I.

INTRODUCTION

UPPER GASTROINTESTINAL BLEEDING
Originates in the GI tract from the mouth to the ligament of Treitz where the duodenum, the
first part of the small intestine, ends. Bleeding from the esophagus may occur from esophageal
varices, dilation of the veins in the esophagus. One of the symptoms of upper GI bleeding is
vomiting of blood (hematemesis).If the blood travels
through the GI tract, the stool may appear tarry and black (melena) because of digested blood,
though the stool can still be stained with red blood (hematochezia). About 75% of patients
presenting to the emergency room with GI bleeding have an upper source. The diagnosis is
easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of
patients in the emergency room with GI bleeding have an upper source. Determining whether a
patient truly has an upper GI bleed versus lower gastrointestinal bleeding is difficult. Mortality
is about 11% in patients admitted with an UGIB.2 It is as high as 33% in patients who
develop bleeding whilst in hospital. A score of less than 3 using the Rockall system above is
associated with an excellent prognosis, whereas a score of 8 or above is associated with high
mortality.3 Most deaths occur in elderly patients with co-morbidity. Mortality is reported to be
lower in specialist units possibly because of adherence to protocols rather than because of
technical advances.2 The prognosis in liver disease relates significantly to the severity of the
liver disease rather than to the magnitude of the haemorrhage

Upper gastrointestinal bleeding is commonly caused by bleeding varices (varicose veins) in the
esophagus, peptic ulcers or a Mallory- Weiss tear at the esophageal gastric junction from
severe retching .Otherwise, bleeding over time results in anemia, characterized by lower than
normal blood hemoglobin and hematocrit with symptoms like weakness, fatigue, and fainting.
The most important step to evaluate upper GI bleeding is upper endoscopy. During this
procedure, performed by a gastroenterologist, a tube with a camera (endoscope) is passed
into the mouth and down the esophagus. The gastroenterologist can proceed to the stomach
and duodenum and localize the source of the bleeding, if possible. Other examination to
determine UGIB are Vital signs, in order to determine the severity of bleeding and the timing of
intervention. Abdominal and rectal examination, in order to determine possible causes of
hemorrhage. Assessment for portal hypertension and stigmata of chronic liver disease in order
to determine if the bleeding is from a variceal source.
Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio.

Emergency treatment for upper GI bleeds includes aggressive replacement of volume
with intravenous solutions, and blood products if required. As patients with esophageal
varices typically have coagulopathy, plasma products may have to be administered. Vital signs
are continuously monitored.Early endoscopy is recommended, both as a diagnostic and
therapeutic approach, as endoscopic treatment can be performed through the endoscope.
Therapy depends on the type of lesion identified, and can include:injection of adrenaline or
other sclerotherapy, electrocautery, endoscopic clipping, or banding of varices. Stigmata of high
risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the
bleeding lesion are usually removed in order to determine the underlying pathology, and to
determine the risk for rebleeding. Pharmacotherapy includes the following: Proton pump
inhibitors (PPIs), which reduce gastric acid production and accelerate healing of certain gastric,
duodenal and esophageal sources of hemorrhage. These can be administered orally or
intravenously as an infusion depending on the risk of rebleeding. Octreotide is
a somatostatin analog believed to shunt blood away from the splanchnic circulation. It has
found to be a useful adjunct in management of both variceal and non-variceal upper GI
hemorrhage. It is the somatostatin analog most commonly used in North America.
Terlipressin is a vasopressin analog most commonly used in Europe for variceal upper GI
hemorrhage. Antibiotics are prescribed in upper GI bleeds associated with portal hypertension.

If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy
with antibiotics and a PPI is suggested.









II. OBJECTIVES

General objectives:

This case study focuses on the advancement of my skills in managing and
administering the extensive range of my intervention to my client with Upper
Gastrointestinal Bleeding (UGIB). This study will further help me to expand my knowledge
about the said disease.

Specific objectives:

1. To established good rapport to the client and to get the physical assessment.
2. To define what is Upper Gastrointestinal Bleeding (UGIB).
3. To trace the pathophysiology of UGIB.
4. To enumerate the different signs and systems of UGIB.
5. To formulate and apply necessary nursing care plans utilizing the nursing process.











III. DEMOGRAPHIC DATA
Name: Mrs. E.M.C
Age: 47 y/o
Gender: Female Spouse: Armando A. Cacho
Status: Married Chief Complaint: Change in Sensoruim
Nationality: Filipino Date admitted: November 11, 2010
Religion: INC Time admitted: 10:30 am
Blood type: O+
Address: BKL3 LOT 10 PH Dela Costa Homes 3, SJDM, Bulacan
Final Diagnosis: Upper Gastrointestinal Bleeding (UGIB)

