Saint Francis of Asissi College

045, Admiral Village, Talon III, Las Pinas City

COLLEGE OF NURSING

A Case Study of a 58-year-old Male

with Admitting Diagnosis
Hypovolemic Shock secondary to
Massive Upper Gastrointestinal
Bleeding

A Case Study Presented to the Faculty of the College of Nursing of Saint Francis of
Assisi College, Las Pinas City

In Partial Fulfillment of the requirements in Related Learning Experience (NCM-

113) for the Degree of Bachelor of Science in Nursing

Submitted to: Miss Carolyn Calupitan

Submitted by:ElinneMheBallon

Bianca Mae H. Carnate

Marie Flor L. Lugo

Roselyn M. Deduque
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

Introduction

Upper gastrointestinal bleeding is a common medical emergency worldwide and refers to

bleeding from the esophagus, stomach, or duodenum. Patients present with hematemesis
(bloody or coffee ground emesis) or melena, although hematochezia can occur in the context of
a major bleed and is typically associated with hemodynamic instability. Patients with melena
present with lower hemoglobin values than patients with hematemesis, probably because
presentation is more likely to be delayed.Therefore, patients with melena more often require
transfusion, although mortality is lower in patients with melena than in those with hematemesis
in some series.Numerous improvements in the management of upper gastrointestinal bleeding
have been incorporated into clinical practice in recent years. However, many patients now have
risk factors for a poorer outcome, including increasing age and major medical comorbidities.

Although the cause of a bleeding episode is uncertain until endoscopy is undertaken, guidelines
often separate upper gastrointestinal bleeding into variceal and non-variceal bleeding because
management and outcomes differ.This article covers the acute management of patients with
overt upper gastrointestinal bleeding, summarizing evidence for risk assessment, resuscitation,
blood transfusion, medical and endoscopic therapy, and early post-endoscopic management.

This medical condition is one of the most important cause of hospitalization and mortality
worldwide. In Asia, with a high prevalence of Helicobacter pylori infection, a potential
difference in drug metabolism, and a difference in clinical management of UGIB due to
variable socioeconomic environments, it is considered necessary to re-examine the International
Consensus of Non-variceal Upper Gastrointestinal Bleeding with emphasis on data generated
from the region.
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

General Objectives:

The aim of the study is to conduct a case review and to provide a nursing health care to the
client who diagnosed with Hypovolemic Shock secondary to Massive Upper Gastrointestinal
Bleeding.

Specific Objectives:

 Identification of the disease, its clinical manifestations, risk variables, pathophysiology

and disease diagnostic procedures.
 Identify different medical and nursing management of hypovolemic shock secondary to
massive upper gastrointestinal bleeding
 Learn on how to effectively evaluate and manage gastrointestinal bleeding in the
critically ill patient
 Formulation of nursing care plan and apply it to the client
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

I. Case Abstract
A case scenario of a 54-year-old male admitted at Emergency Department for
Hypovolemic shock secondary to Massive Upper Gastrointestinal Bleeding with a
chief complaint of “general chest discomfort and nausea with massive hematemesis”
as verbalized by the client.
The client has several treatment modalities that includes the following:
Hydrochlorothiazide 25mg once a day, IV NS Fluid Bolus, Blood Transfusion 2U,
Massive Transfusion Protocol Activation, IV PPI (Bolus and Infusion), Intubation,
Vasopressin Intubation, Sengstaken – Blakemore tube, IV Antibiotic (Ceftriaxone),
and PCC Vitamin K.
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

A. Theoretical Framework
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045, Admiral Village, Talon III, Las Pinas City
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II. Assessment
A. Client Profile

Patients Initial: Mr. FJ Gender: Male Age: 58 Marital Status: Single

Educational Attainment: Occupation: Religion:Catholic Place of
High School Graduate Fish vendor Birth:Mandaluyong
Health Care Usual Source of Source of
Financing:Philhealth Medical Information:
Care:N/A N/A
Date of Date of Date of Admitting Diagnosis:
Admission:10/03/2015 Interview:N/A Discharge: N/A Hypovolemic shock
secondary to massive
upper gastrointestinal
bleeding

B. Nursing Health History

Chief Complaint
“general chest discomfort and nausea with massive hematemesis” as verbalized by
the client.

C. History of Present Illness

Forty years prior to hospitalizationpatientfirst tried drinking alcohol and cigarette
with the influenced of his friends. He consumed two bottles of beer and one stick
of cigarette in the entire gathering because according to him he doesn’t like the
taste of cigarette.

Thirty-nine years prior to hospitalization the patient got broken hearted for the first
time of his entire life. That’s the time that he abuses himself and he often drink a
beer as a way of coping up to the break up he experienced.

Thirty-five years prior to hospitalization, according to the patient he consumed five

to six bottles of beer a day. He drinks with his friends most of the time after his
work.

Twenty-five years prior to admission the client was able to drink 10 bottles of beer
as his maximum and half of a packed of cigarette.
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045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

Fifteen years prior to hospitalization the drinking behavior of the client and the use
of cigarette get worsened because he is broken hearted. The client was 43 years old
way back then and he is very much hopeless to have someone with him when he
gets old. The woman that he liked rejected him because of his bad habits in life.

Ten years prior to hospitalization the patient complaint of abdominal pain but he
insists that he just needs to drink some beer to cure it and just eat a lot of food. The
patient is able to finish 10 to 20 bottles per day and one packed of cigarette.

Five years prior to hospitalization he experiences headache that he never been

before and went to a Health Center and he diagnosed of hypertension. The
physician prescribed him a medication but the client didn’t take it seriously
because he believes that he is healthy and only needs to avoid fatty foods.

Two days prior to the client experience of vomiting which began as coffee grounds
and progressed to bright red.

Three hours prior to admission the client drinks 3 bottles of beer until such time
that he feels chest discomfort and nausea. His neighbors immediately brought him
to the nearest hospital because they saw him fell down in front of his house with a
blood to his mouth.

