Upper gastro bleeding

Submitted by : Roldan Q. Vidad

ACKNOWLEDGEMENT

The proponents of this case study would like to extend their warmest gratitude to all the

people who made the success of this undertaking a reality.

First and foremost, to the Almighty Father, for His unceasing love and blessings; for

giving us enough power and fortitude to face all the hardships in the making of this work. To

Him be all glory and praise!

To our Clinical Instructors, Lasanas , for their invaluable time, knowledge and effort

rendered to us.

To the staff and personnel of Armed Forces of the Philippines Medical Center - V. Luna

General Hospital, especially in the ONCO ward for giving us the opportunity to complete this

endeavor. Thank you ma`am and sir.

INTRODUCTION

The first group of section 2D were given the opportunity to have a hospital exposure last

march 16 ,17 18 and 23 , 23, 25 2015 at AFP medical center – ONCO ward.

The patient, to be mentioned in this paper as EBD, was one of the patients admitted to the

onco ward. She was admitted due to diagnosed upper gastroinstestinal bleeding b.

Upper gastrointestinal bleeding (sometimes upper GI or UGI bleed or hemorrhage)

refers to bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from

the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in

altered form in the stool (melena). Depending on the severity of the blood loss, there may be

symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal

bleeding is considered a medical emergency and typically requires hospital care for urgent

diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers,gastric

erosions, esophageal varices, and some rarer causes such as gastric cancer.

The initial assessment includes measurement of the blood pressure and heart rate, as well

as blood tests to determine hemoglobin concentration. In significant bleeding, fluid

replacement is often required, as well as blood transfusion, before the source of bleeding can be

determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy.

Depending on the source,endoscopic therapy can be applied to reduce rebleeding risk. Specific

medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such

as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to

need for surgery, although this has become uncommon as a result of improved endoscopic and

medical treatment.

Upper gastrointestinal bleeding affects around 50-150 people per 100,000 annually. Depending

on its severity, it carries an estimated mortality risk of 11%

I chose ESD as my subject primarily because her case posed as a very intricate case requiring

due understanding and knowledge. thus making this case a good avenue to broaden the

proponents’ knowledge about the disease and the surgical procedures involved.

OBJECTIVES

General Objective:

My main goal of is to be able to present the case study of our chosen client that would

provide a comprehensive discussion of the pathological mechanism of the disease to yield

significant information for the case study.

Specific Objectives:

In order to meet the general objective, the group aims to:

establish rapport to the patient and the patient’s significant others,

interpret the pertinent data gathered from the patient and her significant others,

state past and present health history of the patient,

define the complete diagnosis of the patient,

discuss the anatomy and physiology of the organ involved in the patient’s disease,

trace the pathophysiology of the patient’s disease,

obtain and rationalize the doctor’s order,

discuss the nature of the drugs given to the patient,

discuss the surgical procedure performed to the patient

present a specific, measurable, attainable, realistic and time-bounded nursing care plans

for the client,

justify the client’s prognosis according to the different criteria,

outline recommendations based on the case study’s findings.

PATIENT’S DATA

Personal Data:

Patients Name: “E,B`D”

Age: 72 years old

Gender: female

Birth date:

Birth Place

Civil Status

husban

Occupation :

October 18 1942

cavity

Married

N/A

N/A

City Address:

Family Income:

Socioeconomic class:

cavity

N/A

N/A

Nationality: Filipino

Religion [Denomination]: Roman catholic

Educational Attainment: N/A

Number of Siblings: 5

Ordinal Rank: N/A

Clinical/ Admitting Data:

Date of admission: January 26 2015

Time of admission: 9:30 am

Hospital & Hospital Number: N/A

Ward [Room & Bed Numbers]: ONCO ward (room A bed #5)

Attending Physician: N/A

Admitting Diagnosis: Upper gastroinstestinal bleeding related to peptic ulcer dse.

Pre-Op Diagnosis: Upper gastroinstestinal bleeding related to peptic ulcer dse.

Vital signs on admission:

Temperature:

Pulse Rate:

Respiratory Rate:

Blood pressure:

Source of Information:

37.3 Degrees Celsius

118 Beats per Minute

28 Cycles per Minute

130/80 mmHg

Patient, Patient’ daugther and Patient’s Chart

FAMILY BACKGROUND AND HEALTH HISTORY

HEALTH BACKGROUND

A. Family Background

`EBD` is a 72 years old male. He got 1 sibling. His father is not alive and his

mother is still living and is hypertensive. Among her 7 siblings, one is also hypertensive.

Out patient is married for 10 years. He is police officer. Her wife is a teacher. .

They have a 6 years old son and is currently in Grade 1 at Batangas elementary School.

The family lives in their owned house at Km. 7, Batangas

The family’s source of income his salary in her work as being a police officer. He

has a daily salary of P 7000/ day or about P 21000/month. From this, the family can

afford eating three times a day. Their usual diet is composed of fish and vegetables since

their son likes to eat vegetables. They only cook meat once or twice a week. Sometimes,

they also go to mall to have family bonding and time for fun.