CLINICAL ABSTRACT
This is the case of EMC 47 y/o female from BKL3 LOT 10 PH Dela Costa Homes 3, SJDM, Bulacan. She
was born on September 15, 1963. She is married for 22 years now and has 6 children. Mrs. EMC is a
non smoker and non alcoholic beverages drinker.
Mrs. EMC was admitted to East Avenue Medical Center on November 11, 2010, 10:30 in the morning.
She was admitted due to dizziness, loss of consciousness and change of sensorium.
HISTORY OF PRESENT ILLNESS
One week prior to admission the patient had experienced dizziness and vomiting of previous ingested
food but still conscious and able to communicate. Three days prior to admission Mrs. EMC had
experienced anorexia and abdominal pain. Few hours prior to admission Mrs. EMC still in the previous
symptoms, and rushed to the ER of EAMC.
November 11, 2010 the physician ordered CBG monitoring, serum glucose control which revealed type
2 DM, start of empiric antibiotic which revealed complicated UTI and had her laboratory examinations
like blood chemistry, hematology test and urinalysis. On the same day she undergone upper
endoscopy with biopsy which revealed gastric ulcer. On the 13
th
day of Nov. she had her cross
matching which revealed her blood type which is type O positive. Nov. 21 she had undergone to IJ
catheter insertion for dialysis.

PAST MEDICAL HISTORY
According to the patient she has a hypertension, DM and BA (last attack 20 vq). She is negative to PTB
and thyroid disease. She had no maintenance on her HPN, for her DM she took Metformin.
FAMILY MEDICAL HISTORY
(+) Hypertension (-) PTB
(+) DM (-) Thyroid disease
(+) BA


LIFE STYLE
A. Personal Habit
The patient does not smoke nor drinks alcoholic beverages.
B. Diet
She eats three times a day and drinks 6-8 glass of water per day and sometimes
she also drinks soft drinks. The patients usual diet includes rice, meats like pork,
beef, chicken and fish. According to the patient, she seldom eats vegetables. She is
fond of eating sweets and lechon. She also drinks coffee often (4x a day).
C. Recreational Activity
She watch television during her free time after she had finish the household
choirs.
D. Sleep and Rest
She said that she spends 6 hours of sleep every night and she takes naps if she
had free time. She usually sleeps at 11:00 in the evening and wakes up at 5:00 in
the morning she said that it is continuous and she feels refreshed after waking up.
E. Activities of Daily Living
The patient works everyday in their house and sometimes she accepts laundry.
Every weekend she allotted time to rest and to have bonding with her family. She
said she do the household choirs before she starts washing her accepted laundry
from her neighbors.

PATIENTS SOCIAL HISTORY
A. Family Relationship and Friends
The patients family is nuclear type together with her husband Armando A.
Cacho, her six children. According to her she has a good relationship with each
member of her family and also with her friends. She allotted time to bond with
her family.
B. Occupational History
The patient is self employed.
C. Economic History
According to the patient her husband is a constructor and an OFW before. Her
husband is the one who brings income in their family. According to her
husband work is enough to support their childrens need. Her accepted laundry
from their neighbors helps them in their needs and it is an additional income to
them and it satisfies their needs.











IV. PHYSICAL ASSESSMENT

Actual Findings Normal Findings Interpretation
Head
Skull








Scalp



Hair








Face



Eyes




Eyebrows



Eyelashes



-Normocephalic
-No lumps







-No nits, lice and dandruff
-no baldness



-Straight, Black with white hair,
oily hair






-Symmetrical with movement
-Expressions appropriate to
situations

-Symmetrical
-No cloudiness
-No Lacrimation


-Symmetrical



-Equally distributed
-Curved slightly outward

-Skin intact

-Normocephalic
-Smooth
-No lumps
-Absence of modules or masses
-No area of tenderness
-Symmetrical with protrusions
on the lateral part of parietal
forehead and occipital bone.

-Whitish
-No nits, lice and dandruff
-no baldness

-Black or brown in color
-Hair is evenly distributed
-No area of baldness
-Thick
-Fine
-Curly/kinky/straight
-Dry/oily/shiny hair


-Symmetrical with movement
-Expressions appropriate to
situations

-Symmetrical
-No protrusions
-Dear or no Cloudiness
-No excessive Lacrimation

-Moves symmetrically
-Hair evenly distributed
-Skin Intact

-Equally distributed
-Curved slightly outward

-Skin intact

-Normal








-Normal



-Normal








-Normal



-Normal




-Normal



-Normal


-Normal
Eyelids







Lid margins




Lower palpebral
conjunctiva



Sclera




Iris






Pupils




Eye Movement



Field of vision
*Visual acuity


-No discharge
-No discoloration
-Lids close symmetrically
-approximately 15-20
involuntary blinks per minute;
bilateral blinking

-No secretions
-No erythema
-No redness


-Pink, shiny, with visible blood
vessels
-No discharges


-White in color
-Clear
- No redness


-Flat
-Brown
-Round
-Transparent/Shiny



-PERRLA





-Moves in unison
-coordinated






-Same as the color of the face
-No discharge
-No discoloration
-Lids close symmetrically
-approximately 15-20
involuntary blinks per minute;
bilateral blinking