D. Past Medical History

Childhood Illness(s) Not stated in the case scenario

Childhood / Adult Immunization(s) Not stated in the case scenario
Accidents and Injuries Not stated in the case scenario
Previous hospitalization / Surgery Hypertension
Medication(s) prior to confinement hydrochlorothiazide

E. Family History of Illness

Patient FJ grandfather and grandmother in both sides were already dead due to
unknown reason or old age. Both parents of the patient are deceased due to
unknown reason. The eldest brother of the patient was already died due to Heart
Disease three years ago.
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045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

GENOGRAM

FATHER SIDEMOTHER SIDE

GRANDFATHER GRANDMOTHER GRANDFATHER

GRANDMOTHER
Decease Decease Decease
decease
unknown unknown reason unknow
unknown

FATHER MOTHER
Decease decease
unknown reason unknown

2. 3. 4.
1.
Patient 50 yrs.old 43 yrs. old
59 yr. old
58 yrs. Old No illness No illness
decease
heart Disease

LEGEND:

MALE Patient

FEMALE

DECEASE
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045, Admiral Village, Talon III, Las Pinas City
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F. Developmental History
Theory Ag Development Task Client Description Interpretation
e
Psychosexual by 58 Genital Stage Pt. is single. He had
Sigmund Freud Puberty to death a partner when he
The onset of puberty was 19 years old but
allows the libido to once she leaved him after
again become engaged. her working
The person develops a contract expired
strong sexual interest in without any traces.
the opposite sex during They met at their
the final stage of perspective work,
psychosexual she was a sales lady
development. During and he was a
puberty, this stage startsdelivery man at that
but last for the rest of the
time. He had an
life of a child. idea they have a
child because before
she leaved, he and
their neighbor
noticed the changes
of her body. Until
then, he lost interest
to the women.
Psychosocial by 58 Generativity vs. Pt. have a good
Erik Erikson Stagnation During this relationship with his
stage, middle-aged friends and
adults begin contributing neighbor. His
to the next generation, friends are his
often through childbirth backrest during his
and caring for others; needs, they are his
they also engage in ally when it comes
meaningful and to his problem
productive work which
contributes positively to
society. Those who do
not master this task may
experience stagnation
and feel as though they
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

are not leaving a mark

on the world in a
meaningful way; they
may have little
connection with others
and little interest in
productivity and self-
improvement.
Cognitive by 58 Formal Operational Pt. has been
Jean Piaget Theoretical, working for his
hypothetical, and needs and helping
counterfactual thinking. out his neighbor in
Abstract, logic, and terms of financial
reasoning. Strategy and matter if he can
planning become handle
possible. Concepts
learned in one context
can be applied to another

Moral by 58 Post- conventional

Lawrence individual
Kohlberg
An individual able to
understand the morality
of having democratically
establishment. The
person understands the
principles of human
rights and personal
conscience.
Spiritual by 58 Universalizing Faith
James Fowler The individual would
treat any person with
compassion as he/she
views people as form of
universal community,
and should be treated
with universal principles
of love and justice.
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045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

G. Personal / Social History

Patient FJ. 58 years old is a fish vendor in a wet market near in his area. He loves
to eat fruits and vegetables every day. He preferred to wake when going to work,
as per him walking is his exercise every day. Patient FJ is a smoker since he is high
school student, he consumed 1 pack per day, and he also drinks alcohol since high
school student, can consume ten to twenty bottles of beer per day. As his
educational attainment he is high graduate, as per him there’s a lot of problem like
his family and financial problem that he cannot pursued his college education.

H. Environmental History
Patient FJ was leaving in Mandaluyong City since birth. He don’t usually go to
outside Mandaluyong. Their house is bungalow type; he is leaving there with his
brother, no hazard precautions. Public market are near to their home that can
supply their basic needs. They have friendly neighborhood, and the houses is close
to each other. Also, they have Barangay center not too far from their house.

I. Gordon’s Typology of 11 Functional Health Pattern

a. Health Perception / Health Management Pattern

Prior to hospitalization, patient was aware that being an alcoholism is bad to his
health but he insists that he only live once and just wanted to enjoy his
existence while he can. Patient FJ is aware of having a hypertension but he
don’t comply to the prescribed medication

During hospitalization, patient experience active hematemesis and complains of

general chest discomfort and insists that will be fine and just needs a beer.

Analysis: Health is a state of complete physical, mental, and social well-being,

and not merely the absence of disease of infirmity (WHO, 1948)
Interpretation:Patient FJ has a bad health perception and didn’t practice what
is best for him.
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045, Admiral Village, Talon III, Las Pinas City
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b. Nutritional / Metabolic Pattern

Prior to hospitalization, patient was an alcoholism that he can consumed ten to
twenty bottles of beer a day thoughhe has a good appetite in everything that
food being served in the carinderia. He usually ate vegetables and steak.
During hospitalization, patient doesn’t eat anything due to his esophageal
varices that cause him for vomit.
Analysis:Malnutrition was related to the intensity of ethanol intake,
development of social or familial problems, irregularity of feeding habits and
cirrhosis with ascites. Irregularity of feeding habits was also related to heavy
drinking and to social or familial derangement. (www.researchgate.net)
Interpretation:

c. Elimination Pattern
Prior to illness, Patient FJ frequency urinated during the day and at bed time
with yellowish color and bubbles as per him it because of alcohol. He defecated
every other day or sometimes once a day with dark brown in color depending
on what he ate. The patient doesn’t used any laxative or diuretic in order to
facilitate excretion.
During hospitalization, Patient FJ urination pattern does not change though he
is using diaper in order to avoid going to the toilet because of active
hematemesis.

Analysis:Alcohol use disorders in elderly people are associated with

widespread impairments in physical, psychological, social, and cognitive
health. Age related changes in body composition means that, while absorption,
metabolism, and excretion of alcohol are largely unchanged, equivalent
amounts of alcohol produce higher blood alcohol concentrations in older
people.www.ncbi.nlm.nih.gov
Interpretation: Patient FJ is alcohol abuse which is the cause of his frequent
urination.
d. Activity – Exercise Pattern
Prior to hospitalization, patient way of exercise was walking every day from his
house into the market where his work at and preparing all the heavy equipment
that he needed for his space. According to patient FJ working daily is his way to
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045, Admiral Village, Talon III, Las Pinas City
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have an active physical body because once that he stayed at his home he fells
weak.
During hospitalization, patient just lay in bed because of chest discomfort and
nausea that he complaining when he tries to.

