Patient is a 42 years old female who is admitted with an acute gastrointestinal (GI) bleeding caused by gastritis and peptic ulcer related to non-steroidal anti-inflammatory drugs (NSAIDs) use

Pathoparmacology

Patient is a 42 years old female who is admitted with an acute gastrointestinal (GI) bleeding caused by gastritis and peptic ulcer related to non-steroidal anti-inflammatory drugs (NSAIDs) use. Based on patient statement, she woke up in the morning with nausea, and headache, and later she vomited a large amount of dark brown liquid, and had large dark brown liquid diarrhea. Patient reported that she used acetaminophen, ibuprofen and prescribed vicoprofen to relieve pain from dental procedures for the last four weeks. Patient has a history of bleeding episodes which happened during childhood, and pregnancy.  Both bleeding episodes required her to visit ED. She also had a complicated delivery with bleeding which resulted in a hysterectomy and multiple transfusion.  Patient has depression, and takes treatment medication. Patient denied use of tobacco, alcohol or any other illegal intoxicants. She is married and has one 16-year-old child. Patient denied recent travel.

Pathophysiology

The stomach is an extraordinary organ which has both an endocrine and exocrine function (Porth, 2015 p 679-700). The Stomach breaks down foods for absorption by secreting gastric acid, and a mix of enzymes. Stomach is coated with a mucous layer that protects it from digesting itself. But if the amount of acid is increased or the amount of protective mucous layer is decreased, a person can develop complications. The mucosal barrier consists of an intrinsic barrier and the extrinsic barrier. The intrinsic barrier includes the epithelial cells lining of the digestive tract and the tight junctions that tie them together to prevent acid penetration. An impermeable hydrophobic lipid layer covers the junctions and blocks ionized water soluble molecules from crossing the membrane.  The extrinsic barrier includes secretions. A prime example of these extrinsic components is bicarbonate ions. The surface epithelial cells secrete these ions and they neutralize abrasive acids. Moreover, prostaglandin has a vital role in protecting the gastric mucosa. Prostaglandins helps with protecting the lining of the stomach from the damaging effects of acid. Therefore, when the mucosal barrier is impaired for any of those reasons, compilations like GI bleeding related to peptic ulcer and gastritis can develop (Porth, 2015 p 679-727). According to estimates from U.S. studies, most GI bleeding cases are associated with nonsteroidal anti-inflammatory drug (NSAID) use, and Helicobacter pylori (H.pylori) infection (Wilkins,Kahan & Schade, 2012).

             Non-steroidal anti-inflammatory drugs (NSAIDs) are the most prescribed medications for pain and inflammation (Lehne, 2013 p 844-847). NSAIDs work by blocking cyclooxygenase (COX). The COX enzymes are responsible for producing prostaglandins, which are a family of chemicals that have several important functions. They promote inflammation, pain, and fever; support the blood clotting function of platelets; increase stomach mucosal blood flow, lowers stomach acid secretion, and increases bicarbonate secretion. Since NSAIDs indirectly inhibit prostaglandins production, they promote GI bleeding, gastritis, and ulcers in the stomach. In addition, due to their lipid soluble property, some NSAIDs can diffuse through the hydrophilic lipid layer, and damage the lining of gastric mucosa by increasing permeability (Porth, 2015 p 679-727).

Another common cause of GI bleeding is infection of the stomach by bacteria called Helicobacter pylori (H.pylori) (Wilkins,Kahan & Schade, 2012). Most people with peptic ulcers have these bacteria living in their gastrointestinal (GI) tract (Wilkins,Kahan & Schade, 2012). H. pylori evades attack by the host’s immune system, and causes chronic inflammation in several ways. H. pylori can damage the mucosal defense system by reducing the thickness of the mucosal layer, diminishing mucosal blood flow, and interacting with the gastric epithelium. Also, H. pylori infection can increase gastric acid secretion by producing various antigens, virulence factors, and soluble mediators. The bacteria interfere with gastric epithelial cell-signaling pathways which are responsible for regulating cellular responses. This can contribute to apical junction barrier disruption, interleukin-8 secretion and phenotypic changes to gastric epithelial cells (Porth, 2015 p 679-727). In addition to NSAIDs use and H. pylori infection, causative factors for GI bleeding are advanced age, gender, familial tendency, malignant tumors in stomach, alcohol ingestion, portal hypertension, chronic smoking, high level of stress, high-dose corticosteroid, Selective Serotonin Reuptake Inhibitors (SSRI), anti-coagulant therapy, blood coagulation disorder and irritating foods (Wilkins,Kahan & Schade, 2012).

