Signs and Symptoms of GI Bleeding and Loss of Blood Volume

QUESTION

1. use client data and evidence-informed literature support answers. Include in-text citations and references.
2. Be very concise! Use point-form, lists, tables (ie: column for data and one for rationale) rather than narrative.

Case Study

The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at 0430. She told the ED triage nurse that he had diarrhea for the past 2 days and that last night he had a lot of “dark red” diarrhea. When he became very dizzy, disoriented, and weak this morning, she decided to bring him to the hospital. C.W.’s vital signs (VS) in the ED were 70/− (systolic blood pressure [SBP] 70, diastolic blood pressure [DBP] inaudible), pulse rate 110, respiratory rate 22, oral temperature 99.1 ° F (37.3 ° C). A 16-gauge IV catheter was inserted and a lactated Ringer’s infusion was started. Two years ago, he had a cardiac arrest that was attributed to hypokalemia. He has a long history of hypertension and arthritis. He had atrial fibrillation in the past, but it has been under control recently. Fifteen years ago he had a peptic ulcer.

Endoscopy showed a 25- × 15-mm duodenal ulcer with adherent clot. The ulcer was cauterized, and C.W. was admitted to the medical intensive care unit (MICU) for treatment of his volume deficit. You are his admitting nurse. As you are making him comfortable, Mrs. W. gives you a paper sack filled with the bottles of medications he has been taking: enalapril (Vasotec) 5 mg PO bid, warfarin (Coumadin) 5 mg/day PO, digoxin (Lanoxin) 0.125 mg/day PO, potassium chloride 20 mEq PO bid, and diclofenac (Voltaren) 50 mg PO tid. As you connect him to the cardiac monitor, you note he is in sinus tachycardia and that he has peaked t waves. Doing a quick assessment, you find a pale man who is sleepy but rousable and slightly disoriented. He states he is still dizzy and feels weak and anxious overall. His BP is 98/52, pulse is 118, and respiratory rate 26. You hear S3 and S4 heart sounds and a grade II/VI systolic murmur. Peripheral pulses are all 2+, and trace pedal edema is present. Capillary refill is slightly prolonged. Lungs are clear. Bowel sounds are present, mid-epigastric tenderness is noted, and the liver margin is 4 cm below the costal margin. Has not yet voided since admission. Rates his pain level as “2.” A triple lumen IJ central line and a radial arterial line are inserted.

1. From his history and assessment, identify 5 signs and symptoms of GI bleeding and loss of blood volume, and explain the patho-physiology for each one listed. What may have precipitated C.W.’s gastrointestinal (GI) bleeding?

2. From your head to toe assessment list which systems are impacted and the findings that led you to that conclusion. What nursing interventions would implement?

3. After examination of the lab results, what are the concerns with C.W.’s electrolyte levels? In view of the lab results, what diagnostic test will be performed and why? Identify what changes/findings you expect or are present and how those changes may impact the condition of C.W.

What other blood work results are of concern? Why?

4. Calculate C.W’s mean arterial pressure (MAP) and explain why this measure is important. Is C.W currently taking home medications that may impact his blood pressure? What other medications do you anticipate may be added?

5. Use client data to:

1. identify type of shock
2. explain the identifying factors of this shock state.
3. determine/identify appropriate interventions.

6. Which members of the interdisciplinary team are you expecting to participate in the care of C.W and what would you expect them to contribute?

ANSWER

Signs and Symptoms of GI Bleeding and Loss of Blood Volume

Dark red diarrhea: Dark red color indicates the presence of blood in the stool, suggesting GI bleeding.
Dizziness and weakness: Result from hypovolemia due to blood loss, leading to decreased perfusion to vital organs.
Disorientation and anxiety: Occur due to decreased cerebral perfusion from hypovolemia and anemia.
Pale appearance: Anemia resulting from blood loss leads to a decrease in red blood cells and causes paleness.
Systolic murmur: Can be caused by anemia-induced increased blood flow through the heart.