Analysis: Activity- exercise refer to a person’s routine of exercise, activity,

leisure, and recreation. It includes activities in daily living that require energy
expenditure such as hygiene, dressing, cooking, shopping, home maintenance,
and types of quality and quantity exercise. (Kozier and Erbs, Fundamental of
Nursing 8th edition. p.1106)

Interpretation: Pt. activity- and exercise pattern is his lifestyle and was change
because of his illness.

e. Sleep – Rest Pattern

Prior to hospitalization, patient FJ had4-5 hours per night and 2-3 hours siesta.
Usual hours of sleep was from 11: P.M to 3:00A.M. and 2-4 PM. He has no
sleeping pills or other medications taken in order to facilitate sleep and rest.
However, according to the patient drinking beer help him to have a good sleep.

During hospitalization, patient FJ sleep pattern has change, he become

uncomfortable because of nausea and chest discomfort.

Analysis:Alcohol consumption can induce sleep disorders by disrupting the

sequence and duration of sleep states and by altering total sleep time as well as
the time required to fall asleep (i.e., sleep latency). The effects of alcohol
consumption on sleep patterns, the potential health consequences of alcohol
consumption combined with disturbed sleep, and the risk for relapse in those
with alcoholism who fail to recover normal sleep
patterns.https://pubs.niaaa.nih.gov/publications/aa41.htm
Interpretation: patient FJ
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f. Cognitive – Perceptual Pattern

Prior to admission, patient FJ has no memory lapses and memory
deficit. Patient wasn’t wear an eye glasses and he didn’t wear any device to
facilitate hearing and speaking. He also knows how to understand and follow
instructions.
During admission, patient can understand and have not difficulty of hearing but
he is drowsy and have mild confusion due to his condition.Heinsists that will
just need a beer in order to be fine.

Analysis: : in older, changes in cognitive abilities are more often a difference in

speed than in ability. Overall, the older maintain intelligence, problem solving,
judgement, creativity, and other well- practiced cognitive skills. (Kozier,
Fundamental of Nursing, 2008)

In terpretation : Patient insisting a beer to be fine is he way to avoid learning

about his medical condition

g. Self – Perceptual Pattern

Analysis:
h. Role – Relationship Pattern
Analysis:
i. Sexually – Reproductive Pattern
Analysis:
j. Coping and Stress Tolerance Pattern
Analysis:
k. Value – Belief Pattern
Analysis:
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Physical Assessment

a. Physical Examination

GENERAL SURVEY
Body Built Proportionate
Posture and Gait Drowsy
Hygiene and Un kept
Grooming
Body Odor Smell of EtOH
Sign of Distress Mild confusion
Affect or Mood Alert
Speech Hoarse

Vital Sign
Temperature 37.8
Pulse Rate 115 bpm
Respiratory Rate 24 cpm
Blood Pressure 105/60mmHg
Oxygen Saturation 96%

ANTHROPOMETRIC MEASUREMENT
Height N/A
Weight 80kg
Body Mass Index N/A
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SKIN
ACTUAL FINDINGS ANALYSIS &
INTERPRETATION
Color Jaundice Caused by high level of
bilirubin that secreted by
the liver. Liver disfunction
(medlineplus.gov)
Symmetry of Color Uniform No remarkable remarks
Edema No edema No remarkable remarks
Skin Lesions No lesion No remarkable remarks
Moisture Dry It may cause of dehydration
Temperature Cool skin It may cause of his current
medical condition
Skin Turgor Poor It may cause of dehydration

Hair
ACTUAL FINDINGS ANALYSIS &
INTERPRETATION
Distribution Evenly distributed No remarkable remarks
Thickness Thick No remarkable remarks
Texture and Oiliness N/A N/A
Infestations N/A N/A
Body Hair N/A No remarkable remarks

Nails
ACTUAL FINDINGS ANALYSIS &
INTERPRETATION
Curvature and Angle N/A N/A
Texture N/A N/A
Nailbed Color N/A N/A
Surrounding Tissue N/A N/A
Capillary Refill N/A N/A
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SKULL AAND FACE

ACTUAL FINDINGS ANALYSIS &
INTERPRETATION
Size and Shape Normocephalic No remarkable remarks
Contour N/A No remarkable remarks
Facial Feathers Symmetrical No remarkable remarks
Edema/Hollowness No Edema No remarkable remarks
Facial Movement Symmetrical No remarkable remarks

EYE STRUCTURE AND VISUAL ACUITY

ACTUAL FINDINGS ANALYSIS &
INTERPRETATION
Eyebrows Evenly distributed No remarkable remarks
Eyelashes Equally distributed No remarkable remarks
Eyelids N/A N/A
Conjunctiva Jaundice May cause of liver
disfunction
Lacrimal Gland N/A N/A
Cornea Transparent No remarkable remarks
Pupils N/A N/A
Peripheral Vision Intact No remarkable remarks
Extraocular Movement N/A N/A

EARS AND HEARING

ACTUAL FINDINGS ANALYSIS &
INTERPRETATION
Pinna N/A N/A
Ear Canal Dry No remarkable remarks
Tympanic Membrane N/A N/A
Hearing Acuity Intact No remarkable remarks
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NOSE AND SINUSES

External Nose External Nose External Nose

Nasal Cavity Nasal Cavity Nasal Cavity
Sinuses Tenderness Sinuses Tenderness Sinuses Tenderness

MOUTH AND OROPHARYNX

ACTUAL FINDINGS ANALYSIS &
INTERPRETATION
Teeth Smooth, movable, No remarkable remarks
symmetrical
Gum N/A N/A
Tongue Dark Cause of nicotine
Palate N/A N/A
Uvula N/A N/A
Oropharynx In Midline No remarkable remarks
Tonsil Presence of blood Due to his medical
condition
Gag Reflex N/A N/A
Lips Absent Due to his medical
condition

NECK
ACTUAL FINDINGS ANALYSIS &
INTERPRETATION
Muscles N/A N/A
Movement N/A N/A
Rage of Motion N/A N/A
Muscle Strength N/A N/A
Lymph Nodes N/A N/A
Trachea N/A N/A
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Thyroid Gland N/A N/A