-No scaling
-No secretions
-No erythema
-No redness

-Pink, shiny, with visible blood
vessels
-No discharges


-White/yellowish in black
Americans
-Clear, No cloudiness
-No redness

-Flat
-Brown
-Even coloration
-Symmetrical
-Round
-Transparent/Shiny

-PERRLA(Pupils Equally Round,
Reactive to Light &
Accommodation



-Moves in unison
-coordinated


-Good peripheral vision
-20/20 in both eyes


-Parallel with outer canthus of







-Normal




-Normal




-Normal




-Normal






-Normal





-Normal



-Normal



-Normal
Ear







Ear Canal





Hearing acuity


Nose






Lips







Gums





Teeth




-No swelling
-Shell shape





- Waxy cerumen
-Presence of cilia




-With good hearing acuity in
both ears


-No lesions
-Presence of cilia





-Darker lips
-Ability to purse lips






-Pink, moist
-No swelling
-No tenderness
-No discharges


-white





the eyes
-Same as the color of the face
-No swelling
-No tenderness
-Shell shape
-Firm cartilage

-Yellowish
-Dry/waxy cerumen
-Presence of cilia
-No foreign body


-With good hearing acuity in
both ears


-Symmetric and straight
-No discharge or flaring
-Uniform color
-No tenderness
-No lesions
-Presence of cilia

-Uniform pink color(darker,
e.g,Bluish hue, in Mediterranean
groups and dark-skinned clients)
-Soft, moist, smooth texture
-Symmetry of contour
-Ability to purse lips
-No tenderness

-Pink, moist
-No swelling
-No tenderness
-No discharges
-No retraction(lower and upper)

-32 in number
-White
-Upper teeth over-rides lower
teeth










-Normal




-Normal



-Normal






-Decrease of
oxygen supply






-Normal





-Normal





Tongue



Frenulum




Soft Palate



Hard Palate


Uvula




Tonsils




Neck











Upper Extremities
Skin



-Pink, even, rough dorsal surface
and moist


-Midline
-pinkish
-With visible veins

-Pink, moist, no swelling/No
tenderness


-Bony, Light pink in color, moist


-Midline moves when the client
says Aah




-Pinkish
-No discharge
-No inflammation


-Same as the skin color
-No lymphs, No mass










-No abrasions or other lesions
-When pinched, skin springs
back to previous state
- with edema


-Pink, even, rough dorsal surface
and moist


-Midline
-pinkish
-With visible veins

-Pink, moist, no swelling/No
tenderness


-Bony, Light pink in color, moist


-Pink, moist
-Midline moves when the client
says Aah



-Pinkish
-No discharge
-No inflammation


-Erect & midline
-Same as the skin color
-No tenderness
-No lymphs, No mass
-Symmetrical
-Muscles equal in size; head
centered
-Coordinated, smooth
movements with no discomfort



-Varies from light to deep
brown; from ruddy pink to light
pink; from yellow overtones to
olive
-No edema
-No abrasions or other lesions
-Normal



-Normal



-Normal



-Normal



-Normal




-Normal




-Normal











-accumulation
of excess fluid











Nails











Chest and back
Posterior
Thorax










Anterior Thorax







Abdomen










-Convex curvature
-white












-No tenderness
-No masses










-Full expansion
-Tachypnea






-Unblemished skin
-Uniform color

-Freckles, some birthmarks,
some flat and raised nevi
-When pinched, skin springs
back to previous state

-Convex curvature
-Smooth texture
-Highly vascular and pink in
light-skinned clients; dark-
skinned clients may have brown
or black pigmentation in
longitudinal streaks
-Intact epidermis
-Prompt return of pink or usual
color(generally less than 4
seconds)


-Chest symmetric
-Skin Intact; uniform
temperature
-Chest wall intact
-No tenderness
-No masses
-Full and symmetric chest
expansion
-Vesicular and bronchovesicular
sounds




-Quiet, rhythmic, and effortless
respirations
-Full symmetric excursion
-Bronchial and tubular breath
sounds in the trachea
-Vesicular and bronchovesicular
breath sounds

-Unblemished skin
-Uniform color
-Silver-white striae or surgical
scars







-Decrease O2
supply











-Normal












-Difficulty of
breathing






-Normal












Lower extremities

Skin










Nails











Motor
functions:













-Brown in color
- with edema
- No abrasions or other lesions
- with edema







- Concave curvature
-Brown pigmentation in
longitudinal streaks









- Repeatedly and rhythmically
touches the nose
- Rapidly touches each finger to
thumb with each hand
- Can readily determine the
position of fingers and toes
-Flat, rounded(convex),or
scaphoid (concave)
- Symmetric movements caused
by respiration
- Audible bowel sounds
- No tenderness
- Relaxed abdomen with
smooth, consistent tension




- Varies from light to deep
brown; from ruddy pink to light
pink; from yellow overtones to
olive
- No edema
- No abrasions or other lesions
- Freckles, some birthmarks,
some flat and raised nevi
- when pinched, skin springs
back to previous state

- Concave curvature
- Smooth texture
- highly vascular and pink in
light-skinned clients; dark-
skinned clients may have brown
or black pigmentation in
longitudinal streaks
- Intact epidermis
- Prompt return of pink or usual
color (generally less than 4
secs.)