            There are three main factors that contributed to the patient’s current situation. Patient used ibuprofen and vicoprofen for pain. Patient has a history of bleeding episodes which significantly puts her at higher risk of more bleeding.  Also, patient takes sertraline (SSRI) 50mg each day which is a risk factor for GI bleeding. SSRIs interferes with platelet function and reduce clot formation (Skidmore-Roth, 2013).

            Some of the signs and symptoms of GI bleeding are dyspnea, headache, stomach pain, nausea, weakness, cold moist skin, low blood pressure, reflexive tachycardia, tachypnea, dizziness, bloody stool and emesis (Porth, 2015, p 723) If acute GI bleed is not treated, it might lead to shock or even death. The patient showed most of the above signs and symptoms. Patient complained of nausea, weakness, and headache. She had melanotic emesis with the same color of diarrhea and she appeared to be pale. Patient’s CBC result indicated low hemoglobin, hematocrit level (H &H), and elevated BUN. Patient was tachycardic, 110b/m, and tachypneic, 26-28b/m; blood pressure was on the low side, 102/55, SaO2 96% on 2L/min oxygen.  Since patient is bleeding, her blood pressure and O2 saturation is below normal, and heart rate and respiratory rate are elevated to maintain homeostasis. (Ignatavicius & Workman, 2015).

            Many nursing and medical treatments are applied for the patient. Patient is on 2L of oxygen via nasal cannula to maintain normal saturation level, and to reduce respiratory distress. Patient is receiving normal saline at rate of 125ml/hr. This helps to replace fluid lost from bleeding. At the same time, it helps to bring her blood pressure to normal by increasing blood volume. She is about to get 2L packed red cells transfusion to expand intravascular fluid as well as to elevate her H & H level. As a treatment for GI bleeding, patient is taking 40mg omeprazole twice a day by mouth. This medicine decreases gastric secretion by inhibiting proton pumps.  Moreover, nasogastric (NG) tube is placed to apply suction to the GI tract, this is performed using a low intermittent suction device. This treatment helps to monitor acute bleeding, to assess re-bleeding, and to drain gastric secretion. The patient is scheduled for endoscopy therapy because it is the first line treatment choice to localize site of bleeding, to collect specimens, and to treat source of bleeding. Patient is on NPO for endoscopy to ensure stomach is empty for the procedure, to give better view of internal organs, and to avoid possible aspiration into lungs. Patient is also on bed rest to prevent falls, and to reserve energy. Patient’s input and output are monitored to avoid fluid overload, to monitor fluid and electrolyte balance, to assess renal function, and to check for bleeding (Ignatavicius & Workman, 2015). Over all, patient’s actual treatment plans are similar with the evidence based recommendations for GI bleed.

            The nurse will assess vital signs and SaO2 level often, and compare the findings with baseline vital signs. The nurse also will take blood pressure in different positions because fluctuations in blood pressure indicates hemorrhage. The nurse will assess patient’s mental status because change in metal status can be caused by continuous hemorrhage, hypoxemia or inadequate fluid replacement. The nurse also will strictly monitor fluid intake and output because it reflects blood volume in the body as well as cardiac and renal response to bleeding; it also reflects how effective fluid replacement therapy is. The nurse will maintain patient on bed rest to prevent vomiting, falls, and reserve energy because vomiting aggravates intra-abdominal pressure, and predisposes to further bleeding. Also, severe bleeding causes falls from dizziness, and weakness. The nurse will infuse IV fluids, and packed red blood cells, and administer medications as indicated because fluid replacement is essential in improving patient’s blood volume, and medications are important to treat GI bleed. The nurse will monitor drained fluid for any changes in amount and color because change in color, and amount can be from acute bleeding/re-bleeding. The nurse will monitor laboratory findings like hemoglobin, hematocrit, BUN and creatinine because laboratory findings determines how much blood transfusion is needed, how the patient responded to the treatment, and how well other organs are functioning. The nurse will prevent skin break down that can be caused from bedrest, NG tube, and oxygen tube. So, the nurse will position the patient every 2 hours, will apply lubricant around nostrils and pad tubes in areas that put pressure on skin. The nurse will also prevent immobility complications by having the patient use spirometer, and walk as tolerated. (Ignatavicius & Workman, 2015).

Laboratory values and diagnostic test

TestValuesReference range adult femalesResult
Sodium mEq/L 136-145Normal
Potassium mEq/L 3.5 – 5.0Normal
Phosphorus mg/dL 3.0 – 4.5Normal
Magnesium mEq/L 1.3 – 2.1Normal
Calcium mg/dL 9.0 – 10.5Normal
Total Protein g/dL 6.4 -8.3Normal
Albumin g/dL 3.5-5.0Normal
Prothrombin time sec 11.0 – 12.5Normal
International normalized ratio 0.8 – 1.1Normal
White blood count (x103/µL) 4.8 – 10.8Normal
Creatinine mg/dL 0.5 – 1.1Normal
Platelet (x103/µL)223150 – 400Normal
Hematocrit (%)19.437.0 – 47.0Low
Hemoglobin (g/dl)7.212.0 – 15.0Low
Blood urea nitrogen (BUN)  mg/ml278 – 21High
Coombs test  Positive

            (Ignatavicius & Workman, 2015).

