Solution Manual for Understanding the Essentials of

Critical Care Nursing : 0131722107

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Solution Manual for Understanding the Essentials of Critical Care Nursing : 0131722107

Perrin 1e IRM

Chapter 12 Care of the Patient with an Acute Gastrointestinal

Bleed or Pancreatitis
RESOURCE LIBRARY

COMPANION WEBSITE

Case Study: The Patient with Patient with Pancreatitis

Nursing Care Plan

NCLEX Review Questions

Media Links

Media Link Applications

IMAGE LIBRARY

Figure 12-1 Organs of the alimentary canal and related accessory organs.

Figure 12-2 The Pancreas. The gross anatomy of the pancreas. The head of the pancreas is

tucked into a C-shaped curve of the duodenum that begins at the pylorus of the stomach.

Figure 12-3 Peptic Ulcer Disease.

Figure 12-4 Diverticular Disease.

Figure 12-5 MRCP stone.

Learning Outcome 1
List common risk factors and causes of gastrointestinal bleeding.

Concepts for Lecture

1. Predisposing factors upper GI bleed-peptic ulcer disease

2. Gastrointestinal hemorrhage

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3. Causes of lower GI bleed

4. Peptic ulcer disease

PowerPoint Lecture Slides

1. Gastrointestinal Hemorrhage

• Occurs in approximately 25% of critically ill patients

• Self-limiting versus life-threatening

• Nonvariceal Hemorrhage

o Peptic ulcer disease 55% of UGI

o Diverticular disease 20–50% of LGI

• Variceal Hemorrhage

2. Peptic Ulcer Disease

• Most in stomach or first part of duodenum

3. Risk factors

• Heliobacter pylori

• Nonsteroidal anti-inflammatory drugs

• Stress ulcers

• Gastric acid and pepsin cocontributors

• Other causes

o Mallory Weiss tear

o Erosive esophagitis, gastritis, duodenitis

o Tumors

o Vascular abnormalities
 • Alcohol and smoking are contributory

Learning Outcome 2
Describe the clinical manifestations of gastrointestinal bleeding.

Concepts for Lecture

1. Manifestations of GI bleeding

a. Hematemesis

b. Hematochezia

c. Melena

PowerPoint Lecture Slides

1. Hematemesis—vomiting of blood that is either bright red or has a coffee grounds appearance

2. Hematochezia—passage of bright red blood from rectum

• May or may not be mixed with stool

• Suggests a LGI bleed; however, it can originate from many different sites including the

UGI tract

3. Melena—passage of black tarry-colored stool

• Characteristic foul odor

• Can result from as little as 50 to 100 ml of blood in the stomach

Learning Outcome 3
Compare and contrast upper and lower gastrointestinal bleeding.

Concepts for Lecture

1. Upper GI bleed
 a. Bright red blood in emesis or stool

2. Lower GI bleed

a. Acute painless passage of bright red blood

PowerPoint Lecture Slides

1. Peptic Ulcer Disease

• Hemodynamic instability

• Multiple blood transfusions

• Presence of bright red blood in emesis or stool

• Age greater than 60

• Concurrent illness

• Coagulopathy

2. Diverticular Disease

• Weak areas on intestinal wall that form sac-like projections (diverticlum)

• Bleeding results from rupture of submucosal arteries of the diverticulum

• Presents as acute painless passage of bright red blood

Learning Outcome 4
Explain the significance of hemodynamic status relative to blood loss.

Concepts for Lecture

1. Assess hemodynamic status initially

a. Maintain oxygen carrying capacity of the blood

b. Maintain cardiac output

 c. Maintain organ function

PowerPoint Lecture Slides

1. Fluid Volume Deficit

• Hypotension

o SBP < 90, MAP <60

• Narrowed pulse pressure

• Orthostatic hypotension

• Tachycardia

• ECG changes

• Chest pain

• Capillary refill > 3 seconds

• Dry mucous membranes

• Decreased urine output

• Mental status changes

2. Emergent Collaborative Management and Assessment of Gastrointestinal Bleeding

• Assess hemodynamic status initially

• H & P to determine source and extent of bleeding

• Resuscitation and stabilization

• Goal: identify source, stop and treat the bleeding, prevent and treat complications

