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 Rock all system above is associated with an excellent prognosis, whereas a score of 8 or above is associated with highmortality.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 hemorrhage. 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-tocreatinine 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 endoscopyis 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. Octreotideisas omatostatin 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.CAge: 47 y/o Gender: male Spouse: Armando A. Cacho Status: Married Chief Complaint: Change in

Sensoruim Nationality: Filipino Date admitted: August 20,2012 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,SDM, Bulacan. She was born on September 15, 1963. She is married for 22 years now and has 6 children. Mrs. EMC is anon smoker and non alcoholic beverages drinker. Mrs. EMC was admitted to East Avenue Medical Center on August 20, 2012, 3:35 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 type2 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 underwent upper endoscopy with biopsy, which revealed gastric ulcer. On the 13thday of Aug. she had her cross matching which revealed her blood type, which is type O positive. Aug. 19 she had undergone to I J 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

LIFESTYLE 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 patient 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 chores. 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 inthe 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 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 withher 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
HeadSkull -Normocephalic -No lumps -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.

Normal Findings
-Normal

Scalp

-No nits, lice and dandruff -no baldness

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

-Normal

Hair

-Straight, Black with white hair, oily hair

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

-Normal

Face

- Symmetrical with movement -Expressions appropriate to situations

-Symmetrical with movement-Expressions appropriate to situations

-Normal

Eyes

-Symmetrical -No cloudiness -No Lacrimation

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

-Normal

Eyebrows

-Symmetrical

-Moves symmetrical -Hair evenly distributedSkin Intact

-Normal

Eyelashes

-Equally distributed -Curved slightly outward

-Equally distributed -Curved slightly outward

-Normal

Eyelids

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

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

-Normal

Lid margins

-No secretions -No erythema -No redness

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

-Normal

Lower palpebral conjunctiva

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

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

-Normal

Sclera

-White in color -Clear - No redness

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

-Normal

Iris

-Flat -Brown -Round Transparent/Shiny

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

-Normal

Pupils

-PERRLA

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

-Normal

Eye Movement -Moves in unison -coordinated

-Moves in unison -coordinated -Normal

Field of vision *Visual acuity

-Good peripheral vision -20/20 in both eyes

-NormaL

Ear

-Same as the color of the face-No swelling-Shell shape

-Parallel with outer canthus of the eyes -Same as the color of the face -No swelling -No tenderness -Shell shape -Firm cartilage

-Normal

Ear Canal

- Waxy cerumen -Presence of cilia

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

-Normal

Hearing acuity

-With good hearing acuity in both ears

-With good hearing acuity in both ears

-Normal

Nose

-No lesions -Presence of cilia

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

-Normal

Lips

-Darker lips-Ability to purse lip

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

-Decrease of oxygen supply

Gums

-Pink, moist -No swelling

-Pink, moist -No swelling

-Normal

-No tenderness -No discharges

-No tenderness -No discharges -No retraction (lower and upper) -32 in number -White -Upper teeth over -rides lower teeth -Pink, even, rough dorsal surface and moist -Normal

Teeth

-white

Tongue

-Pink, even, rough dorsal surface and moist

-Decrease O2supply

Frenulum

-Midline -pinkish -With visible veins

-Midline -pinkish -With visible veins

-Normal

Soft Palate

-Pink, moist, no swelling/Note tenderness

-Pink, moist, no swelling/Note tenderness

-Normal

Hard Palate

-Bony, Light pink in color, moist -Midline moves when the client says aah

-Bony, Light pink in color, moist

-Normal

Uvula

-Midline moves when the client says aah

-Normal

Tonsils

-Pinkish -No discharge -No inflammation

-Pinkish -No discharge -No inflammation

-Normal

Neck

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

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

-normal

Upper Extremities Skin

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

-Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones too live -No edema

-accumulation of excess fluid

Nails

-Convex curvature -white

-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 4seconds)

-Decrease supply of O2

Chest and back Posterior Thorax

-No tenderness -No masses

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

-Normal

Anterior Thorax

-Full expansion -Tachypnea

-Quiet, rhythmic, and effort less respirations -Full symmetric excursion -Bronchial and tubular breath sounds in the trachea -Vesicular and broncho vesicular breath sounds