            The patient’s H & H levels are low. That is caused by hypovolemia, blood loss, hemolysis, and dehydration (Pagana & Pagana, 2015, P 488-497). Patient took antibiotics when she suffered from dental abscess, and a fractured tooth. Patient also took NSAIDs to relieve pain. Those drugs can lower H &H level (Pagana & Pagana, 2015 P 488-497). Since hemoglobin helps to deliver oxygen to vital organs, low H and H level can result in shock and death. Therefore, IV fluids and blood transfusion must be given as quickly as possible. Also, lab values should be reassessed after fluid and infusion to check how the patient responded to the treatment, and if other interventions are needed. (Ignatavicius & Workman, 2015, P 210). Moreover, the patient’s elevated BUN level with normal creatinine level which indicates acute GI bleeding, and dehydration. Furthermore, BUN level can be elevated from high protein tube feeding and digesting own blood (Pagana & Pagana, 2015 P 488-497).

            A direct coombs checks antibodies that attack RBCs (Ignatavicius & Workman, 2015 P.864-865). This is when antibodies are made to attack own red blood cells.  The antibodies stick and destroy red blood cells (RBCs).  The patient’s positive result for this test shows that the antibodies are present, and indicates hemolytic anemia. This is the possible cause of patient’s previous bleeding episodes.  In addition, antibiotics can cause a false positive result.  So, monitoring CBC results especially H & H, WBC, platelet, RBC, INR, and PTT is vital (Ignatavicius & Workman, 2015 P.864-865).

There are additional diagnostic tests and treatments for GI bleed. Blood sample and biopsy can help to detect H.pylori infection (Ignatavicius & Workman, 2015 P.1220-1239). X-ray with contrast medium can detect ulcer crater and to exclude gastric carcinoma. Other than endoscopy, the disease can be investigated using a nuclear medicine GI bleeding study, laparoscopy, and MRI. Esophagogastroduodenoscopy, interventional radiologic procedure and acid suppression are used to stop bleeding, and to prevent re-bleeding (Ignatavicius & Workman, 2015 P.1220-1239).

When it comes to medication, H2 receptor antagonist, and sucralfate can be given (Ignatavicius & Workman, 2015 P.1220-1239). H2 receptor antagonist inhibit gastric secretion by blocking H2 receptor, and sucralfate reduces damage from gastric secretions. As alternative therapy, patient can participate in stress reduction techniques such as yoga and meditation. Also, they can use herbs since its believed that herbs heal inflamed tissue, and increase blood flow to the gastric mucosa (Ignatavicius & Workman, 2015 P.1220-1239).

Medications

Patient is on 2L of oxygen via nasal cannula. Oxygen is a gas used as a drug to increase oxygen level in the blood when one has problem with breathing (Ignatavicius & Workman, 2015 P. 563-569). The patient is getting low flow oxygen therapy to manage hypoxemia.  The therapeutic effect is reached when patient’s SaO2 level, and respiration rare are normal.  The amount of oxygen delivered depends on oxygen concentration required by the patient. As any other drug, oxygen has some side effects such as oxygen toxicity, dry mucous membrane, infection, and absorption atelectasis. Oxygen has a combustion property so open fires even small ones should be avoided, and patient should be advised to take precautions. Warning sign must be put on the door when oxygen is in use. For the patient on oxygen, nurse will assess vital signs, and analyze arterial blood gas. The nurse will assess shortness of breathing, cough, chest pain and GI upset for oxygen toxicity. The nurse also will auscultate lung sound for absorption atelectasis. The nurse will apply lubricant, pad the tubing, clean the tubing and assess pressure points for skin break down (Ignatavicius & Workman, 2015 P. 563-569).