This is the first time in their family that an above knee amputation. However,

B. Past Health History

The patient was hypertensive for 5 years. Highest Blood pressure IS 15/80. W/A

blood pressure 130 /80.the patient is also diabetic.

B. Effects/ Expectations of Illness to Self/ Family

This condition of the patient has really affected the family. This loss saddened the

family, most notably the patient.It could have been a lot better if this didn’t happen. How-

ever, as the patient verbalized, he couldn’t do anything about it since it’s God’s will.

His daughter has been very y supportive and provided all the support the patient

needed. Emotionally, the family support has been overwhelming. They really gave their

effort to help the patient cope up with this situation. Moreover, they didn’t have problem

in relation to finances since other family members and relative contributed in paying the

bill.

DEFINITION OF COMPLETE DIAGNOSIS

UPPER gastro bleeding related to peptic ulcer dse. S/p anterior circulation infarction right at herothrombotic in origin HCVD FC 11

PHYSICAL ASSESSMENT

I. Personal Data

Name: EBD Sex: female

Age: 72 years old Diagnosis: upper gastro bleeding

II. General Survey

The patient was assessed lying on bed in supine position, awake, conscious and coherent

and in respiratory distress. he was oriented to person, place and time and talks coherently.

Thoughts were coherent and with logical sequencing. IVF was attached to her. she was on NPO

diet.he had a dressing in the hypogastric area covered with binder.he was properly groomed but

slight body odor was noted. The patient has an endomorphic body structure and looked

according to her age. he was cooperative and responsive during the entire assessment.

III. Vital Signs

The patient has a body temperature of 37°C e. Respiration was assessed to be 28 cycles in

one full minute; her breathing was deep and in normal pace. Her pulse rate was 100 beats per

minute with a regular rhythm. Her cardiac rate is 103 beats per minute. Her blood pressure was

120/80 mmHg taking while he was lying supine on bed.

IV. The Integument

A. Skin

The patient’s skin is dry with poor skin turgor. Skin color is brown , the legs and

soles of the feet. Skin is warm to touch, which is uniform on both extremities. A surgical wound

covered by a sterile dressing is noted on the hypogastric area of the patient’s abdomen. Both the

right and left hands have scratches as it served as IV insertion sites.

B. Hair

Hair is evenly distributed over scalp. It is oily and black in color. Dandruffs are

present. Fine hairs are evenly distributed on both extremities.

C. Nails

Nails were unclean and not well trimmed with whitish to light pink nail beds, with

normal angle curvature, and with a capillary refill of 3 seconds. Fingernails and toenails were

pale. Surrounding tissues were intact; no lesions nor lacerations were observed.

V. The Head

A. Skull and Face

The patient’s head is normocephalic and proportional to body size. Presences of nodules

or masses are not noted. Facial features and movements are symmetrical. The patient is able to

raise her eyebrows, close her eyes, frown, and smile. Her face manifests a feeling of slight

tiredness.

B. The Eyes

The hair in the patient’s eyebrows is evenly distributed; skin is intact and

symmetrically aligned with equal movement and there was no noted scaling and flakiness of

skin. The eyelashes are equally distributed and curled slightly outward. Her eyelids close

symmetrically; discharges and discolorations were not noted. Her pupil size in both eyes are

equal, with a diameter of 3mm when dilated and 2mm when constricted; with brisk reaction to

light accomodation. According to her, when looking straight ahead, she can see objects in

periphery. There was no edema or tenderness noted over her lacrimal glands.

C. Nose and Sinuses

The external nose is symmetrical, straight and uniform in color. Nasal

flaring was not noted. Color is the same with the entire face; there was no tenderness noted upon

palpation. Lesions and tenderness were both absent. Nasal mucosa was pinkish. Both left and

right nares were patent, with no discharges; air could freely move in and out when the patient

breathes. The nasal septum is intact and in the midline without deviations. The frontal and

maxillary sinuses were non-tender upon palpation. Sense of smell was good. Patient was able to

differentiate water from that of alcohol, through scent.

D. Ears

Auricles are smooth, symmetrical and no discoloration noted. Her external pinna is

normoset; deformities, lesions or inflammations were not present. Pinna recoils after it is being

folded; it is firm and non tender. The ears were physically symmetrical in size and normoset

since boh are located in line with the outer canthus of his eyes. Normal voice tones are audible.

She was able to repeat whispered words and was able to hear ticking sound from the watch in

both ears.

E. Mouth and Oropharynx

There were no lesions and masses noted on the lips and they appear moist and

pinkish. Oral mucosa was pinkish and the tongue was located at the midline, pink in color,

slightly dry and furry with whitish coating. She was able to move her tongue freely. The gums

was pinkish, with no signs of bleeding. The uvula is in the midline and the mucosa surrounding it

is slightly pink. His tonsils were free from inflammation. Dental carries were present

VI. Neck

The muscles in her neck were equal in size. His neck movement was coordinated and

difficulty in moving was not noted. He was able to flex, hyperextend, laterally flex and rotate his

neck without distress. He can also turn his head on one side against the resistance of our hand

with the similar strength and shrug his shoulders up against the resistance of our hand with equal

strength. The trachea is in the midline. No lymph nodes were palpable.

