Student cohort: September 2018

Module code: AN623

Module title: Adult Nursing Skills Underpinning Complex Care

Word count: 2866 words (excluded references and in-text citation)

Submission date: Tuesday 19th January 2021

Module leader: Joyce Williams

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This assignment discusses the impact of hypovolemic shock to a patient with upper
gastrointestinal bleeding utilizing a structured assessment and lastly, to be able to
respond with an appropriate evidenced-based treatment.

Abdominal pain is pain that occurs between the chest and pelvic regions [ CITATION
Cox09 \l 2057 ]. The three main types of abdominal pain are visceral, parietal, and
referred pain [ CITATION Apa10 \l 2057 ]. Abdominal pain is also a usual occurring
problem in primary care settings such as in Accident and Emergency Departments
[ CITATION Dan20 \l 2057 ]. According to Daniels, et al (2020) there are various causes
wherein it can be quite challenging for healthcare professionals to reach a definite
diagnosis for patients with abdominal pain as presenting symptoms because of
possibility of a medical emergency and the necessity of appropriately in-depth
clinical assessments for purposes of exclusion. It is imperative that the clinicians
assess the severity of the patient’s condition, but most importantly in identifying any
life-threatening symptoms known as 'red flags’ in order to decide the next
intervention to take. This is important to decide the next step for that patient
pathways.

In accordance with the Nursing and Midwifery Council (NMC, 2018), all names have
been changed for patients confidentiality and consent has been granted.

Fabio age 72, presented to Accident and Emergency with acute, crushing pain on his
central upper quadrant, abdomen for the past 24 hours. He admitted to taking
Ibuprofen to treat his chronic back pain. This morning, Mr. Fabio experienced three
episodes of hematemesis and was brought into the Medical Assessment Unit by
ambulance with a provisional diagnosis of gastrointestinal bleeding.

Upon arrival, the staff nurse performed an holistic assessment, which encompassed
using the ABCDE approach. The timing, persistence, severity and duration, should
be defined by the medical history (Chapman, et al., 2019). Additionally, by

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performing thorough pain assessments, such as the unidimensional numerical pain
rating scale (NPRS) of 0-10; or by reading Fabio’s medical history, this will provide
an objective understanding of the severity and an appropriate plan of care to improve
Fabio’s quality of life [ CITATION Sch08 \l 2057 ].

Mr Fabio's condition was evaluated to ascertain a life-threatening condition using the

ABCDE (Airway, Breathing, Circulation, Disability, and Exposure) framework by
Resuscitation Council UK (2015). The ABCDE framework is universally accepted as
the uniform method for assessing potential deteriorating patients; to those who are
critically unwell [ CITATION Jev10 \l 2057 ]. Chapman, et al., (2019) journal conveyed a
positive link between using the ABCDE framework and its improvements in
multidisciplinary team outcome, thus improving the patients quality of life. Similarly,
the NMC (2018) states that nurses must maintain accurate and clear records, which
is paramount in monitoring and recording vital signs, thus the ABCDE approach is
favoured.

The National Early Warning Score (NEWS) is a tool developed by the Royal College
of Physicians (2017) which improves the detection and response to clinical
deterioration in adult patients and is a key element of patient safety and improving
patient outcomes. The six normal physiological parameters according to NEWS
scoring system are blood pressure systolic 111–219mmhg, respiratory rate 12-
20bpm, heart rate 51-90bpm, temperature 36.1-38.0 centigrade, oxygen saturation
96%-100% on room air. NEWS is used to identify early signs of abnormalities
requiring immediate further escalation. Mr. Fabio NEWS score was seven Blood
pressure is at 90/60mmHg. Heart rate 124bpm. Respiratory rate of 26bpm.
Temperature of 35.8 centigrade. Oxygen saturation of 90% on air. Delayed capillary
refill time of 4 seconds. Mr. Fabio appeared pale and his skin was cold and clammy

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to touch. He appears pale, looks drained and lethargic after the three episodes of
hematemesis. He furthered showed signs of a compensatory response to a
hypovolaemic shock.

According to Monahan et al. (2010), shock refers to a complex physiological situation

that puts lives at risk. It is the clinical indication of an inadequate tissue perfusion,
resulting in changes at the cellular, metabolic, and haemodynamic levels (Silva, et
al., 2018). An issue of insufficient supply of oxygen to the cells with cellular Dysoxia
when the bleeding commenced. When hypoxia sets in, the body's cells do not
receive the oxygen or nutrients they need and cannot eliminate the metabolic
byproducts (Silva, et al., 2018). If such functional cellular disturbance is not treated
immediately, it may eventually result in multi-organ dysfunction and death (Monahan,
et al., 2006).

Starling's law states a direct relationship between the preload, defined as the volume
of blood within the ventricle stretching the myocardium fibres and the contractility of
the heart, that pertains to the forcefulness of the myocardial contraction that affects
the stroke volume and cardiac output (Aitken et al., 2015).