-DOB

Abdomen

-Unblemished skin -Uniform color

-Unblemished skin -Uniform color -Silver-white stripe or surgical

-normal

Lower extremities Skin -Brown in colorwith edema - No abrasions or other lesions - with edema Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones too live

-accumulation of excess fluid

- No edema - No abrasions or other lesions - Freckles, some birthmarks, some flat and raised nevi - when pinched, skin springs back to previous state

Nails

- Concave curvature -Brown pigmentation in longitudinal streaks

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

-Normal

Motor functions

- Repeatedly and rhythmically touches the noseRapidly touches each finger to thumb with each hand- Can readily determine the position of fingers and toes

-Has upright posture and steady gait with opposing arm swing; walks unaided, maintaining balanceMay sway slightly but is able to maintain upright posture and foot stance.- Maintain stance for at least 5secs- maintains heeltoe walking along straight line- Repeatedly and rhythmically touches the noseRapidly touches each finger to thumb with each hand- Can readily determine the position of fingers and toes

-Normal

V. GORDONS
Before Hospitalization 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. During Hospitalization During her hospitalization she is incomplete bed rest. Interpretation She was not able to perform the activities because of the disease process. Analysis 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.

Activityexercise patternhobbies

Elimination pattern

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

For the period of hospitalization her defecation does not vary but her urine output decreases Throughout her hospitalization sleeps 12 hours and can take naps.

The patients elimination pattern changed during hospitalization because she is under medication. Due to confinement the patient has no problem with her sleep.

Sleep and rest pattern

Before she sleeps 6 hours every day.

Good elimination pattern reduces the risk of having cancer. It helps us to detoxify waste in our body to free ourselves from complications Enough and good sleep and rest pattern can reduce stress, helps us to think better.

Cognitive perceptual pattern

The patient is a 2nd year college Under graduate. She is literate.

Same

Due to confinement the patient has no problem with understanding

Good education is important to over come poverty.

Self perception and selfconcept pattern

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

During her hospitalization she is still a positive thinker.

Even she is in the hospital herself perception does not change.

Good self-perception and self-concept pattern helps us to over come problems and trials

Rolerelationship pattern

The patients family is nuclear type. They are 8 in the family. They have 6 children and she

Throughout her hospitalization her family is with her

She stayed the same as she was before. Due to her

Good relationship to each member of the family creates unity

allotted time for her family to bond. She is sociable to everyone

side at all times to support her

hospitalization the family becomes closer to one another rand become stronger

and compact relationship with each other. Good relationship with other people can gain trust, acceptance, support, and someone to call on when you need a hand.

Copingstress tolerance pattern

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

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

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

Having a good coping to stress an over come stressors and depressions.

Health perception

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

During her hospitalization she still believes that health is wealth.

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

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

Sexualityreproductive pattern

Before hospitalization she menstruates regularly.

Same

Her reproductive system works properly.

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

Valuesbelief pattern

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

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

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

Strong values-beliefs help us to over come difficulties and trials

VI. 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 muscularaction 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: thenasopharynx 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 gland 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 name duodenum is from the Latin duodenum digitorum, or twelvefingers' 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.

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 Color Transparency Reaction Sp Albumin Glucose RBC count WBC count Epithelial cells Mucus threads Bacteria Amorphous Urates Casts

Results Light Yellow Slightly Cloudy 5 1,020 (-) 1-2 25-30 Few 0 ccl Moderate

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 here 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

Total Hgb B/C ECC 4.87 111

Interpretation Sodium and potassium are normal which means there is still fluid and electrolyte balance.

X. 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.

UNIVERSAL COLLEGE OF PARANQUE

CASE STUDY

UPPER GASTRIC INTESTINAL BLEEDING

PRESENTED BY: JIMBETH PARENO CLINICAL INSTRUCTOR: MRS. TESS NATIVIDAD EAST AVENUE MEDICAL CENTER