Pathophysiology

GI bleeding in C.W. is likely due to the duodenal ulcer found during endoscopy. The ulcer’s cauterization and subsequent clot formation led to the dark red diarrhea. The clot may have detached, causing a sudden increase in bleeding, leading to his symptoms of dizziness, weakness, and disorientation due to hypovolemia.

Systems Impacted and Nursing Interventions

Impacted Systems:
Cardiovascular: Sinus tachycardia, S3 and S4 heart sounds, grade II/VI systolic murmur, hypotension.
Neurological: Dizziness, weakness, disorientation, anxiety, slightly prolonged capillary refill.
Gastrointestinal: Mid-epigastric tenderness, trace pedal edema.

Nursing Interventions:
Administer IV fluids to restore blood volume and maintain blood pressure.
Monitor vital signs, cardiac rhythm, and perfusion.
Assess neurological status frequently and monitor for changes.
Elevate the head of the bed to improve cerebral perfusion.
Provide pain relief and assess for GI bleeding.
Monitor intake and output, and encourage fluid intake.
Administer prescribed medications and assess for adverse effects.
Educate the patient and family about the importance of medication compliance and diet modifications.

Concerns with Electrolyte Levels and Diagnostic Test

Concerns:
Hypokalemia: Potassium chloride supplementation indicates a history of low potassium levels.
Elevated BUN and Creatinine: Indicate possible kidney impairment due to hypovolemia and decreased perfusion.
Anemia: Low hemoglobin and hematocrit levels due to blood loss.

Diagnostic Test:
Hemoglobin and Hematocrit: To confirm and quantify the extent of anemia.

Changes/Findings and Impact:
Decreased potassium levels may cause cardiac arrhythmias.
Elevated BUN and Creatinine suggest renal impairment, requiring close monitoring.
Anemia requires addressing to improve oxygen delivery to tissues.

Calculation of MAP and Medications

MAP Calculation: MAP = [(2 x DBP) + SBP] / 3
MAP = [(2 x 52) + 98] / 3 ≈ 67.3 mmHg

Importance of MAP: MAP indicates tissue perfusion and is crucial for assessing organ perfusion and function.

Home Medications Impact on Blood Pressure:
Enalapril (Vasotec) is an angiotensin-converting enzyme (ACE) inhibitor that may lower blood pressure.
Warfarin (Coumadin) has no direct impact on blood pressure.

Anticipated Medications:
IV vasopressors (e.g., norepinephrine) to maintain blood pressure.
Proton pump inhibitors (PPIs) to reduce acid production and promote ulcer healing.

Type of Shock, Identifying Factors, and Interventions

Type of Shock: Hypovolemic Shock
Identifying Factors:
Significant blood loss from GI bleeding.
Hypotension, tachycardia, and decreased urine output.
Pale appearance and altered mental status.

Interventions:
Immediate fluid resuscitation with IV lactated Ringer’s to restore blood volume.
Monitor hemodynamic status and response to fluids.
Administer vasopressors as needed to maintain perfusion.
Monitor for signs of organ dysfunction and intervene promptly.

Interdisciplinary Team and Contributions

Expected Team Members:
Medical Intensivist: Oversees medical management and decision-making.
Gastroenterologist: Manages GI bleeding and ulcer treatment.
Cardiologist: Monitors cardiac function and medications.
Nephrologist: Assesses kidney function and manages renal complications.
Pharmacist: Ensures safe medication management and interactions.
Dietitian: Provides nutrition support and recommendations.

Contributions:
Medical Intensivist: Leads the overall management and treatment plan.
Gastroenterologist: Addresses GI bleeding and ulcer treatment.
Cardiologist: Manages cardiac issues and medications.
Nephrologist: Monitors and treats renal complications.
Pharmacist: Ensures appropriate medication use and doses.
Dietitian: Provides dietary modifications and supports nutrition needs.