Acute gastrointestinal (GI) bleed and nonsteroidal anti-inflammatory drugs (NSAIDs)
Patient is a 56 year old woman who came into the emergency department (ED) with acute GI bleed. Admitting diagnosis is gastritis and possible peptic ulcer secondary to use of NSAIDS. Patient reports having had feelings of nausea and headache upon awakening which was followed by large amount of dark brown liquid vomitus and similar diarrhea. Patient has been having dental pain for the past four weeks which was treated consecutively with over the counter (OTC) acetaminophen, OTC ibuprofen, and prescribed vicoprofen. Patient has a past medical history of epistaxis requiring an ED visit during childhood and pregnancy at age 21. The same pregnancy has ended with a complicated delivery with hemorrhage, hysterectomy and multiple transfusions. She also has a history of depression for which she takes sertraline 50 mg each day. Patient was born in India and relocated to the United States 10 years ago. She lives with her husband and 16 year old child. She does not smoke, drink alcohol or use illegal substances.
Stomach lining is usually well protected by the gastric mucosal barrier. This barrier works through the combined effort of epithelial cell tight junction, bicarbonate secretion and an impermeable hydrophobic lipid layer. The gastric mucosa is also composed of prostaglandins which play a major role in enhancing these effects as well as increasing blood flow to the mucosa and decreasing secretion of gastric acid (Porth, 2015).
NSAIDs are used for their anti-inflammatory effects as well as their ability to reduce fever and relieve pain. They generally work through inhibition of cyclooxygenase (COX), an enzyme which is important for prostaglandin synthesis, platelet aggregation and regulation of several process in the body. Side effects of continual use of these medications include gastric ulceration and erosion, increased bleeding tendencies and renal damage (Lehne, 2013). NSAIDs are weak acids and have a lipid soluble property that enables them to penetrate the mucosa. Chronic use of these medications allow accumulation within the mucosal epithelial cells leading to cellular damage and compromise the integrity of the intercellular junction. This increased mucosal exposure to stomach acid. Furthermore, COX inhibition leads to decreased blood flow, decreased mucus production, increased acid production and anti-platelet aggregation causing injury to small vessels, GI bleeding, gastritis and peptic ulcer formation or exacerbation of preexisting affected area (Bjarnason, 2013).
In addition to chronic use of nonsteroidal anti-inflammatory drugs (NSAIDs), Helicobacter pylori (H. pylori) bacterial infection is considered as major risk factor for developing gastrointestinal (GI) bleeding and complications. Other risk factors include age, smoking history, alcohol, nicotine, caffeine use, advanced age, spicy foods, stress, prior history of hemorrhage, use of corticosteroids, genetic factors and people with type O blood (Ignatavicius & Workman, 2015).
The patient possesses most of the risk factors mentioned above. The patient is in her late 50’s. She has been taking NSAIDs such as ibuprofen and vicoprofen (a combination hydrocodone and ibuprofen). She has a history of epitaxies episodes and hemorrhage which could be indicative of blood coagulation or other GI complications in the past. She has been taking sertraline, an antidepressant, which increases bleeding risk when used simultaneously with NSAIDs (Skidmore-Roth, 2013). She has type O+ blood. Having lived in India for most of her life, she might also have frequented spicy foods.
The patient had reported having feelings of nausea and headache. She had diarrhea and vomitus consisting of large quantities of dark brown liquid. On assessment she had pale appearance and complained of feeling tired. The complete blood count (CBC) test showed she has decreased hemoglobin and hematocrit. She also has a decreased blood pressure of 102/55, an increased heart rate of 110 beats per minute and an increased respiratory rate of 26-28 breath per minute. This shows the body is trying to compensate the drop in blood pressure and oxygen saturation by raising the heart and respiration rate. These are all signs and symptoms of upper GI bleeding and complications such as gastritis and peptic ulcer (Ignatavicius & Workman, 2015).