- Has upright posture and steady
gait with opposing arm swing;
walks unaided, maintaining
balance
- May sway slightly but is able to
maintain upright posture and
foot stance.
- Maintain stance for at least 5
secs













- accumulation
of excess fluid










-Normal











-Normal
- maintains heel-toe walking
along straight line
- Repeatedly and rhythmically
touches the nose
- Rapidly touches each finger to
thumb with each hand
- Can readily determine the
position of fingers and toes




GORDONDS
Before
hospitalization
During
hospitalization

Interpretation Analysis

a. activity-
exercise pattern
- hobbies











Elimination
pattern









According to her
she does the
household
choirs and at the
same time it is
her way of
exercising and
she can perform
different
activities.




Prior to
hospitalization
she defecates
every day. She
urinates normal
amount and
normal color.
urinates



During her
hospitalization
she is in
complete bed
rest.









For the period of
hospitalization
her defecation
does not vary
but her urine
output
decreases.




She was not able
to perform the
activities
because of the
disease process.









The patients
elimination
pattern changed
during
hospitalization
because she is
under
medication.



Exercise is very
important to our
body because it
promotes good
health and helps
us build and
maintain healthy
muscles, bones,
and joints and it
reduces
depression and
anxiety.

Good
elimination
pattern reduces
the risk of
having cancer. It
helps us to
detoxify waste
in our body to
free ourselves
from
complications



Sleep and rest
pattern






Cognitive-
perceptual
pattern




Self perception
and self-concept
pattern







Role-
relationship
pattern
















Before she
sleeps 6 hours
every day





The patient is a
2
nd
year college
undergraduate.
She is literate.



Prior to
hospitalization
she is a happy
person and
positive thinker.





The patients
family is nuclear
type. They are 8
in the family.
They have 6
children and she
allotted time for
her family to
bond. She is
sociable to
everyone.








Throughout her
hospitalization
sleeps 12 hours
and can take
naps.



Same






During her
hospitalization
she is still a
positive thinker.






Throughout her
hospitalization
her family is
with her side at
all times to
support her.













Due to
confinement the
patient has no
problem with
her sleep.



Due to
confinement the
patient has no
problem with
understanding


Even she is in
the hospital
herself
perception does
not change. She
stayed the same
as she was
before.


Due to her
hospitalization
the family
becomes closer
to one another
and become
stronger.












Enough and
good sleep and
rest pattern can
reduce stress,
helps us to think
better.


Good education
is important to
overcome
poverty.



Good self-
perception and
self-concept
pattern helps us
to overcome
problems and
trials.



Good
relationship to
each member of
the family
creates unity
and compact
relationship with
each other.
Good
relationship with
other people can
gain trust,
acceptance,
support, and
someone to Call
On When You



Coping-stress
tolerance
pattern






Health
perception









Sexuality-
reproductive
pattern









Values- belief
pattern



Ever time she
encounters
difficulties she
asks guidance
and help from
God.



According to her
health is very
important
because it is
wealth.






Before
hospitalization
she menstruates
regularly.








She is an INC.
They go to
church every
Thursday and
Sunday.



During her
hospitalization
she just prays
every time shes
in pain.




During her
hospitalization
she still believes
that health is
wealth.






Same











During her
hospitalization
her husband and
her always prays
for her health.



Her coping
stress is the
same as what
she is doing
before.




Her health
perception is the
same as what
she believes
before.






Her reproductive
system works
properly.









Her values-
belief pattern
does not change
and her faith to
God become
stronger.
Need a Hand.


Having a good
coping to stress
can overcome
stressors and
depressions.



Good health
perception can
maintain health,
the body can
function
properly and it
acts as personal
strength.



Good sexuality-
reproductive can
easily determine
the fertilization
and can prevent
cancers in
reproductive
system.




Strong values-
beliefs help us to
overcome
difficulties and
trials.



V. ANATOMY AND PHYSIOLOGY
UPPER GI







The upper GI tract consists of the mouth, pharynx, esophagus, and stomach. This is where ingestion
and the first phase of digestion occur.
MOUTH

The mouth includes the tongue, teeth, and buccal mucosa or mucous membranes containing the ends
of the salivary glands, continuous with the soft palate, floor of the mouth and under side of the
tongue. Chewing (mastication) is the mechanical process by which food, constantly repositioned by
muscular action of the tongue and cheeks, is crushed and ground by the teeth through the muscular
action of the lower jaw (mandible) against the fixed resistance of the upper jaw (maxilla).
Saliva excreted in the oral cavity by three pairs of exocrine glands (parotid, submandibular, and
sublingual) is mixed with chewed food to form a bolus, or ball-shaped mass. There are two types of
saliva: a thin watery secretion that wets the food and a thick mucous secretion that lubricates and
causes the food particles to stick together to form the bolus.
Digestive enzymes in saliva begin the chemical breakdown of food, primarily starches at this
point, almost immediately.
PHARYNX