The depleted circulating volume of Mr. Fabio's preload, resulted in a decreased

stroke volume and low cardiac index, which coincides with his low systolic blood
pressure (Jevon et al., 2012). The suggestive findings in hypovolemic shock includes
dry mucous membranes, reduced urine output, low jugular vein <3cm, decreased
skin turgor and low blood pressure.

However, deemed sufficient for some patients, a systolic blood pressure of 90mmHg
is good enough for a 72-year-old man. In comparison to his low cardiac index,
however, Mr. Fabio's blood pressure appeared to be sufficient. Mr. Fabio's current
state highlights a compensatory stage of hypovolaemic shock. Patients in shock
appears to be cold, clammy, and cyanotic.

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Initial findings show that Mr. Fabio’s airways are not compromised as he was
responsive verbally to the questions that were asked.

Mr. Fabio's respiratory assessment included taking his respiratory rate, the depth of
inspiration and the observance of his symmetrical chest expansion (Jevon, 2010).
Mr. Fabio was tachypnoeic with a respiratory rate of 26 breaths per minute. Rapid
and shallow breaths were noted as well as the use of accessory muscles. Mr. Fabio
was saturating at 90% on room air and self-ventilating. However, few complicating
issues appeared. He was continuously vomiting on large volumes and this poses a
risk to his airways. With this accounted for, Mr. Fabio was placed on a recovery
position to help lessen the stress on the said region. Suction was also applied orally
to remove excess secretions and blood[ CITATION Mor17 \l 1033 ].

To check on signs for hypovolemic shock that are typically presented as tachycardia
and hypotension, nurses usually closely monitor every patient’s blood pressure and
pulse rate. Secured intravenous access with a minimum of two large-bore cannulas
are allowed for the rapid infusion of fluids and blood—urine output monitoring may
also indicate haemorrhagic shock (NICE, 2012) [ CITATION Bar18 \l 1033 ].

Blood pressure is the force exerted by the blood on the vessels' walls (arteries,
arterioles, veins, and venules) of the cardiovascular system. Blood pressure is
generated by the heart's pumping action, measured as cardiac output and the
peripheral resistance to the flow of the blood through the cardiovascular system
exerted by the relatively narrow vessels such as the arterioles and venules. The
control of blood pressure within normal physiological limits achieve by altering the
cardiac output and the peripheral resistance in response to changes in blood
pressure detected by baroreceptors located principally in the aortic arch and the
carotid sinus. Alteration of the heart rate and peripheral resistance appears when
baroreceptors send signals to the cardiac centres and the medulla oblongata's

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vasomotor centre. The significant influence on blood pressure is peripheral
resistance and this is mostly controlled by the vasomotor centre, which is part of the
sympathetic nervous system. The vasomotor centre always maintains a degree of
peripheral resistance, known as vasomotor tone. This is effected via the release of
noradrenaline at the sympathetic nervous system's nerve endings that supply the
cardiovascular system's vessels. Blood pressure serves two closely related
purposes. The first purpose is blood circulation, and the second purpose is the
perfusion of tissues with blood to supply nutrients and remove waste products. The
blood circulation achieves because the blood pressure is highest in the aorta and
lowest, almost zero, at the venae cavae. Tissues cannot perfuse if blood circulation
does not take place (Watson, 1997) (Kisiel & Perkins, 2006) (Alexis, 2009).

Mr. Fabio's circulatory condition provided further detail regarding the cause of his
disease. Assessment of circulation involves assessing pulse, blood pressure, and
tissue and organ perfusion. The observation presented a heart rate of 124 beats per
minute; a core temperature of 35.8 degrees centigrade, blood pressure was 90/60
mmHg, and capillary refill was 4 seconds. These results revealed that Fabio was
tachycardic and hypotensive, suggesting he was in shock. Mr. Fabio's cool
peripheries and prolonged capillary refill time indicated that he had decreased tissue
perfusion [ CITATION Kis06 \l 1033 ].

A reduced systemic vascular resistance index is a classic sign of sepsis, in which

widespread vasodilation would contribute to warm, flushed peripheries. However, Mr.
Fabio's raised systemic vascular resistance index indicates he was vasoconstricting.
A reduced cardiac index and stroke volume signified a low blood volume, a diagnosis
underpinning the reduced central venous pressure. After further assessment, there
were clinical symptoms that showed signs of hypovolaemic shock [ CITATION Mor17 \l
1033 ].

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Blood samples were taken from Mr. Fabio for cross-matching, full blood counts, urea
and electrolytes, and clotting. Blood gas test was done so as to rapidly estimate
haemoglobin levels. If Mr. Fabio’s results presented low, blood transfusion may be
needed.