Carotid Pulse N/A N/A
Jugular Veins N/A N/A

THORAX and LUNGS

ACTUAL FINDINGS ANALYSIS &
INTERPRETATION
Breathing Pattern Dyspnea Due to his medical
condition
Coastal Angle N/A N/A
Shape and Symmetrical N/A N/A
Spinal Alignment N/A NA
Skin N/A N/A
Respiratory Excursion N/A N/A
Percussion Sound N/A N/A
Breath Sound N/A N/A

HEART
ACTUAL FINDINGS ANALYSIS &
INTERPRETATION
Precordium
Heart Sound 115bpm The heart muscle is weakened
that forces it to beat more
often to pump enough blood
to the rest of the body

BREAST AND AXILLA

ACTUAL FINDINGS ANALYSIS AND
INTERPRETATION
Size and shape N/A N/A
Skin N/A N/A
Areola N/A NA
Nipples N/A N/A
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ABDOMEN
Actual findings Analysis and interpretation
Skin Integrity + caput medusa, cirrhotic Cause by portal
habitus hypertension and liver
problem.
Contour Distended Increase pressure in the
portal vein can cause
abdomen ascites.
Symmetry + caput medusa Cause by portal
hypertension
Bowel sounds Hyperactive increase in intestinal
activity such as vomiting
Percussion Dull presence of a solid mass under
the surface
Palpation Non-tender No remarkable findings

GENITALS
Actual findings Analysis and Interpretation
Pubic hair N/A N/A
Labial folds N/A N/A
Clitoris N/A NA
Vaginal orifice N/A N/A
Penile shaft and glands N/A N/A
Urethral Meatus N/A N/A
Scrotum N/A N/A
Lymph nodes N/A N/A

ANUS AND RECTUM

Actual findings Analysis and Interpretation
Anus N/A N/A
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Anal sphincter N/A N/A

Rectal wall N/A NA
Discharge N/A N/A

UPPER AND LOWER EXTREMITIES

Actual findings Analysis and Interpretation
Muscle size N/A N/A
Muscle tone N/A N/A
Muscle strength N/A NA
Bones N/A N/A

b. Review of System

ACTUAL FINDINGS ANAALYSIS AND

INTERPRETATION
GENERAL Drowsy, smell of etoh Due to his medical
condition
SKIN Jaundiced, cool skin May result of liver
problem
HEENT (head, eyes, ears, Presence of blood in Due to active
nose, throat) oropharynx and nares. hematemesis
NECK Thyroid gland non No Remarkable Findings
palpable
BREASTS N/A N/A
RESPIRATORY GAEB No Remarkable Findings
CARDIOVASCULAR Normal S1 and s, No No Remarkable Findings
EHS
GASTROINTESTINAL Hemetesis for 2 days, May result of UGIB
coffee grounds (bright
red blood, ongoing)
URINARY ulcer Kidney Problem
GENITAL N/A N/A
PERIPHERAL N/A N/A
VASCULAR
MUSCULOSKELETAL Normal No Remarkable Findings
PSYCHIATRIC Mild confusion Sign of mild confusion
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NEUROLOGIC due to his condition

HEMATOLOGIC N/A N/A
ENDOCRINE

III. Anatomy and Physiology

Mouth - the opening through which food is taken in and vocal sounds are made
Pharynx - the passageway leading from the mouth and nose to the esophagus and
larynx. The pharynx permits the passage of swallowed solids and liquids into the
esophagus.
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Esophagus - Its main job is to deliver food, liquids, and saliva to the rest of the
digestive system. Along its course, it runs down the neck, through the thorax (chest
cavity), before entering the abdominal cavity, which contains the stomach.
Stomach -it receives food from the esophagus. As food reaches the end of the
esophagus, it enters the stomach through a muscular valve called the lower esophageal
sphincter

IV. Pathophysiology / Psychopathology

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V. Laboratory and Diagnostic Study

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 Saint Francis of Asissi College
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COLLEGE OF NURSING
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Sinus tachycardia:

 Heart rate 115 bpm

 P waves are hidden within each preceding T wave.
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Laboratory result
LABORATORY RESULTS
Laboratory and Result Normal Indication/Significance Analysis &
date Interpretation
(K) Potassium 4.5 mEq/L 3.5 – 5 mEq/L to prevent or treat low Potassium within the
blood levels normal range
Chloride 104 mEq/L 96 – 109 mEq/L maintenaance of osmotic Chloride within the
pressure, acid base balance normal range
and electrical neutrality
(Na)Sodium 129 135 – 145 mEq/L an electrolyte that the body Sodium within normal
needs to function normally range
and help maintain fluid and
blood volume in the body
Bicarbonate 23 22 – 26 mEq/L it keeps the pH of blood Bicarbonate within the
from becoming too acidic normal range
BUN (blood urea 40 10 – 20 mg/dL test can reveal whether Increase BUN means it
nitrogen ) your urea nitrogen levels has renal impairment
are higher than normal,
suggesting that your
kidneys or liver may not be
working properly.
(Cr) Creatinine 200 60 – 110 one of the substances that increase level of
micromoles/L your kidneys normally creatinine signifies
eliminate from the body. impaired kidney function
Doctors measure the level
of creatinine in the blood to
check kidney function.
High levels of creatinine
may indicate that your
kidney is damaged and not
working properly.
(GLU) Blood 10 3.9 – 6.4 provides carbohydrate may be a sign of
glucose calories to a person who diabetes, a disorder that
cannot eat because of can cause heart disease,
illnesss, trauma, or other blindness, kidney failure
and other complications
medical condition
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Venous Blood Gas