3. Assessment of Fluid Volume Status

• Hypotension
 o SBP < 90, MAP <60

• Narrowed pulse pressure

• Orthostatic hypotension

• Tachycardia

• ECG changes

• Chest pain

• Capillary refill > 3 seconds

• Dry mucous membranes

• Decreased urine output

• Mental status changes

4. Laboratory Studies with Hypovolemia

• Hematocrit—relative to clinical picture and timing of bleed

• Platelets—if low, may indicate underlying thrombocytopenia

• Electrolytes—diarrhea and vomiting

• BUN/creatinine—hydration and renal function

• PT/INR—underlying coagulopathy

• Liver function—underlying disease

• Type and crossmatch—available volume replacement with blood products

Learning Outcome 5
Describe collaborative management and nursing responsibilities for a patient with a

gastrointestinal bleed.
Concepts for Lecture
1. Collaborative goals

a. Restore intravascular volume

b. Maintain cardiac output

c. Restore blood cells

d. Prevent complications of red blood cell loss

e. Ongoing assessment

PowerPoint Lecture Slides

1. Evidence-based Interventions to Maximize Oxygen Carrying Capacity of the Blood

• Protect airway

• Administer supplemental oxygen

• Monitor pulse oximetry

o Maintain O2 saturation at 92%

2. Evidence-based Interventions for Restoration of Normovolemia

• 2 large bore intravenous lines

• Initial resuscitation with rapid infusion of crystalloid solution such as saline

o Maintains circulation until T & C is complete

o Continue to maintain B/P

o Monitor vital signs, cardiovascular, and respiratory status as long as rapid infusion

▪ Observe for signs of fluid overload

3. Blood Transfusions

• Based on patient’s clinical picture

 o Hemodynamic status

o Age

o Estimated blood loss/severity

o Evidence of active bleeding/rate of bleeding/risk for rebleeding

o Comorbidities

o Hematocrit

▪ Should be kept > 20% for young and > 30% for elderly

4. Packed Red Blood Cells (PRBC)

• Administered to alleviate signs of inadequate tissue oxygenation

• Monitor for transfusion reactions

• 300 ml unit of PRBC raises hematocrit by 3%

o After volume resuscitation with crystalloids, hematocrit may be diluted immediately

after transfusion

5. Platelets/Fresh Frozen Plasma (FFP)/Cryoprecipitate (Factor VIII)

• Used for preexisting coagulopathy

o PT > 13/INR > 1.5

o Thrombocytopenia (platelets < 50,000)

• If patient infused with multiple units of PRBC

o Platelets after 10 units

o FFP after 8 units

6. Patient Positioning

• Supine with legs elevated if SBP < 90 mm Hg

7. Nursing Management: Ongoing Assessment

• Evaluate history for:

o Common disorders related to age

o Previous gastrointestinal disease

o Prior surgery

o Aspirin or NSAID use

o Alcohol abuse or dependence

o Liver disease

o Anticoagulant or clotting disorders

o Pain

o Vomiting or retching, weight loss, anorexia, change in bowel habits

• Evaluate physical for:

o Abdominal assessment

o Evidence of liver disease

o Quantity, frequency, and characteristics of emesis or stool

Learning Outcome 6
Discuss the importance of endoscopy in the care of the patient with a gastrointestinal bleed.

Concepts for Lecture

1. Endoscopy
 a. Establish site and etiology of bleeding

b. Allow for endoscopic assessment to determine risk for rebleed

c. Perform therapeutic interventions

PowerPoint Lecture Slides

1. Bowel Preparation

• Prior to colonoscopy to increase visualization

2. Collaborative Management of the Patient Undergoing Endoscopy

• Flexible fiber-optic endoscope inserted for direct visualization of organs

• Purpose:

o Establish site and etiology of bleeding

o Allow for endoscopic assessment to determine risk for rebleed

o Perform therapeutic interventions

3. Types of Endoscopic Procedures

• Esophagogastroduodenoscopy (EGD)

o Visualize esophagus, stomach, proximal duodenum

o If performed within 24 hours of bleed, improved outcome

• Colonoscopy

o Visualize large intestines from rectum to ileocecal valve

o For active LGI bleed, indicated in 8–24 hours after admission

• Sigmoidoscopy

o Visualization of rectal-sigmoid area of colon

 4. Categories of Therapeutic Interventions

• Injection therapy with epinephrine

o To sclerose, vasoconstrict, or tamponade the site

o Often in combination with other therapeutic interventions

• Thermal coagulation

o Application of thermal coagulation to the vessel via direct or nondirect contact

o Usually with acute bleeds

• Mechanical techniques

o Application of endoclips or band ligation that cause hemostasis through compression

of tissue

Learning Outcome 7
List the predisposing factors for pancreatitis.