Multiple treatments have been put in place for the patient. She is receiving supplemental oxygen of 2L via nasal cannula to improve oxygen saturation and respiratory rate. To manage fluid depletion and expand intravascular volume, she has IV normal saline running at a rate of 90 ml/hr. Packed red cells are ordered to increase blood volume and increase hematocrit and hemoglobin level. She has nasogastric tube placed that is connected to low intermittent suction which helps to monitor acute bleeding and drain gastric secretion. She is also placed on NPO. This helps to avoid the risk of aspiration and allow clear view for the endoscopy. (Ignatavicius & Workman, 2015). She is also receiving medical therapy with omeprazole to suppress gastric acid secretion. Her treatment plan goes in line with the general recommendations for the disease process.
The nurse should administer all medication including IV fluids as prescribed. Intake and output (I/O) as well as vital signs should be monitored hourly or according to agency policy. This helps to monitor for fluid overload or a drop in blood pressure. Presence of orthostatic hypotension should also be checked to avoid risk of fall. The abdomen should be assessed for bowl sounds, tenderness and bloating. If pain is present, the location, character, severity, duration and aggravating factors should be checked. NG tube placement should be checked and lubricant for lip and nasal area should be provided to avoid skin irritation. Oral hygiene should be administered every 2-4hrs. Hospitalization and change in health status add stress to the body. Since the patient has also been taken off sertraline, the nurse should assess how the patient is coping and teach techniques that reduce stress. Patient should also be thought to avoid or modifiable risk factors to avoid further complications. Lab values and other diagnostic test results should also be checked to find out if a change in intervention is needed (Ignatavicius & Workman, 2015).
Laboratory values and diagnostic test
|Test||Values||Reference range adult females||Result|
|Hematocrit (%)||19.4||37.0 – 47.0||Low|
|Hemoglobin (g/dl)||7.2||12.0 – 15.0||Low|
|White blood count (x103/µL)||9.8||4.8 – 10.8||Normal|
|Platelet (x103/µL)||223||150 – 400||Normal|
|Blood urea nitrogen (BUN) mg/ml||27||8 – 21||High|
|Creatinine mg/dL||0.5 – 1.1||Normal|
|Potassium mEq/L||3.5 – 5.0||Normal|
|Phosphorus mg/dL||3.0 – 4.5||Normal|
|Magnesium mEq/L||1.3 – 2.1||Normal|
|Calcium mg/dL||9.0 – 10.5||Normal|
|Total Protein g/dL||6.4 -8.3||Normal|
|Prothrombin time sec||11.0 – 12.5||Normal|
|International normalized ratio||0.8 – 1.1||Normal|
(Pagana & Pagana, 2015)
The patient’s hematocrit and hemoglobin level are below normal range. Low levels indicate anemia, hemorrhaging and hemolysis. Dehydration as well as drugs such as antibiotics and NSAIDS can lower the number as well (Pagana & Pagana, 2015). The patient has been taking these medication. The low value can also be explained with her acute blood and fluid loss form diarrhea and vomitus. As hematocrit and hemoglobin level correspond to oxygen caring capacity and amount of blood in circulation, immediate intervention and close monitoring is required (Ignatavicius & Workman, 2015).
Blood urea nitrogen (BUN) level is checked along with creatinine to test renal function. An increase only in BUN level indicates dehydration. BUN level may also be elevated in the presence of GI bleed like the patient’s. In such cases, the excess amount of protein is catabolized by the liver and result in an elevated BUN (Pagana & Pagana, 2015). Endoscopic therapy can be used to try to isolate and stop the bleed.
A direct coombs test is used to identify immune hemolysis. It looks for antibodies that stick to red blood cells (RBCs) and cause hemolysis. A positive result indicates the presence of these antibodies. This condition can be caused by an auto immune disease. This may also help to explain the patient’s multiple hemorrhage episodes in the past. Drugs such as ampicillin and penicillin can also produce false positive result (Pagana & Pagana, 2015). Since the patient has been treated with antibiotics recently, the patient should be asked to classify the antibiotics she was on. The finding also indicates she is prone to developing hemolytic anemia. Hence, close monitoring of hematocrit and hemoglobin level is necessary.