The pharynx is contained in the neck and throat and functions as part of both the digestive
system and the respiratory system. The human pharynx is divided into three sections: the
nasopharynx behind the nasal cavity and above the soft palate;
The oropharynx behind the oral cavity and including the base of the tongue, the tonsils, and the
uvula; the hypopharynx or laryngopharynx includes the junction with the esophagus and the
larynx, where respiratory and digestive pathways diverge. The swallowing reflex is initiated by touch
receptors in the pharynx as the bolus of chewed food is pushed to the back of the mouth.
Swallowing automatically closes down the respiratory or breathing pathway as an anti-choking reflex.
Failure or confusion of reflexes at this point can result in aspiration of solid or liquid food into the
trachea and lungs.
ESOPHAGUS






The esophagus is the hollow muscular tube through which food passes from the pharynx to the
stomach. It is also lined with mucous membrane continuous with the mucosa of the mouth and into
which open the esophageal glands.

The esophagus is surrounded by relatively deep muscles that move the swallowed bolus of masticated
food through peristaltic action, piercing the thoracic diaphragm to reach the stomach.
STOMACH






The stomach is a hollow muscular organ, located below the diaphragm and above the small intestine
that receives and holds masticated food to begin the next phase of digestion. Two smooth muscle
valves, the esophageal sphincter above and the pyloric sphincter below, keep stomach contents
contained.
The stomach is surrounded by stimulant (parasympathetic) and inhibitor (orthosympathetic) nerve
plexuses which regulate both secretory and muscular activity during digestion. With a volume of as
little as 50 mL when empty, the adult human stomach may comfortably contain about a liter of food
after a meal, or uncomfortably as much as 4 liters of liquid.










DUODENUM








The duodenum precedes the jejunum and ileum and is the shortest part of the small intestine, where most
chemical digestion takes place. The nameduodenum is from the Latin duodenum digitorum, or twelve
fingers' breadths.
In humans, the duodenum is a hollow jointed tube about 1012 in long connecting the stomach to
the jejunum. It begins with the duodenal bulb and ends at the ligament of Treitz.
The duodenum is largely responsible for the breakdown of food in the small intestine, using
enzymes. Brunner's glands, which secrete mucus, are found in the duodenum. The duodenum wall is
composed of a very thin layer of cells that form the muscularis mucosae. The duodenum is almost entirely
retroperitoneal.
The duodenum also regulates the rate of emptying of the stomach via hormonal
pathways. Secretin and cholecystokinin are released from cells in the duodenal epithelium in response to
acidic and fatty stimuli present there when the pylorus opens and releases gastric chyme into the duodenum
for further digestion. These cause the liver and gall bladder to release bile, and the pancreas to release
bicarbonate and digestive enzymes such as trypsin,lipase and amylase into the duodenum as they are
needed.




VI. PATHOPHYSIOLOGY
Precipitating factors Contributing factors Predisposing factors



















-Generalized body weakness BP: 180/90 RR:25 PR:90
-Dizziness

old NSAIDs use
Stress
Diet: spicy foods and coffee
addict

diet
Elicit their effects on
cyclooxegenase
Disruption of mucous
barrier
Inflammatory effect on
gastric mucusa
Neutrophils 86%
Ulcers burrows deep
Weakening and necrosis of
arterial
Development of pseudo
anuerysms
Weakened wall raptures leading
Peripheral vasoconstriction
Pale nail beds and
conjuctivitis
UGIB
VII. LABORATORY
URINALYSIS
Definition:
Is an array of tests performed on urine and one of the most common methods of medical
diagnosis.
Indication:
It is used to detect the presence of UTI, Proteinuria,Glucosuria, Ketonuria, presence of urinary
sediments which indicates renal pathology.
Nursing Responsibility:
Instruct the patient perform perineal care prior to the procedure
Collect urine from the first voiding in the morning and examine within 30 mins.
Label specimen properly
Instruct patient to keep labia majora separated while urinating
Instruct the patient to collect specimen by a midstream catch
Parameters Results
Color Light yellow
Transparency Slightly cloudy
Reaction 5.0
Sp gravity 1,020
Albumin + 2
Glucose (-)
RBC count 1-2
WBC count 25-30
Epithelial cells Few
Mucus threads 0 ccl
Bacteria Moderate
Amorphous
Urates
Casts none
Analysis and interpretation
Laboratory results revealed that there is presence of Albumin in the blood, this indicates that
the glomerular cannot filter large molecules such as that of Albumin. It also revealed that
there is infection as evidence by presence of bacteria and red cells in the urine.
Hematology
Definition
Is the branch of internal medicine, physiology, pathology, clinical laboratory work,
and pediatrics that is concerned with the study of blood, the blood-forming organs, and blood
diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis,
and prevention of blood diseases. The laboratory work that goes into the study of blood is
frequently performed by a medical technologist. Hematologists physicians also very frequently do
further study in oncology - the medical treatment of cancer.
Indication
This test determines the concentration of hemoglobin in whole blood.

Nursing responsibility:
Explain the procedure to the patient
Collect blood sample by extraction from the vein in arm using needle or finger prick
Label the specimen properly.