Concepts for Lecture

1. Predisposing factors

a. Gallstones

b. Alcohol use

c. Other causes

PowerPoint Lecture Slides

1. Predisposing Factors

• Gallstones

o Evaluated for stone removal within the first 24 hours

 o Possible future gallbladder removal

• Excessive alcohol use

2. Less common causes

o Infections

o Medications

o Toxins

o Developmental abnormalities

o Hypertriglyceridemia

o Trauma

o Heredity

o Vascular abnormalities

Learning Outcome 8
Explain why the predisposing factors may result in pancreatitis.

Concepts for Lecture

1. Causes of acute pancreatitis

a. Exact mechanism is unknown

b. Autodigestion

PowerPoint Lecture Slide

1. Causes of Acute Pancreatitis

• Exact mechanism is unknown

• Autodigestion

o Acinar cells damaged causing activation of trypsinogen to trypsin

 o Trypsin activates enzymes that begin digestive process in the pancreas

o Results in inflammation and tissue damage

o Increased vascular permeability causing edema, hemorrhage, and necrosis

Learning Outcome 9
Differentiate between the manifestations of mild and severe pancreatitis.

Concepts for Lecture

1. Severity of pancreatitis

a. Medical history

b. Differential diagnoses

c. Clinical assessment

d. Laboratory

2. Radiographic imaging studies

a. Edematous and interstitial or mild

B.Necrotizing or severe

C.Unrelated to the amylase or lipase levels

PowerPoint Lecture Slides

1. Diagnosis requires two of the following:

• Characteristic abdominal pain

• Serum amylase and/or lipase > 3x the upper limit of normal

o If enzymes are less, CT scan can definitively diagnose

2. Severity of Pancreatitis
 • Edematous and interstitial or mild

o 80% of all cases

o Minimal or no organ damage

o Interstitial edema with inflammatory infiltrates

• Necrotizing or severe

o 20% of all cases

o Extensive inflammation and necrosis, pancreatic dysfunction, and multisystem organ

failure

• Unrelated to the amylase or lipase levels

Learning Outcome 10
Describe collaborative management and nursing responsibilities when caring for the patient with

severe pancreatitis.

Concepts for Lecture

1. Collaborative management of the patient with pancreatitis

a. Assessment focuses on:

i. Hemodynamic stability

ii. Pain

iii. Electrolyte balance

iv. Safety

v. Preventing and recognizing complications

b. Management focuses on:

i. Correct underlying cause

 ii. Aggressive supportive care including fluid resuscitation

iii. Pain relief

iv. Restoring electrolyte balance and nutritional support

PowerPoint Lecture Slides

1. Causes of Hypovolemia

• Fluid loss related to:

o External fluid loss

o Internal fluid shifts

o Third spacing

• Inflammatory response

o Interstitial edema

o Vascular damage causing increased permeability

o Loss of albumin

o Decreased microcirculation in pancreas causing necrosis

o Tissue damage and fat necrosis eating through pancreas

• SIRS if inflammation extends beyond pancreas into systemic circulation

2. Assessment of Hypovolemia

• Thirst, poor skin turgor, and dry mucous membranes

• Cool, clammy skin; flat jugular veins

• Hypotension or orthostatic hypotension with dizziness, low CVP of PAWP

• Narrowed pulse pressure and tachycardia

• Decreased capillary refill, decreased urine output

 • Mental status changes

3. Classic signs of severe necrotizing pancreatitis

o Cullen’s sign

o Bluish discoloration around umbilicus from fluid extravasation into peritoneum

o Grey-Turner’s sign

o Bluish-brown discoloration around the flank from blood in retroperitoneal space

4. Assessment Using Laboratory Studies

• Hematocrit

o > 44 on admission indicates hemoconcentration, volume depletion, and possibly a

risk factor for pancreatic necrosis

o Low on admission indicates bleeding

o Normal on admission suggests uneventful course

• Leukocytes

o Degree of elevation indicates severity

• Electrolytes

• BUN/creatinine

o Evaluated together to determine presence of hypovolemia versus decreased

glomerular filtration rate

• Liver enzymes

o Determine presence of gallstones

• Calcium/magnesium
 o Ca < 8 indicative of severity

• Glucose

o Hyperglycemia on admission

3. Restoration and Maintenance of Hypovolemia

• Avoid hypovolemia

• Prevent systemic complications and organ involvement

• Prevent or limit pancreatic necrosis

4. Fluid Resuscitation

• Choice of fluid determined by hematocrit, albumin, and electrolytes

o Saline boluses for 24–48 hours unless hemorrhage is present

o Hemorrhagic pancreatitis may require transfusion of PRBC or clotting factors

o Electrolyte solutions based on electrolyte values

• Outcomes for successful fluid resuscitation

o Normal blood pressure

o Decreased/normal pulse

o Urine output approximately 30 cc/hour

o Increased CVP/PAWP

o Normal capillary refill

o Decreased hematocrit if initially hemoconcentrated

5. Assessment and Management of Pain

 • Pain is diagnostic of pancreatitis

o Results from irritation and edema of inflamed pancreas

• Assess pain characteristics

o Sudden, severe epigastric pain that peaks in 30 minutes and lasts hours to days