Laboratory and date Result Normal Indication/Significance Analysis &
Interpretation
(Ph) power of 7.21 7.35 – 7.45 measures hydrogen ion in A lower pH means that
hydrogen blood your blood is more acidic
(PCO2) partial 32 34 – 45 measures how much carbon The partial pressure
pressure carbon dioxide is dissolved in the carbon dioxide is below
dioxide blood and how well carbon the normal range
dioxide is able to move out
of the body
(PO2) partial pressure 40mmhg 80 – 100 mmHg measures the presssure of The P02 is below in the
of oxygen oxygen dissolved in the normal range
blood and how ell oxygen
is able to move from the
airspace of the lungs into
the blood
(HCO3) Bicarbonate 23 22 – 26 mEq/L chemicaal that keeps the Bicarbonate within the
pH of blood from becoming normal range
too acidic
Lactate 4.0 0.5 – 1 mmol/L used to monitor hypoxia an increase in lactate can
and response to treatment indicate that organs are
being treated for acute not functioning properly
condition

important part of the an increased production

immune system that help of white blood cells to
to fight infections by fight an infection
attacking bacteria, viruses
WBC 12.1 5 to 10 x 10.9/L and germs that invade the
body. WBC originate in
thhe bone marrow but
circulate throughout the
bloodstream.
Is the main component of  Low hemoglobin levels
erythrocytes, which serves lead to anemia, which
(Hg) hemoglobin 50 130-180 g/L as the vehicle for the causes symptoms like
transport of oxygen and fatigue and trouble
carbon dioxide. breathing
In directly measures the Low hematocrit may is
RBC mass, and the result due to Anemia
(Hct) Hematocrit 22% 40.7% to 50.3% are expressed as
percentage by volume of
packed red blood cells.
has an important role in Platelet within the normal
hemostatis by plugging range
(Plt) Platelet 220 150 – 350x10^9/L and repairing damaaged
blood vessels, thus
preventing blood loss.
They also participate in a
cascade of events that
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leads to blood clotting by

triggering the release of a
series of coagulation
factors.
(INR) international 1.8 0.8 - 1.2 ratio Its is used to monitor
normalized ratio blood thinning medicines,
which are also know as
anticoagulant.
(PTT) Partial 51 60- 70 seconds blood test that measures
thromboplastin time the time it takes your
blood to clot, can be used
to check for bleeding
problems.
(AST) aspartate 175 100 to 200 IU/L one of the two enzymes
aminotransferase produced by the liver
(ALT) Alanine 73 male: 29 – 33 u/L test measures the level of
transaminase ALT in your blood. ALT
is an enzyme made by
cells in your liver.
(Bili) Bilirubin 756 3 - 20 an enzyme found in the
micromoles/litre blood that helps break
down proteins. ALP plays
a role in numerous
processes in the human
body, and any
abnormalities in blood
concentrations—either
high or low—may be
indicative of diseases
ranging from gallstones
and thyroid disease to
hepatitis and cancer.
EtOH 40 0-50 mg/dL To determine if a person
has consumed ethanol and
to measure the level of
ethanol in order to detect
and evaluate impairment,
intoxication, or overdose
means that your blood
clots more slowly than
desired
low level may be
indicative of liver disease,
primary fibrinolysis (a
breakdown of clots), or
disseminated
intravascular coagulation 
Aspartate
aminotransferase is within
the normal range
High levels of ALT in the
blood can indicate
a liver problem, even
before you have signs
of liver disease, such as
jaundice, a condition that
causes your skin and eyes
to turn yellow
Higher than normal levels
of bilirubin in your blood
may indicate your liver
isn't
clearing bilirubin properly
Etoh result is within the
normal range
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VI. Drug Study

Drug Name Dosage Action Indication Contraindicat Adverse Nursing
ion Effect Reponsibilities
Generic name: D: Increase Indicated alone Contraindicate CNS: dizziness, vertigo, > monitor fluid
Microzide,Oreti 25mg sodium or combination d in patient headache, paresthesia, intake and
c and water for the with anuria weakness, restlessness output, weight,
F: QD excretion management of and patients CV: orthostatic, BP and
hypotension, allergic,
Brand name: by edema hypersensitive electrolyte
myocarditis, vasculitis.
hydrochlorothia inhibiting associated with to other GI: pancreatitis,
levels: correct
zide R: Oral sodium congestive heart sulphonamide anorexia, nausea, electrolyte
and failure, hepatic derivatives epigastric distress, disturbance
Classification: chloride cirrhosis, vomting, abdominal before start of
reabsorpti nephritic pain, diarrhea, therapy.
Pharmacologic on in syndrome, acute constipation > watch for sign
class: distal glomerulonephri GU: renal failure, and symptoms
Thiazide segment tis and estrogen polyuria, frequent, of hypokalemia,
Diuretics of the therapy. urination, interstinal such as muscle
nephron. Hydrochlorothia nephritis, erectile weakness and
Therapeutic class: dysfunction.
Diuretics
zide is also cramps.
Hematologic: aplastic
indicated alone anemia agranulacytosis, > drug may be
or in leukopenia, used with
combination for thrombocytopenia, potassium-
the management haemolytic anemia. sparing diuretic
of hypertension. Hepatic: Jaundice to prevent
Metabolic: asymptomatic potassium loss.
hyperurecemia. > consult
Hypokalemia: prescribe and
hyperglycemia and dietitian about a
impaired glucose
high- potassium
tolerance: fluid and
electrolyte imbalance
supplement.
including dilutional > monitor
hyponatremia and creatinine and
hypochloremia; BUN levels
metabolic alkalosis, regularly.
hypercalcemia; volume Cumulative
depletion and effects of drug
dehydration. may occur with
Musculoskeletal: muscle impaired renal
cramps. function.
Respiratory: respiratory
> monitor uric
distress, pneumonitis.
Skin: dermatitis, acid level,
photosensitivity especially in
reactions, rash, purpura, patients with
alopecia, erythemia history of gout.
multiforme, exfoliative, > monitor
determititis. glucose level,
especially in
diabetic
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patients.

