Critical Care and Ethical Dilemmas in Managing a Duodenal Ulcer Complication

QUESTION

Valerie Jones is a 78-year old patient with a history of osteoarthritis. A few months
ago, her physician started her on ibuprofen 600 mg three times a day. Recently she
was found on the floor in her home by her daughter and was admitted to the
hospital due to abdominal pain and tarry stools. An endoscopy confirmed a
duodenal ulcer. Her religion is Jehovah Witness.

•  80/48 mmHg, 118 HR, 28 RR, 90% on 2L NC, 36.1 C
  Patient alert and oriented X 3, appears drowsy, generalized weakness
   S1S2, pulses equal +1, cap refill 4 seconds, patient pale, skin dry
   Lungs clear in all lobes, no cough, mild increase work of breathing
   Hyperactive bowel sounds, abdomen tender in all quadrants, pt NPO, pt had a
  black, tarry bowel movement
   Peripheral IV in right forearm with NS @ 100 mL/hr, no redness or swelling,
  dressing intact
• Hgb 5.0 (Low)
• Hct 30 (Low)
• RBCs 4 (Low)
• Osmolality 320 (High)

1. Determine whether or not your patient is in need of immediate interventions. Provide the
data to support your decision.

2. Create one priority care plan for this patient 

3. Describe the dilemma a nurse may face when caring for Ms. Jones.  Suggest an approach for dealing with this type of dilemma.

ANSWER

Critical Care and Ethical Dilemmas in Managing a Duodenal Ulcer Complication

Immediate Interventions

Based on the patient’s presentation and the provided data, Valerie Jones is in need of immediate interventions due to her critical condition. Several key factors indicate the urgency of her situation:

Hemodynamic instability: Ms. Jones presents with hypotension (80/48 mmHg), which is significantly lower than the normal blood pressure range. This poses a risk of inadequate tissue perfusion and organ damage.
Anemia: The hemoglobin (Hgb) level is critically low at 5.0 g/dL, and the hematocrit (Hct) is also significantly reduced at 30%. These values indicate severe anemia, leading to decreased oxygen-carrying capacity and potential organ hypoxia.
Gastrointestinal bleeding: The presence of tarry stools (melena) suggests upper gastrointestinal bleeding. The patient may be actively bleeding from her duodenal ulcer.
Lethargy and drowsiness: Valerie Jones appears drowsy and weak, indicating potential cerebral hypoperfusion or hypoxia, further emphasizing the need for urgent intervention.
Pale appearance: The patient is pale, a sign of reduced hemoglobin levels and compromised circulation.

Based on these data, immediate interventions are required, including resuscitation to stabilize blood pressure, blood transfusions to correct anemia and restore oxygen-carrying capacity, and endoscopy or other therapeutic procedures to address the source of gastrointestinal bleeding.

Priority Care Plan

Diagnosis: Acute Gastrointestinal Bleeding due to Duodenal Ulcer

Interventions

Hemodynamic stabilization: Administer IV fluids (e.g., crystalloids) to restore blood pressure and tissue perfusion.
Transfusion therapy: Provide packed red blood cells to correct anemia.
Gastrointestinal intervention: Consult a gastroenterologist for potential endoscopic intervention or surgical evaluation.
Medication management: Evaluate the necessity of ibuprofen and consider alternative pain management strategies with lower risk of ulcer formation.
Monitoring: Continuously monitor vital signs, oxygen saturation, and gastrointestinal bleeding.

 Ethical Dilemma

A nurse caring for Ms. Jones may face an ethical dilemma concerning the patient’s religious beliefs as a Jehovah’s Witness. Jehovah’s Witnesses are known to refuse blood transfusions based on their religious doctrine. In a critical condition like Ms. Jones’, where blood transfusions may be life-saving, a nurse’s duty to provide the best medical care may conflict with the patient’s religious beliefs.

Approach to Dealing with the Dilemma

To address this ethical dilemma, the nurse should:

Respect and uphold the patient’s autonomy and religious beliefs.
Engage in open, empathetic, and non-judgmental communication with the patient and her family to understand their perspective.
Collaborate with a hospital ethics committee to navigate complex ethical decisions.
Explore alternatives to blood transfusions, such as volume expanders or hemostatic agents, if appropriate and in alignment with the patient’s wishes.
Continuously reassess and discuss the patient’s condition and treatment options, ensuring a patient-centered and informed approach.

Ultimately, the patient’s preferences and values should guide the decision-making process while striving to provide the highest quality of care that respects her autonomy and dignity.