Parameters Normal Values Results
Hemoglobin M- 130- 180 g/l
F 120-160 g/l
60
Hematocrit M- 0.42-0.52
F- 0.37- 0.48
0.181
WBC count 4.3-10.8x 10/l
Segments 0.45-.0.74 0.83
Lymphocytes 0.16-0.45 0.15
Eosinophils 0-0.07
Monocyte 0.04-0.10 0.02
Basophils 0-0.02
Bands 0.02-0.04
Platelets 130-400x 10 /l 239
ESR M- 0.15 mm/hr
F- 0.20 mm/hr

RDW= 14.7 Normal MCV= 85.2 Normal MCH-= 28.3 Normal
MCHC= 332 Normal
Interpretation:
This test showed that the hemoglobin is less than the normal value therefore it indicates a
decrease of oxygen in the blood.
Blood chemistry
Definition
A blood test is a laboratory analysis performed on a blood sample that is usually extracted from
a vein in the arm using a needle, or via finger prick.
Indication
Blood tests are used to determine physiological and biochemical states, such
as disease, mineral content, drug effectiveness, and organ function. They are also used in drug
tests. Although the term blood test is used, most routine tests (except for most haematology ) are
done on plasma or serum, instead of blood cells.
Nursing responsibility
Explain the procedure to the patient
Collect blood sample by extraction from the vein in arm using needle or finger prick.
Label specimen properly


Parameters Normal values Results
Glucose 3.9-8 + mmol/l
Uric acid .16-.43
Urea nitrogen 2.5-6.1 1.2
Creatinine 53-115 umol 61
Cholesterol 0-5.2 mmol/l
Triglycerides .23-1.71 mmol/l
HDL .91 mmol/l
Total bilirubin 0.17-1 umol/l
Direct bilirubin .5 umol/l
Indirect bilirubin 0-12.1umol/l
Total protein 61-82 g/l
Albumin 34-50 g/l
Globulin 25-35 g/l
A/G ratio 1.5-2.5
SGOT 15-37 u/l
SGPT 30-65 u/l
Alkyl phosphate 50-136 u/l
Na 140-148 mmol/l 126
K 3.6-5.2 mmol/l 3.9
CHON Value control secs
APPT Value control secs
24 hr urine ECC M- .78-1.155 ml/sec
F- 1.03-1.81 ml/sec

24 hr urine CHON 28-41 mg/24hr
Glycosylated Hgb Up to 66%
Total Hgb
B/C 4.87
ECC 111
Interpretation
Sodium and potassium are normal which means there is still fluid and electrolyte balance.















IX. Discharge plan
Clients with Upper Gastrointestinal Bleeding are instructed to take the following
plan for discharge.

M- Medications should be taken regularly as prescribed, on exact dosage, time,
& frequency, making sure that the purpose of medications is fully disclosed by
the health care provider.
Losartan 50 mg/tab 1tab OD
Hydrocortisol 50 mg/tab 1tab
FeSo4 + folic acid 1tab TID
CaCo3 1tab
NaHCo3 1tab TID
Kalium durule 1tab x 2 days
Nefidipine 30 mg/tab BID

E- Exercise should be promoted in a way by stretching hand and feet every
morning. Encourage the patient to keep active to adhere to exercise program and
to remain as self sufficient as possible
- bed rest

T- Treatment after discharge is expected for patients and watcher with UGIB to
fully participate in continuous treatment.

H- Health teachings regarding the importance of proper hygiene and hand
washing, intake of adequate water and vitamins especially vitamin C-rich foods to
strengthen the immune response and increasing of oral fluid intake should be
conveyed. Avoid spicy foods, carbonated beverages and coffee.

O- OPD such as regular follow-up check-ups should be greatly encouraged to
clients with UGIB as ordered by physician to ensure the continuing management
and treatment.

D- Diet which is prescribed should be followed.
S- Pray for faster healing and dont losses hope.







Endoscopy: Risk assessment in upper gastrointestinal bleeding
Ernst J. Kuipers About the author
Abstract
Endoscopy is the mainstay for diagnosis and therapy of upper gastrointestinal bleeding. Early
risk assessment is crucial for effective timing of endoscopy and determination of the need for
other measures to be takenscoring systems should be used for this purpose. A new prospective
study suggests that the Blatchford score can identify patients who do not need endoscopic
intervention.
Acute upper gastrointestinal bleeding (UGIB) is the gastrointestinal tract condition most likely to result in a medical
emergency. The estimated incidence of acute UGIB is 50150 per 100,000 population per year: 4060% of these bleeds are
caused by a peptic ulcer, 10% are related to varices, 10% are attributable to erosive esophagitis and the remainder are
caused by a variety of conditions. Endoscopic treatment is the main therapy for patients with UGIB. However, risk
assessment is necessary to determine whether endoscopic treatment is required; a study by Pang et al. has now assessed the
predictive value of two risk assessment scoring systems.
Endoscopic treatment, either with clips or thermocoagulation with or without epinephrine injection, can stop the initial
bleed and reduce the risk of rebleeding considerably. This treatment improves outcome, as it can shorten the hospital stay,
decrease the need for a blood transfusion, further endoscopic or surgical intervention, and reduce mortality. After adequate
endoscopic therapy, the outcome for high-risk patients (such as those with a visible vessel) can be further improved by
profound acid suppressive therapy by means of a PPI given intravenously.
Early risk assessment is crucial in patients presenting with UGIB to ensure optimal timing of endoscopy, and to determine
whether other measures (such as hospital admission, blood transfusion and treatment in an intensive care unit) are
required. Several risk assessment scales have been developed over the past 15 years that are based on retrospective
analyses of cohorts of patients presenting with UGIB. Prospective cohort studies are required to assess the validity and
usefulness of these scoring systems. For that purpose, Pang and colleagues compared two frequently used risk assessment
scalesthe Blatchford and pre-endoscopic Rockall scoring systemsfor their ability to predict the need for endoscopic
therapy.
3