Drug Name Dosage Action Indication Contraindicati Adverse Nursing

on Effect Reponsibilities
Generic Inhibits cell- UTI : lower Contraindicated GI:  If large doses are
name: D: wall respiratory in patients pseudomembrane given, therapy is
Ceftriaxone Infusion : synthesis tract, hypersensitive colilitis, diarrhea. prolonged , or
Sodium 1g ,2g, promoting gynaecologic to drug or other patient is at high
1g/50ml ostomicinsta , bone or cephalosphorins Hematologic: risk, monitor
Brand name: bility ; joint, intra- eosinophilia, patient for sign
Rocephin F: usually abdominal thrombocytosis, and symptoms of
bactericidal skin, or skin leukopenia. superinfection
R: IV structure  Monitor PT and
infection; Skin: pain INR in patients
Classificatio septicaemia. induration, with impaired
n: tenderness, at vitamin K
injection site, therapy may be
Pharmacologi rash. needed.
c class:  Drug is
Third – commonly used
generation in home
cephalosporin
antibiotic
Therapeutic
programs for
class: outpatient
Antibiotic treatmentof
serious infection,
such as
osteomyelitis and
communit-
acquired
pneumonia.
 Monitor patients
for
superinfection,
diarrhea and
anemia and treat
appropriately
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Drug Name Dosage Action Indication Contraindicatio Adverse Nursing

n Effect Reponsibilities
Generic Relaxes Bronchospasm Contraindicated CNS: drowsiness,  In patient with
name: Injectio bronchial hypersensitivit with in patients headache,nervousnes Parkinson
Ephineprine n 0.3- smooth y reactions with angle s, tremor, cerebral disease, drug
(adrenaline) 0.5mL muscle by anaphylaxis closure glaucoma hemorrhage, stroke, increase
stimulating ,shock, organic vertigo, pain, rigidity and
Brand name: R: IM beta 2 To restore brain damage, disorientation, tremor.
Epinephrine receptors cardia rhythm cardiac dilation, agitation, fear,  Drug interferes
hydrochlorid and alpa in cardiac arrhythmias, restlessness, with test for
e F: 5 to and beta arrest coronary dizziness, weakness, urinary
10mins receptors insufficiency or subarachnoid catecholamines
Classification (prn) in the cerebral hemorrhage .
: sympatheti arteriosclerosis CV: palpitation,  Epinephrine is
c nervous ventricular drug of choice
system fibrillation in emergency
Pharmacologic shock,widened pulse treatment of
class: pressure, acute
Adrenergics hypertension, anaphylactic
tachycardia, angina reactions.
Therapeutic
pain, cardiac
class:
arrhythmias, altered
Vasopressors
ECG
GI: nausea, vomiting
Respiratory: Dyspnea
Skin: urticaria,
hemorrhage at
injection site, pallor
sweating.
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VII. Treatment Modalities

Description Indication Contraindication Nursing Responsibility

IV NS Fluid Bolus This route is normally Contraindicated in any Monitor vital signs, assess for
used in the acute care situation where salt retention edema, lung sounds, and heart
setting when a rapid is undesirable such as edema, sounds, and continue monitoring
infusion of fluids is heart disease, cardiac during and after the infusion.
necessary (e.g., decompensation and primary Monitor for continued signs of
hypovolemia). Delivery or secondary aldosteronism. hypovolemia, including urine output
of fluid should be < 0.5 mL/kg/hour, poor skin turgor,
administered through tachycardia, weak pulse, and
large-bore peripheral hypotension.
lines or via central-line
access.
Blood Transfusion Indications for Megaloblastic anemia Verify doctor’s order. Inform the
2U transfusion include (vitamin B12 or folate client and explain the purpose of the
symptomatic anemia deficiency - transfusion may procedure.Check for cross matching
(causing shortness of cause heart failure and death), and typing. To ensure compatibility.
breath, dizziness, iron deficiency anemia, Obtain and record baseline vital
congestive heart failure, transfusion in healthy adults signs. Practice strict asepsis. At
and decreased exercise and children where use of oral least 2 licensed nurse check the
tolerance), acute sickle iron could rectify a low label of the blood transfusion.
cell crisis, and acute hemoglobin. Check the following:Serial number,
blood loss of more than Blood component, Blood type, Rh
30 percent of blood factor, Expiration date, Screening
volume. test (VDRL, HBsAg, malarial
smear) – this is to ensure that the
blood is free from blood-carried
diseases and therefore, safe from
transfusion.Warm blood at room
temperature before transfusion to
prevent chills.Identify client
properly. Two Nurses check the
client’s identification.Use needle
gauge 18 to 19 to allow easy flow of
blood.Use BT set with special
micron mesh filter to prevent
administration of blood clots and
particles.Start infusion slowly at 10
gtts/min. Remain at bedside for 15
to 30 minutes. Adverse reaction
usually occurs during the first 15 to
20 minutes.Monitor vital signs.
Altered vital signs indicate adverse
reaction (increase in temp, increase
in respiratory rate)Do not mix
medications with blood transfusion
to prevent adverse effects. Do not
incorporate medication into the
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blood transfusion. Do not use blood

transfusion lines for IV push of
medication.Administer 0.9% NaCl
before; during or after BT. Never
administer IV fluids with dextrose.
Dextrose based IV fluids cause
hemolysis.Administer BT for 4
hours (whole blood, packed RBC).
For plasma, platelets,
cryoprecipitate, transfuse quickly
(20 minutes) clotting factor can
easily be destroyed.Observe for
potential complications. Notify
physician.

Massive Transfusion Massive transfusion There are no absolute Ensure right patient gets right blood
Protocol Activation protocols are activated contraindications for massive product. Blood administration sets
by a clinician in transfusion. should be as follows, according to
response to massive whichever criterion is met first:
bleeding. Generally this between every 4 units of blood,
is activated after between administration of different
transfusion of 4-10 blood products, between similar
units. MTPs have a blood products but different blood
predefined ratio of groups, every 12 hours, before
RBCs, infusion of fluids other that 0.9%
FFP/cryoprecipitate and saline. Blood Warming, only use
platelets units (random agent compatible with blood
donor platelets) in each products and lastly document all
pack (e.g. 1:1:1 or 2:1:1 products administered for the follow
ratio) for transfusion. up of any possible complications
related to Infusion therapy.
IV PPI (Bolus and IV PPI is indicated in Contraindicated in patients 5 R’s in medicine administration.
Infusion) the treatment of high- with PPI hypersensitivity, Proper administration, safety and
risk peptic ulcers and vitamin B12 deficiency, comfort measures, institute a bowel
decreases the size of hepatic disease, diarrhea, program, monitor nutritional status,
esophageal varices and pseudomembranous colitis, ensure follow up, provide support,
whenever it is gastric cancer, bone fractures, educate patient and family.
impossible or osteopenia, osteoporosis,
impractical to give oral hypomagnesemia, long qt
therapy. syndrome, Rebound acid
hypersecretion, pregnancy,
breast feeding,
phenylketonuria, infants and
neonates, SLE, Lab test
interference, geriatric.
Intubation Indications for Contraindicated in severe 1. Never leave the patient alone.
intubation to secure the airway trauma or obstruction 2. Watch and maintain an open
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airway include that does not permit the safe airway.