            The patient takes omeprazole 40 mg by mouth twice a day. Omeprazole is from the proton pump inhibitors drug class (Skidmore-Roth, 2013, P 884-886). This class of medication suppresses hydrogen/K-ATPase enzyme system of gastric acid secretion. This Patient is taking this medication for gastritis and peptic ulcer. For adults with ulcer, 40 mg a day for 4-8 weeks is recommend. The patient takes 40mg twice a day which is a higher dose. Some of the many side effects are headache, nausea, abdominal pain, heart failure, hepatic failure, pneumonia, proteinuria, hematuria, thrombocytopenia, anemia and Stevens-Johnson syndrome. This medication should not be crushed or chewed, and should be taken on empty stomach. Bleeding might occur if it is given with warfarin. The therapeutic response of this medication includes absence of epigastric pain, swelling, fullness, and bleeding. Patient must be told to report abdominal pain, and change in stool color and form. Patient also should be extra careful when driving as dizziness may occur. The nurse must assess GI for positive bowel sound every 8 hours, in addition to pain, swelling, and stool color. Chemistry panel tests should be done to evaluate change in fluid, electrolyte and liver function (Skidmore-Roth, 2013, P 884-886).

Normal saline (0.9% sodium chloride) is the most commonly used isotonic solution which has the same osmolality as intracellular fluid (Porth, 2015 P 159-209). Normal saline is given to replace body fluid. In this case, patient is given normal saline because of fluid imbalance from bleeding, severe diarrhea, vomiting, and suctioning. The side effects are hypernatremia, fluid over load, high blood pressure, heart failure, IV site reactions, kidney damage, and electrolyte abnormalities. Therapeutic response is achieved when vital signs and lab values are normal, and when there is a decrease in skin turgor. The amount given is determined by vital signs and laboratory values. The nurse should assess for breathing sound, pounding pulse, level of consciousness, edema, and distended neck vein. The nurse will assess vital signs and monitor laboratory findings, weight, and I &O. The nurse will assess IV site for infection, infiltration, and inflammation. (Porth, 2015 P 159-209). 

The patient has an order for 2L leukoreduced packed red cells transfusion. As the name indicates, it contains low white blood cells (Ignatavicius & Workman, 2015 P. 900).  The recommended infusion volume per rate is 200-25ml in 2-4 hours. The therapeutic goal is reached if H &H level and oxygen saturation level are within normal range. The blood transfusion and a positive coomb’s test increase the patient’s chance of getting hemolysis.  Therefore, the nurse will assess hemolytic reaction manifestations such as chest pain, low back pain, hypotension, tachycardia and tachypnea. During transfusion, and after transfusion vital signs must be closely monitored. Lab values must be monitored to assess treatment response, and to check electrolyte imbalances. Patient should be assessed every 20 minutes for allergic transfusion reaction, and circulatory overload. If patient experiences signs and symptoms of reactions, transfusion must be stopped. Blood transfusion is very risky, so the nurse must teach about the possibility of getting reactions, and blood borne pathogens (Ignatavicius & Workman, 2015 P. 898).

The patient takes sertraline 50mg each day by mouth for depression. Sertraline belongs in the Selective Serotonin Reuptake Inhibitors (SSRI) drug group (Skidmore-Roth, 2013 P.1077-1079). Sertraline works to block the reabsorption of the serotonin at the presynaptic neuron, and increases serotonin action. For adults 25-50mg per day is recommended. Some side effects of sertraline are bleeding, insomnia, involuntary movements, diminished sexual performance and libido, and elevated suicidal tendency. The medication should be avoided while pregnant as it may be harmful to the fetus especially during the third trimester. This medication can be fatal if it is take with monoamine oxidase inhibitors. Therapeutic response is reported when there is significant improvement in depression. Since sertraline has slow onset the therapeutic effect may take more than a week. Patient should use caution when they engage in activities needing alertness because drowsiness, dizziness, and blurred vision may occur. Patient also should be advised not to stop taking the medication abruptly. The nurse should assess mental status and mood changes. The nurse should assess the patient for bleeding. Thyroid function tests must be monitored. Patient’s vital signs including weight must be taken and compared to baseline. The nurse also should monitor input and output and bowel movement as the medication causes urinary retention, and constipation (Skidmore-Roth, 2013 P.1077-1079).

References

Ignatavicius, D. & Workman, L., M. (2015). Medical-surgical nursing: Patient-centered         collaborative care (8th ed.). St. Louis, MO: Elsevier Saunders.

Lehne, R. (2013). Pharmacology for nursing care. (8th ed.). St. Louis, MO: Saunders, Elsevier Inc.

Pagana, K.D. & Pagana, T.J. (2015). Mosby’s manual of diagnostic and laboratory test Reference. (12th ed.). St. Louis, MO: Elsevier Mosby.

Porth, C.M. (2015). Essentials of pathophysiology (4th ed.). Philadelphia, PA. Lippincott Williams & Wilkins.

Skidmore-Roth, L. (2013). Mosby’s 2013 drug guide for nurses (26th ed.). St. Louis, MO: Elsevier Mosby.

Wilkins, T., Khan, N., Nabh, A., & Schade, R. (2012). Diagnosis and management of upper gastrointestinal bleeding. American Family Physician85(5), 469-476.