Early risk assessment is crucial in patients presenting with UGIB...
Both the Blatchford and pre-endoscopic Rockall scoring systems are based on parameters that can be assessed during first
presentation. The pre-endoscopy Rockall scoring system is based on the patient's age, comorbidities, and signs of shock on
presentation. By contrast, the Blatchford scale does not consider age, but does assess urea and hemoglobin levels. The
Blatchford scale is also more focused on symptoms than the Rockall scoring system.

Pang and colleagues assessed the two scoring systems prospectively in 1,087 patients presenting with UGIB. Endoscopic
therapy was given to 297 (27.3%) of the patients. The decision to apply endoscopic treatment was made by the individual
endoscopist, who was guided by an in-hospital protocol that required such treatment for all actively bleeding lesions, as well
as for visible vessels and adherent clots.
Patients requiring endoscopic treatment were divided fairly equally over all the Rockall score categories. The pre-endoscopic
Rockall score was thus unable to predict the need for endoscopic treatment. By contrast, the Blatchford score was able to
make this prediction, as none of the patients with a score of 0 needed endoscopic intervention. The investigators conclude
that the Blatchford score, but not the pre-endoscopic Rockall score, is a useful predictor of the need for endoscopic
intervention. The Blatchford score can, therefore, be used to immediately discharge the subgroup of patients that present
with UGIB who are at low risk and so can return to the hospital at a later date for outpatient endoscopic treatment.
3

The results of this study provide valuable confirmation of the usefulness of the Blatchford score for the identification of low-
risk patients, enabling the targeted use of resources. Pang et al.'s findings support the recommendation of the latest
international guidelines that strongly advise the use of pre-endoscopic risk assessment scores in patients with nonvariceal
UGIB.

Several other reports also confirmed that patients with a Blatchford score of 0 rarely require endoscopic intervention.
The clinical impact of these important observations is, however, limited by two closely related factors. First, a minority of
cases have a Blatchford score of 0. In Pang et al.'s study, 4.6% (n = 50) of patients were given this score.3 In other studies the
proportion of patients given a Blatchford score of 0 varied between 1% and 15%.Second, the positive predictive value of a
Blatchford score >1 for the need for intervention is low. For these reasons, the next question that needs to be addressed is
whether the clinical impact of the Blatchford score can be augmented. In contrast to the pre-endoscopic Rockall score, the
probability of the need for intervention increases with increasing Blatchford scores.
In a UK study to validate the Blatchford scoring system, approximately 20% of the participants had a score of 1 or 2, and 5%
of these patients required intervention.
5
Similarly, Pang and colleagues found that one-fifth of patients had a score of 1 or 2,
but 16% required endoscopic treatment.
3
This difference in the need for endoscopic treatment is remarkable because Pang
and colleagues' study only used endoscopic intervention as the outcome parameter, whereas the UK study also included
other interventions, such as blood transfusion, in their outcome parameter. None of the available studies provided more
detailed information regarding the endoscopic appearance of the bleeding lesion and the type of intervention provided. Such
information is needed from future studies to enable the selection of a more sizable proportion of patients with UGIB for
endoscopy on an outpatient basis. This strategy would better reflect the fact that only a minority of patients with UGIB
require endoscopic treatment.
3,5