Additional diagnostic tests can also be used to further check other causative factors. Blood, breath or stool test can be done to detect or rule out H.pylori infection. Biopsy can be taken to establish different type of gastritis diagnosis, to confirm or rule out gastric cancer.
X- ray studies with contrast can also be used to check for ulcer and carcinoma (Ignatavicius & Workman, 2015).
The patient is taking omeprazole 40 mg Intravascularly (IV) twice a day. Omeprazole belongs to the proton pump inhibitor function class of medications. It works by inhibiting the enzyme that generates gastric acid thereby suppressing gastric secretion. Omeprazole is used for the patient for as a therapy for gastric ulcer. The recommended dose of Omeprazole is 40 mg a day and limited use for 4-8 weeks. This indicates the patient is taking higher than the recommended dose. Some side effects of this medication include headache, nausea, vomiting, diarrhea abdominal pain, proteinuria and hepatic failure. Risk for community-acquired and healthcare-associated pneumonia is indicated with regular dosage possibly due to alteration of upper GI flora. Clostridium difficile infection is similarly associated with taking omeprazole at a higher dose. Omeprazole also reduces the therapeutic effect of clopidogrel and warfarin increasing cardiovascular and bleeding risks. Other (Lehne, 2013).
Absence of pain, swelling, tenderness and bleeding indicate effectiveness of medication. The nurse should teach the patient to report severe abdominal pain, cramps or headache. Patient should also be informed omeprazole should not be abruptly stopped to prevent rebound proton pump activation. Vital sign should be monitored regularly to assess response for medication, CBC should be checked to assess for signs of infection, hepatic and renal function should also be assessed (Skidmore-Roth, 2013).
Normal saline is an isotonic solution composed of sodium and chloride. Since it has the same osmolality as that of inside of the cells, it will stay within the extracellular compartment increasing intravascular volume. “It’s administered to treat low extracellular fluid, as in fluid volume deficit from hemorrhage, severe vomiting or diarrhea, and heavy drainage from GI suction, fistulas, or wounds” (Crowford & Harris, 2011, p.33). It is also the only solution administered with blood produce which makes it essential for the patient.
Therapeutic effect can be assessed by the normalization of vital signs such as heart rate and blood pressure as well as improvement in skin turgor. Over infusion can lead to fluid volume overload and can cause hypertension, edema, and cause breathing problem. Monitoring vital signs, input and output is important to check for hypo and hypervolemia. Checking electrolyte imbalance is also important along with this (Crowford & Harris, 2011)
Two units of leukoreduced packed red cells is ready to be transfused for the patient. The majority of the white blood cells have been filtered out from this preparation. This helps reduce transfusion reaction and chronic adverse reaction (Sharma & Marwaha, 2010). The patient’s past medical history and the positive direct coomb’s test indicate there is a potential risk for hemolysis with transfusion. Therefore close attention should be given to monitor and prevent adverse reaction.
Baseline vital signs should be taken at start of the transfusion, followed by a check in the first 15 minutes and then after an hour. The nurse should stay with the patient for the first 15 minutes. Patient should be thought to report any sensation of chills, fever, itching or difficulty breathing. In cases of adverse reaction, transfusion should be stopped immediately, the health care provider should be notified and oxygen therapy started. Electrolyte imbalance should also be assessed as there a risk for potassium to shift out of the cell as a reaction to the transfusion (Ignatavicius & Workman, 2015). Therapeutic effect can be checked by monitoring improvement in the hematocrits and hemoglobin count, oxygen saturation and blood circulation. Patient verbalization of feeling less tired and ease of breathing is also another indicator.
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