VII. Chest and Lungs

The patient has a regular and normal breathing pattern; quiet and rhythmic respirations,

with respiratory rate of 28 cyles in one full minute. No tenderness and masses upon palpation.

No adventitious breath sounds on both left and right lung fields were heard during auscultation.

Tactile fremitus on both lungs are symmetrical. Posterior chest was not assessed.

VIII. Heart

A. Heart and Central Vessels

Point of maximum impulse and beat is auscultated at the 5 th intercoastal space left

midclavicular line. The patient has a cardiacrate of 103 beats per minute. Presence of abnormal

heart sounds were not noted upon auscultation.

B. Peripheral pulses

Peripheral pulses have regular rhythm strong. Her pulse rate is 100 beats

per minute. The skin is warm upon palpation and capillary refill time is 3 seconds.

IX. Abdomen

The patient’s abdomen has same color with his chest. The umbilicus is medially located

and shows signs of inflammation. Abnormal Bowel sounds are present upon auscultation. .

X. Genito-Urinary

The patient reported that there were no lesion, tenderness and masses in her perineum and

anus.

XI. Musculoskeletal

A. Upper Extremities

The patient’s radial and brachial pulses were regular but strong. Good range of

motion was noted. Palm is able to stay in both prone and supine in a good manner without

difficulty. He was able to exhibit strong hand grip on both arms. Client was able to extend

both arms. Reflex on the upper extremity was good.

B. Lower Extremities

The patient left leg is amputated while his right leg is normal.

ANATOMY AND PHYSIOLOGY

Stomach The stomach is a muscular sac that is located on the left side of the

abdominal cavity, just inferior to the diaphragm . In an average person, the stomach is about the size of their two fists placed next to

each other. This major organ acts as a storage tank for food so that the body has time to digest large meals properly. The stomach also

contains hydrochloric acid and digestive enzymes that continue the digestion of food that began in the mouth.

Small IntestineThe small intestine is a long, thin tube about 1 inch in diameter and about 10 feet long that is part of the lower gastrointestinal track. It is located just inferior to the stomach and takes up most of the space in the abdominal cavity. The entire small intestine is coiled like a hose and the inside surface is full of many ridges and folds. These folds are used to maximize the digestion of food and absorption of nutrients. By the time food leaves the small intestine, around 90% of all nutrients

have been extracted from the food that entered it. 

Liver and GallbladderThe liver is a roughly triangular accessory organ of the digestive

system located to the right of the stomach, just inferior to the diaphragm and superior to the small intestine. The liver weighs about 3

pounds and is the second largest organ in the body. The liver has many different functions in the body, but the main function of the liver

in digestion is the production of bile and its secretion into the small intestine. The gallbladder is a small, pear-shaped organ located just

posterior to the liver. The gallbladder is used to store and recycle excess bile from the small intestine so that it can be reused for the

digestion of subsequent meals.

PancreasThe pancreas is a large gland located just inferior and posterior to the stomach. It is about 6 inches long and shaped like short, lumpy snake with its “head” connected to the duodenum and its “tail” pointing to the left wall of the abdominal cavity. The pancreas secretes digestive

enzymes into the small intestine to complete the chemical digestion of foods.

Large IntestineThe large intestine is a long, thick tube about 2 ½ inches in diameter

and about 5 feet long. It is located just inferior to the stomach and wraps around the superior and lateral border of the small intestine. The

large intestine absorbs water and contains many symbiotic bacteria that aid in the breaking down of wastes to extract some small amounts of nutrients. Feces in the large intestine exit the body through the anal

canal.

PATHOPYSIOLOGY

Vehicular accident

Serious infection that does

not get better with antibiotics

or other treatment

Above the knee amputation

January 31 1600 HAltered bleeding

Pale skin , fatigue , low body temperatureDoctors order with on going luparin drip D5W 240 cc – 10000 with teparin 13 cc/hr , continue PT, APIT every 6 ours >continuity patient accordingly

DOB 1700 H RR : 28 Administer oxygen Place the patient semi fowler position>relief DOB

Febraury 1 2000 Hhyperthemia

Temp: 40.2As assessed pt. closely>paracetamol 300 mg given as ordered>tepid sponge bath

Impaired skin integrity 2300 H D> post op dressing in the left leg , with external tarter at leg , A > assessed skin integrity , maintained and absence of aseptic technique , on daily wound care: monitored fr signs and symptoms of infectionR> No sign and symptoms of infection

Course in the ward

Assessment Diagnosis Planning Intervention Evaluation Subjected :

nahihirapan akong huminga “as

verbalize by the patient

Objected: RR:3302 sat: 89%

DOB relate to allergic

reaction of the blood

transfusion secondary to

blood loss

After 30 minutes nursing intervention the patient will experience lessened of difficulty of breathing.

>stop the blood transfusion as doctors order>administer 0xygen 2-3 L/m as doctor order>elevate the bed 30 %>monitored the Respiratory patterns including rate , depth and effort .

After 30 minutes nursing

intervention the patient will experience lessened of difficulty of breathing.