Together, these data support the use of prognostic scores for rapid assessment of patients with UGIB, as recommended by
international guidelines. Unfortunately, this strong recommendation is not routinely followed. In a nationwide survey of
6,750 patients with UGIB in more than 200 UK hospitals, pre-endoscopic risk assessment did not influence timing of
endoscopy in hospitalized patients and 42% of high-risk patients did not undergo endoscopy within 24 h, as recommended
by the international guidelines.
9
The results of this audit probably reflect the situation in many other countries around the
world. These results also show that studies, such as the one by Pang et al., are urgently required to assess the performance
of prognostic scales and stress the need for their use in the treatment of patients with UGIBa condition associated with
serious comorbidity and mortality.
In conclusion, international guidelines strongly recommend the use of pre-endoscopic risk assessment scores to stratify
patients as either low-risk or high-risk, and thus determine the use of resources and timing of endoscopy. Pang and
colleagues' findings suggest that the Blatchford score is more useful for this purpose than the pre-endoscopic Rockall score.
A low Blatchford score is adequate for the selection of patients who are unlikely to require endoscopic intervention. In some
series, these patients are identified by a score of 0, in others by a score of <2. Further studies are now required to improve
the predictive value of the Blatchford scoring system.
Competing interests statement
The author declares no competing interests.
References
1. van Leerdam, M. E. et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of
acute upper GI bleeding between 1993/1994 and 2000. Am. J. Gastroenterol. 98, 14941499 (2003)
2. Article
3. PubMed
4. ChemPort
5. Barkun, A. N. et al. International consensus recommendations on the management of patients with nonvariceal upper
gastrointestinal bleeding. Ann. Intern. Med. 152, 101113 (2010).
6. Pub Med
7. Pang, S. H. et al. Comparing the Blatchford and pre-endoscopic Rockall score



SUMMARY

Originates in the GI tract from the mouth to the ligament of Treitz where the duodenum, the first part of the small
intestine, ends. Bleeding from the esophagus may occur from esophageal varices, dilation of the veins in the esophagus. One of
the symptoms of upper GI bleeding is vomiting of blood (hematemesis).If the blood travels
through the GI tract, the stool may appear tarry and black (melena) because of digested blood, though the stool can still be
stained with red blood (hematochezia). About 75% of patients presenting to the emergency room with GI bleeding have an
upper source. The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of
patients in the emergency room with GI bleeding have an upper source. Determining whether a patient truly has an upper GI
bleed versus lower gastrointestinal bleeding is difficult. Mortality is about 11% in patients admitted with an UGIB.2 It is as high
as 33% in patients who develop bleeding whilst in hospital. A score of less than 3 using the Rockall system above is associated
with an excellent prognosis, whereas a score of 8 or above is associated with high mortality.3 Most deaths occur in elderly
patients with co-morbidity. Mortality is reported to be lower in specialist units possibly because of adherence to protocols
rather than because of technical advances.2 The prognosis in liver disease relates significantly to the severity of the liver
disease rather than to the magnitude of the haemorrhage

Upper gastrointestinal bleeding is commonly caused by bleeding varices (varicose veins) in the esophagus, peptic ulcers or a
Mallory- Weiss tear at the esophageal gastric junction from severe retching .Otherwise, bleeding over time results in
anemia, characterized by lower than normal blood hemoglobin and hematocrit with symptoms like weakness, fatigue, and
fainting.
The most important step to evaluate upper GI bleeding is upper endoscopy. During this procedure, performed by a
gastroenterologist, a tube with a camera (endoscope) is passed into the mouth and down the esophagus. The
gastroenterologist can proceed to the stomach and duodenum and localize the source of the bleeding, if possible. Other
examination to determine UGIB are Vital signs, in order to determine the severity of bleeding and the timing of intervention.
Abdominal and rectal examination, in order to determine possible causes of hemorrhage. Assessment for portal
hypertension and stigmata of chronic liver disease in order to determine if the bleeding is from a variceal source.
Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio.
Emergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions,
and blood products if required. As patients with esophageal varices typically have coagulopathy, plasma products may have to
be administered. Vital signs are continuously monitored.Early endoscopy is recommended, both as a diagnostic and therapeutic
approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the type of lesion
identified, and can include:injection of adrenaline or other sclerotherapy, electrocautery, endoscopic clipping, or banding
of varices. Stigmata of high risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the
bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding.
Pharmacotherapy includes the following: Proton pump inhibitors (PPIs), which reduce gastric acid production and accelerate
healing of certain gastric, duodenal and esophageal sources of hemorrhage. These can be administered orally or intravenously
as an infusion depending on the risk of rebleeding. Octreotide is a somatostatin analog believed to shunt blood away from the
splanchnic circulation. It has found to be a useful adjunct in management of both variceal and non-variceal upper GI
hemorrhage. It is the somatostatin analog most commonly used in North America. Terlipressin is a vasopressin analog most
commonly used in Europe for variceal upper GI hemorrhage. Antibiotics are prescribed in upper GI bleeds associated
with portal hypertension.
If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is
suggested.

Reaction:
Nowadays there are many technologies discovered to treat diseases like the Upper Gastrointestinal Bleeding. Before UGIB is
difficult to treat because of lack of equipments and high technology equipments and because of that the mortality of UGIB is
very high. Until they discovered endoscopy (means looking inside and typically refers to looking inside the body for medical reasons using
an endoscope an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices,
endoscopes are inserted directly into the organ) to treat UGIB. It is easier now to treat UGIB with the new way while maintaining the
medications prescribed, but still there is disadvantage with endoscopy like risk for infection due to sepsis. The mortality of
UGIB now is low unlike before.







University of Perpetual Help College of Manila
214 V Concepcion Street Sampaloc Manila





Case Study of
Upper Gastrointestinal Bleeding







Submitted to: Submitted by: Racca, Freegie B.
Ms. Ma. Evelyn Lumio