The disability stage of ABCDE focuses on the assessment of any neurological

alteration and possible causes. Mr. Fabio's neurological state indicated that he was
able to communicate to speech on the AVPU (alert, voice, pain, unresponsive) scale
as he complained of epigastric pain and feeling dizzy. However, Mr. Fabio’s
consciousness level later on declined as he was noted to be a lethargic

Mr Fabio's skin appears pale. As mentioned earlier, Mr. Fabio continuously vomits
fresh blood in huge volumes. It is important to obtain the full medical and social
history of the patient as this cam outline the possible causes of his current condition
and his social condition that may have contributed to his illness. It is vital for medical
professionals to know if there are relevant data that may determine possible causes
for gastrointestinal bleeding. Mr. Fabio’s history of peptic ulcer disease and non-
steroidal anti-inflammatory drug use may have directly contributed to his bleeding
resulting in hypovolemia are also essential.

His continuous vomiting of blood prompted the need for an Endoscopy procedure.
The visual examination of the oesophagus, stomach, and duodenum, during which
biopsies was undertaken. In addition, and if it’s required, therapeutic interventions to
stop bleeding can be arranged. Acute upper gastrointestinal bleeding may also be an
issue and to diagnose, the upper gastrointestinal endoscopy procedure will help.
(Chapman, et al., 2019).

Mitra et al (2012) stated that upper gastrointestinal bleeding is the bleeding that
occurs in any part of the upper gastrointestinal tract such as oesophagus and
stomach. Vomiting blood that looks like coffee grounds, abdominal pain and

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hypotension are the early signs and symptoms of acute upper gastrointestinal
bleeding [ CITATION Mit12 \l 1033 ]. Upper gastrointestinal bleeding can be caused by
peptic ulcer disease (an encumbering perforation of the intestinal wall and gastric
outlet obstruction) and gastritis (general inflammation of the stomach lining)
(Regidor, 2013). Gastritis results from an inability of the gastric lining to protect itself
from the acid it produces. Some causes of gastritis and peptic ulcers includes
medications from non-steroidal anti-inflammatory drugs (NSAIDs) group such as
Ibuprofen. This leads to gastrointestinal bleeding. Anti-inflammatory medications
should not be administered during the acute phase in patients’ presenting with upper
gastrointestinal bleeding (NICE, 2011). According to the National Institute for Health
and Care Excellence (NICE) (2020), bleeding associated with NSAIDs is more
common in the elderly, since they are mostly to have weaker resistance and more
likely to have a severe or fatal outcome. It is important to note that should NSAIDs
be given that only one type of NSAID is administered at any one time [CITATION Med01
\l 1033 ].

Moreover, this particular bleeding may present hematemesis or melaena.

Hematemesis is determined as the vomiting of fresh blood or 'coffee ground' vomit
(containing blood altered by stomach acid), while melaena is the passage of black
tarry stools [ CITATION Mit12 \l 1033 ].

According to Hill and Mitchell (2020), hemorrhage is a serious clinical condition that
poses an acute circulatory failure due to fluid loss. It is characterised by loss a loss
of intravascular circulating volume of 15% or more, leading to inadequate tissue
perfusion and potential tissue necrosis. There are several possible causes of
hypovolaemia, including severe external haemorrhaging or internal fluid shifts
resulting from dehydration. The body compensates this through increased
sympathetic tone, raised heart rate, and raised cardiac contractility and peripheral
vasoconstriction to respond to fluid loss [ CITATION Mor17 \l 1033 ].

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On the other hand, Vaughan and Parry (2016) stated that septic shock usually starts
with the signs and symptoms of infection known as systemic inflammatory response
syndrome (SIRS). The body responds to SIRS by increasing metabolic rates
(indicated by tachycardia and tachypnoea in an effort to maintain perfusion to vital
organs) and inflammation, while an immune response results in pyrexia and an rise
in white cell production (Robson & Daniels, 2013).

Since initially Mr. Fabio was able to converse verbally, the medical professionals
were able to swiftly determine his condition. Mr. Fabio was diagnosed and was
treated accordingly. The importance of truthful, effective and systematic
communication should always be emphasized. The use of a framework, such as the
SBAR (situation, background, assessment, recommendation) system (Institute for
Healthcare Improvement, 2018), provides health professionals with a structured and
efficient way to communicate patient condition details. With the use of this tool,
nurses and other health professionals are able to function efficiently and effectively.
Maintaining such procedures will ensure consistent excellent output that benefits the
organization and most especially, the patients in need of care [ CITATION Sto18 \l 1033 ].

The medical professionals present instigated a proactive medical intervention and

treatments to further avoid deterioration. The patient in the scenario is in
hypovolaemic shock due to haemorrhage, the patient has an oxygen saturation
measurement of 90% via room air. The patient should be having emergency oxygen
of 15 litre via a rebreather mask system with registered nurse in close attendance.

