Nursing Priorities in the Care of a Patient with Gastrointestinal Bleeding

QUESTION

You are caring for a 52-year-old woman who was admitted after vomiting bright red blood last night. She states that she has a history of gastritis and hypertension, and takes medication for both. She cannot provide the names of the medications she is taking. This morning’s nursing assessment findings include:

–States that she has been taking ibuprofen 1600 mg every day for over a year for osteoarthritis in her hands and feet

–Blood pressure = 112/68 (down from last night’s BP of 150/90)

–Apical pulse = 108 beats per minute

–Respirations = 22 breaths per minute

–Has dry, pale skin

–Has a slightly distended abdomen with mid-epigastric moderate pain (5 out of 10)

–Is alert and oriented x 3

1. What assessment information in this client situation is the most important and immediate concern for the nurse? (Hint: Identify the relevant information first to help you determine what is most important.)

2. What client conditions are consistent with the most relevant information? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.)

3. Which possibilities or explanations are most likely to be present in this client situation? Which possibilities or explanations are the most serious? (Hint: Consider all possibilities and determine their urgency and risk for this client.)

4. What actions would most likely achieve the desired outcomes for this client? Which actions should be avoided, are irrelevant, or are potentially harmful? (Hint: Determine the desired outcomes first to help you decide which actions are appropriate and those that should be avoided.)

5. Which actions are the most appropriate and how should they be implemented? In what priority order should they be implemented? (Hint: Consider health teaching, documentation, requested health care provider orders or prescriptions, nursing skills, collaboration with or referral to health team members, etc.)

6. What client assessment would indicate that your actions were effective? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition

ANSWER

Nursing Priorities in the Care of a Patient with Gastrointestinal Bleeding

Introduction

When caring for a patient with gastrointestinal bleeding, it is crucial for nurses to prioritize assessment findings and determine the most immediate concerns. This essay addresses a case study involving a 52-year-old woman admitted after vomiting bright red blood. Through a systematic analysis of the assessment information provided, the most important and immediate concerns for the nurse will be identified. Additionally, relevant client conditions, possible explanations, appropriate actions, and expected outcomes will be discussed to guide nursing interventions.

Identification of the Most Important and Immediate Concern

In this client situation, the most important and immediate concern for the nurse is the history of vomiting bright red blood. Gastrointestinal bleeding is a critical condition that requires prompt assessment and intervention to prevent further complications and ensure patient safety.

Client Conditions Consistent with the Relevant Information

The relevant information suggests possible complications related to gastrointestinal bleeding, such as hypovolemia, anemia, and potential hemodynamic instability. These conditions are supported by the patient’s history of gastritis, hypertension, and current symptoms of dry, pale skin, decreased blood pressure, increased heart rate, and abdominal pain.

Likely Possibilities and Serious Explanations

Possible explanations for the client’s condition include exacerbation of gastritis, which may have been aggravated by the prolonged use of high-dose ibuprofen. Serious possibilities include peptic ulcer disease, esophageal varices, or even a gastrointestinal malignancy. These conditions require urgent assessment, diagnosis, and appropriate interventions.

Actions to Achieve Desired Outcomes

To achieve desired outcomes, the nurse should take the following actions:
Initiate an immediate assessment of vital signs, including blood pressure, heart rate, and respiratory rate, to monitor for signs of hemodynamic instability.
Establish intravenous access and administer fluids to address potential hypovolemia.
Collaborate with the healthcare team to obtain a complete medication history and perform diagnostic tests, such as an upper endoscopy or imaging studies, to identify the source of the bleeding.
Discontinue the use of ibuprofen, as it can worsen gastric irritation and contribute to gastrointestinal bleeding.

Actions to be avoided or potentially harmful include administering non-steroidal anti-inflammatory drugs (NSAIDs) and delaying necessary interventions.

Implementation of Appropriate Actions in Priority Order

The actions should be implemented in the following priority order:
Assess vital signs and obtain a detailed medication history.
Establish intravenous access and administer fluid resuscitation.
Collaborate with the healthcare team to perform diagnostic tests.
Discontinue ibuprofen and any other potentially aggravating medications.

Additionally, close monitoring of the patient’s symptoms, response to interventions, and continuous assessment of vital signs and laboratory results should be ongoing.

Assessment of Effective Actions

The effectiveness of the actions can be assessed by monitoring the patient’s vital signs, particularly blood pressure, heart rate, and respiratory rate, to ensure stability and improvement. Additionally, regular assessment of the patient’s gastrointestinal symptoms, such as the presence or absence of further bleeding, pain level, and skin color, will indicate the effectiveness of the interventions.

Conclusion

The nurse’s role in the care of a patient with gastrointestinal bleeding is vital in identifying and addressing immediate concerns. By prioritizing assessment findings and implementing appropriate interventions, nurses can promote patient safety, prevent complications, and facilitate the timely diagnosis and treatment of the underlying cause. Through close monitoring and ongoing assessment, nurses can evaluate the effectiveness of their actions and ensure optimal patient outcomes.