respiratory failure placement of an endotracheal 3. Remove secretions by effective
(hypoxic or tube. If an endotracheal tube suctioning.
hypercapnic), apnea, a cannot be placed, but an 4. Prevent displacement of the tube.
reduced level of airway needs to be secured, a 5. Watch for complications such as
consciousness surgical airway is indicated. laryngeal oedema, tracheal stenosis,
(sometimes stated as hemorrhage etc.
GCS less than or equal 6. Provide for the humidification of
to 8), rapid change of the air by boiling a kettle of water in
mental status, airway the patient’s unit.
injury or impending 7. Prevent infection introduced into
airway compromise, the lungs.
high risk for aspiration, 8. Prevent contamination of the
or 'trauma to the box inhaled air.
(larynx),' which 9. Maintain adequate nutrition of the
includes all penetrating patient by naso-gastric feeding or by
injuries to the neck, giving intravenous fluids. They
abdomen, or chest. should never be fed on oral feeds as
long as the tube is in the mouth.
10. Maintain the oral hygiene of the
vital signs.
11. Carefully watch and record the
vital signs.
12. Apply suction if there is much
secretions.
13. Give oxygen if the patient is
cyanosed.
14. Keep an emergency
tracheostomy tray with
tracheostomy tubes of correct size at
the bed side of the patient for
emergency care.
Vasopressin Indicated to increase Hypersensitivity; multiple Monitor vital signs, especially blood
Infusion blood pressure in adults dose vial (10 mL) is pressure, hourly during intravenous
with vasodilatory shock contraindicated in patients infusion. Monitor urine output and
(e.g., postcardiotomy or with known allergy or specific gravity. Assess patient
sepsis) who remain hypersensitivity to 8-L- closely for signs of chest discomfort
hypotensive despite arginine vasopressin or or TIA. Look for signs of life-
fluids and chlorobutanol; the 1 mL threatening conditions.
catecholamines. single dose vial does not
contain chlorobutanol;
contraindicated only in
patients with a known allergy
or hypersensitivity to 8-L-
arginine vasopressin
With gastrointestinal (GI)
bleeding, infusion should be
continued for 12-24 hours
after bleeding has stopped,
and dosage should then be
tapered over 24-48 hours
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Continuous infusion should

be administered via controlled
infusion device
Use caution in chronic
nephritis with nitrogen
retention
Patients may experience
reversible diabetes insipidus,
manifested by development of
polyuria, a dilute urine, and
hypernatremia, after cessation
of treatment with vasopressin;
monitor serum electrolytes,
fluid status and urine output
after vasopressin
discontinuation; some patients
may require re-administration
of vasopressin or
administration of
desmopressin to correct fluid
and electrolyte shifts.
Pre- and postoperative
patients with polyuria may
occur.
Use caution in patients with
seizure, migraine, asthma,
heart failure, vascular disease,
angina pectoris, coronary
thrombosis, renal disease.
Use in pregnant women only
when clearly needed
Sengstaken- The Sengstaken- Contraindications include: Assess for aspiration and airway
Blakemore tube Blakemore (SB)tube is Variceal bleeding stops or occlusion, have surgical scissors at
a red tube used to stop slows. Recent surgery that bedside, monitor for respiratory
or slow bleeding from involved the esophagogastric distress, suction saliva from upper
the esophagus and junction. Known esophageal esophagus and nasopharynx, check
stomach. The bleeding stricture. nostrils frequently and cleanse and
is typically caused by lubricate to avoid ulceration,
gastric or esophageal remove after bleeding is controlled.
varices, which are veins
that have swollen from
obstructed blood flow.
PCC Vitamin K Indeed, PCC are The significant Assess bleeding, monitor for signa
indicated for the contraindications to PCC and symptoms for hypersensitivity
treatment or include the following: History and thromboembolism, monitor for
prophylaxis of bleeding of DIC (disseminated infections, For IV administration
in congenital deficiency intravascular coagulation) observe intermittent infusion,
of any of the vitamin K- Angina, myocardial correct rate and y-site
dependent coagulation infarction, peripheral vascular incompatibility. Inform patient of
factors when purified disease, or stroke in the last the purpose and risks of PCC and
specific coagulation three months. for female patients to notify nurse of
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factor products are not Thromboembolic disease pregnant.

available event history in the previous
three months.
Cardiopulmonary Cardiopulmonary The only absolute Usually the nurses are the first ones
resuscitation (CPR) resuscitation (CPR) is contraindication to CPR is a to arrive on the scene so they must
an emergency do-not-resuscitate (DNR) initiatecardiopulmonary
procedure that can help order or other advanced resuscitation (CPR) as well as
save a person's life if directive indicating a person's summon assistance from the
their breathing or heart desire to not be resuscitated in ‘advanced life support/arrest’ team.
stops. When a person's the event of cardiac arrest. A
heart stops beating, they relative contraindication to
are in cardiac arrest. performing CPR is if a
During cardiac arrest, clinician justifiably feels that
the heart cannot pump the intervention would be
blood to the rest of the medically futile.
body, including the
brain and lungs.
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VIII. Problem List