To help alleviate his condition, 2 litres of oxygen via nasal cannulae was
administered. Patients that experienced hypovolemic shock should be administered
with oxygen to meet the myocardial oxygen demand. Through this, signs of central
cyanosis will be prevented [ CITATION Ben04 \l 1033 ].

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With the symptoms presented, Mr. Fabio was commenced on Proton Pump
Inhibitors (PPIs) suppression therapy for primary prevention of upper gastrointestinal
bleeding such as intravenous (IV) Pantoprazole 40 mg once daily for seven days.
Through this, PPIs reduced excess acid secretion in the stomach. By blocking the
hydrogen-potassium adenosine triphosphatase enzyme, PPIs aids with gastric acid
secretion constrain. IV PPIs recommendation is usually the preferred choice if oral
administration is not applicable (NICE, 2020). Common side effects may occur such
as abdominal pain, constipation, diarrhoea, dizziness, dry mouth, headache,
insomnia, nausea, skin reaction, and vomiting. It may also significantly increase the
risk of fractures, mainly when used at high doses for over a year for the elderly.
There is also an increase in the risk of gastrointestinal infections such as Clostridium
difficile infection, conceal the symptoms of gastric cancer (in adults), and patients at
risk of osteoporosis contraindicated with this drug (NICE, 2020).

Furthermore, conservative fluid therapy in patients with shock have proven to

decrease mortality trauma victims (Silva, et al., 2018). The hypotensive resuscitation
aims to minimise the risk of complications related to aggressive resuscitation and
reduce the organism's homeostasis responses interference. Treatment of
hypovolemic shock focuses on regaining sufficient tissue perfusion by restoring fluid
volume and blood pressure. Fluid resuscitation will improve oxygen distribution to
cells, enabling aerobic respiration, which will support the restoration of the acid-base
disparity (Moruzzi & McLeod, 2017). The National Institute for Health Care and
Excellence (NICE) (2013) guidelines recommend a fluid challenge of a 500 ml
crystalloid bolus over 15 minutes for any patient suspected of hypovolaemia.

Restriction in fluid therapy administration is practiced widely in trauma systems.

Restricting the volume of fluids during resuscitation of patients with uncontrolled
haemorrhage was deemed advantageous. However, according to Butler et al (2014)
there is a significant difference in treatment with controlled bleeding and
compressible bleeding. The approach should be different. Cautious monitoring on
the effectiveness of conventional fluid therapy results in recurrent bleeding must be
done.

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A follow-up referral with General Practitioner will support coordinated care for
individual needs and care plan. Coordinated care caters to trust, and service users
will proactively seek participation, work through towards one shared goal, and learn
and improve. Furthermore, providing health education to patients with their condition
and motivation to enhance their health for quality of life.

To conclude, Over time, a rising number of people turn to self-medication as

opposed to taking prescription medications instructed by a health care professional,
has been identified. As a country that values the medical system, a medical reform
and expansion must be arranged. Hospitals, medical professionals, social workers,
experts and the government should start developing programs that will help the
general public understand the danger of overuse of over-the-counter drugs and other
similar instances and related scenarios. As shown in the case study, Mr. Fabio is a
common example of a citizen that sees Ibuprofen as an escape to pain. It was his
immediate answer to his condition that escalated quickly and would have cost him
his life had he not sought medical intervention. Although creating a program to
promote this kind of awareness may be common but challenging, constant
reinforcement is key. Modern and updated ways should also be adopted so that the
younger generation who consumes online information vastly could be reached and
educated. Available and information dissemination is key to a healthier population.
Establishing a more trustworthy image for medical and health practitioners and
organizations should also be considered. Not for vanity but for the ease of patients to
entrust valuable information such as health and social history whenever it is needed.
This way communication will be improved and will eventually affect how the public
use over the counter medications. Improving these facets of everyday grind will
assure a more effective environment, healthier citizens and better understanding of
the country’s current medical issues.

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Fabio is a 72-year-old man who has been taking regular Ibuprofen tablets for his
chronic back pain. Fabio has been experiencing abdominal discomfort for the past
24 hours but has continued taking his ibuprofen to ease the pain. This morning Fabio
experienced three episodes of vomiting fresh blood. Fabio is brought into the
Medical Assessment Unit by Ambulance with a provisional diagnosis of a gastro
intestinal bleeding.

You go to see Fabio and he appears pale and looks drained and lethargic. He
complains of epigastric pain and feeling dizzy. When you check his vital signs, you
find the following parameters:

• • Respiratory rate: 26 breaths per minute

• • Oxygen Saturations: 90% on room air

• • Pulse: 124 beats per minute

• • Blood pressure: 90/ 60 mmHg

• • Capillary refill time: 4 seconds

• • Temperature: 35.8 degrees centigrade

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