cerumen.

The breasts are large, pendulous and symmetrical. Masses are not palpable. There are senile hemangiomas of the skin of the chest. 

The lungs are clear by auscultation. Abnormal heart sounds are absent.

The abdomen is soft, non-tender and slightly round. A 12 cm diagonal scar is present in the right hypochondrium. (Patient neglected to mention that she had a cholecystectomy in 1986). the liver edge is palpable. Bowel sounds are normal and active. Rectal exam reveals no masses. The stool is positive for occult blood. 

Pelvic examination reveals normal external genitalia. The vaginal mucosa is atrophic. 

LABORATORY TESTS: results available on admission to medical unit

Hemoglobin 90 g/L
hematocrit 30%
normal chest x-ray

The physician has diagnosed acute GI bleeding likely from a peptic or duodenal ulcer

Physician’s orders

NPO
IV RL at 150 mL/hr
Crossmatch for 2 units PRBCs
Insert foley catheter
Strict intake and output
Insert Salem pump NG tube to low intermittent suction
Blood glucose q4h while NPO then QID
Insulin per sliding scale
Vital signs q4h and PRN
Test for occult blood with every bowel movement
Pantoprazole 40 mg IV q6h
PT/INR, aPTT now and q6h
CBC
Liver enzyme panel
Electrolytes
O2 to keep sats above 94%

What objective and subjective data and lab data support a diagnosis of acute bleeding?  

What makes the stool blood black?  

What are the likely contributing factors to her GI bleeding?  

After inserting the NG tube the contents of the suction container are clear and pale yellow.  What does this information tell you about the likely site of her GI bleeding?  Peptic ulcer or duodenal ulcer?

Helen is scheduled for an upper endoscopy at 2 pm today.  What preparation will she require for this procedure.  What care will you provide after the procedure?

What other lab tests do you anticipate will be ordered? 

Describe the assessments you make of Helen when she is admitted to your medical unit.  She arrives at 1000 and you are working a 7 to 7 shift.  There are 2 other LPNs working with you and 2 RNs.

Describe the collaboration between you and the other staff members related to the care of Helen.

What is the likely reason for the order for pantoprazole?

 

 

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