A. All Identified Problems
Alcoholism (history of present illness)
Smoker (history of present illness)
Abdominal Pain (history of present illness)
Hypotension (Course in the ward)
Hyperglycemia (Lab Result)
General Chest Discomfort (Chief Complaint)
Bright Red Hematemesis (Chief complaint)
Jaundice (PA Skin)
Nausea and Vomiting
Sinus tachycardia (ECG Result)
Caput Medusa
Drowsy and Mild Confusion
Cirrhotic habitus
Hypoventilation (PA VS)
GCS 13

a. List of Priority Problem

IX. Nursing Care Plan

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X. Evidence – Based Nursing

Present Practice
(Hypovolemic Shock)
Maintain fluid volume at a
functional level
Nursing care focuses on
assisting with treatment
targeted at the cause of the
shock and restoring
intravascular volume.
Safe administration of blood. It
is important to acquire blood
specimens quickly, to obtain
baseline complete blood count,
and to type and crossmatch the
blood in anticipation of blood
Evidence-Based Nursing
Practice
Nasogastric lavage — The use of
nasogastric tube (NGT)
placement in patients with
suspected acute upper GI
bleeding is not recommended,
as studies have failed to
demonstrate a benefit with
regard to clinical outcomes. As
an example, a retrospective
study looked at whether there
were clinical benefits from NGT
lavage in 632 patients admitted
with gastrointestinal bleeding.
Patients who underwent NGT
Recommendation to Present
Nursing Practice
Rapid assessment and
resuscitation should precede
the diagnostic evaluation in
unstable patients with severe
bleeding. Some patients may
require intubation to decrease
the risk of aspiration. Patients
with active bleeding resulting in
hemodynamic instability should
be admitted to an intensive care
unit for resuscitation and close
observation. The physician
should consider transferring a
patient with significant upper
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transfusions. lavage were matched with gastrointestinal bleeding to a

Safe administration of fluids.
The nurse should monitor the
patient closely for
cardiovascular overload, signs
of difficulty of breathing,
pulmonary edema, jugular vein
distention, and laboratory
results.
Ref: https://nurseslabs.com
/hypovolemic-shock/
patients with similar tertiary medical center based
characteristics who did not on local expertise and the
undergo NGT lavage. NGT availability of facilities. Patients
lavage was associated with a admitted primarily for upper
shorter time to endoscopy. gastrointestinal bleeding have
However, there were no lower mortality rates compared
differences between those who with patients admitted for other
underwent NGT lavage and reasons who have subsequent
those who did not with regard upper gastrointestinal bleeding
to mortality, length of hospital during their hospitalization.
stay, surgery, or transfusion
requirement. Similarly, in a
randomized trial with 280
patients with upper GI bleeding,
there were no differences in
rebleeding rates or mortality
between patients who
underwent NGT lavage and
those who did not.
NGT lavage may be used when
it is unclear if a patient has
ongoing bleeding and thus
might benefit from an early
endoscopy. In addition, NGT
lavage can be used to remove
particulate matter, fresh blood,
and clots from the stomach to
facilitate endoscopy.

XI. Course in the Ward

Day Assessment data Doctors order Nursing Client response
intervention
Day 1 BASELINE Rhythm: Siuns tach For progression to Monitors/ full vital Alert, drowsy,
STATE HR: 115/min next state signs intoxicated
BP: 105/60 Physicam exam GCS: 13 active
RR: 24/min 2 minutes Hemoragic 2 large bore IV intermittent bright
O2sat : 96% Shock access red blood
Temp: 37.8 ⁰c IN NS fluid bolus hematemesis
CXR/AXR
EKG
Blood work ordered
including
type&screen +Coags

Hemorrhagic shock - Blood - IV ns Fluid bolus #2 1 episodes of copious

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HR 140 over transfusion/MTP - blood transfusion hematemesis

30seconds initiation HR 120. 2U GCS: 7 (E1V3M4)
BP: 85/50 BP 95/60 - Massive
Transfussion protocol
- IV NS bolus w/o activation
Blood HR 125, BP - IV PPI (Bolus +
90/55 transiently Infusion)
- Central lines access
- Octreotide Bolus +
infusion
- Intubation
- +Vasopressin
infusion

Intubation - sengstaken- - 2 suction tips Patients require

blakemore tube prepared significant suction,
Display - 5 minutes without - Difficult Airway able to intubate via
Vt : 500ml Blakemore tube Kit direct laryngoscopy
RR 12 placement after - Appropriate
Fi02 : 1.0 intubation induction med
EtC02 = 50 normal -PEA Arrest - Appropriate
waveform paralytic med
- Sengstaken –
Blakemore tube
- GI/ICU/surgery
consult
- Preparation (HOB at
Sengstaken – Blakemore tube 45ºc test balloons,
Blakemore Tube confirmed with CXR check tube markings
- placement of tube
- CXR
- IV antibiotics
(Ceftriaxone)

Resolution END SCENARIO + PCC/ Vit K Patient Transferred

HR : 110 for emergent
BP : 105/80 + TXA endoscopy

PEA Arrest GI/ICU arrive and - CPR Patient has no Pulse

declare patient - epinephrine
HR: 130 unsalvageable
BP : 0/0
02sat : 0

XII. Discharge Plan

Medications All the remaining tubes, IV lines, and other
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equipment will be removed.

Exercise and Activity Restriction N/A
Diet N/A
Spiritual A spiritual counselor may do a religious ritual
depending on the person's or his family's wishes.
Nursing Coordinations  If the person or family agreed on organ
donation, certain body organs or tissue
may be taken for donation.
 Family members may want clothing that
was removed or cut away during
resuscitation (reviving) efforts.
 The body may be bathed or dressed. The
funeral home may be called when the
family is ready to have the body moved.

XIII. Evaluation
a. Summary of the Study

b. Conclusion

XIV. References

Nurses Pocket Guide 14th Edition by Marilynn E. Doenges, Mary Frances Moorhouse and
Alice C. Murr

Nursing Drug Handbook 2018 by Wolters Kluwer

Brunner &Suddarth’s Textbook of Medical – Surgical Nursing Volume 1&2 11th Edition by
Suzanne C. Smeltzer, Brenda G. Bare, Janice L. Hinkle and Kerry H. Cheever

Kozier &Erb’s Fundamentals of Nursing Volume 1&2 11th Edition

Retrieved from https://www.bmj.com/content/364/bmj.l536#:~:text=Upper%20gastrointestinal

%20bleeding%20is%20a%20common%20medical%20emergency,bleed%20and%20is
%20typically%20associated%20with%20hemodynamic%20instability.
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https://www.royalwolverhampton.nhs.uk/services/service-directory-a-z/pathology-
services/departments/haematology/haematology-normal-adult-reference-ranges/

https://www.healthline.com/health/alt#risk-factors