o Deep, visceral, and steady

o Poorly localized, radiating to back, chest, lower abdomen, and flanks

o Abdominal guarding, rebound tenderness

o Increased intensity when supine, decreased when sitting with trunk flexed forward

o Accompanied by nausea and vomiting

o Associated with diminished or absent bowel sounds, paralytic ileus

o Tachycardia, hypertension, tachypnea, splinting

o Anxious, distressed

6. Collaborative Management of Pain

• Morphine analgesia via PCA, continuous infusion, or set schedule

• Epidural if intravenous route does not control pain

• Successful outcome if:

o Pain < 4 on 0–10 scale

o Behavioral cues indicating pain are absent

o B/P, HR decrease

o O2 saturation increase

7. Risk of hypoxemia increases if:

 • Potential/actual hypovolemia and decreased tissue perfusion

• Depressant effects of opioid administration

• Abdominal pain causing hypoventilation, decreased lung expansion

• Increased catecholamines causing tachycardia, hypertension, increased metabolic rate,

and increased cardiac workload

• Overhydration from massive fluid resuscitation

• Release of toxins from pancreas causing pleural effusion

8. Assessment of Hypoxemia

• Oxygen saturation < 92%

• Increased or decreased respiratory rate

• Labored breathing or shortness of breath

• Abnormal lung sounds

• Restlessness, anxiety, decreased level of consciousness

• Cardiac dysrhythmias

• Respiratory insufficiency/failure requiring ventilator support

• Arterial blood gases

• Chest x-ray with pleural effusions or infiltrates

9. Collaborative Management of Hypoxemia

• Supplemental oxygen to maintain O2 saturation > 92%

• Manage progressive desaturation aggressively with intubation and ventilation

10. Assessment of Infection

• Fever and increased WBC present with SIRS, so difficult to identify infection

• Suspect in patients who:

o Fail to improve

o Deteriorate rapidly and unexpectedly

o Present with new progressive or persistent signs of infection

o CT showing greater than 30% necrosis

11. Collaborative Management of Infection

• Early enteral nutritional support to prevent migration of bacteria

• Antibiotics

o For 7–10 days if greater than 30% necrosis of pancreas

o Deteriorating condition suggesting infection or sepsis

o Presence of organ dysfunction

• Obtain cultures as ordered

o If negative, antibiotics are discontinued

12. Provision of Adequate Nutrition

• Mild pancreatitis

o NPO because of GI symptoms for 7–10 days

o If fails to start or tolerate eating, enteral feedings initiated

o Clear liquids when free from abdominal pain and opiates no longer required, bowel

sounds present
 o If tolerated for 24 hours, diet is advanced over several days

o 50% carbohydrates, moderate protein and fat

• Severe pancreatitis

o Increased metabolic demands and resting energy expenditure

o Negative nitrogen balance

o Start early

o Initiate enteral nutrition post pyloric junction

o Maintains intestinal barrier, decreased infection rate, decreased hospital

stay

• Total parenteral nutrition

o Indicated if enteral feedings not tolerated or when increased caloric needs

13. Provision of Comfort and Safety

• Antiemetics in nausea and vomiting present

o NG tube may be required

• Position patient so trunk flexed forward

14. Relief of Anxiety

• Anxiety related to severe pain, sudden onset of illness, lack of knowledge about the

disease

• Educate patients and family about what to expect

• Relieve pain
15. Prevention of Complications

• Complications affect clinical course and patient outcomes

• Severity and course cannot be predicted early in the disease

• Prevention requires:

o Prompt diagnosis

o Identification and treatment of causes

o Management of cause

• Fluid resuscitation and supplemental oxygen to preserve organs and tissues

o Early deaths caused by organ failure

o Later deaths caused by infection and sepsis

16. Monitor for systemic complications

• Respiratory failure, ARDS

• Cardiovascular collapse: hypovolemic shock

• Renal failure, ATN

• Decreased cerebral perfusion/neurologic dysfunction

• Metabolic abnormalities

• GI bleeding

• DIC

• Sepsis/septic shock

17. Monitor for local complications

o Pancreatic pseudocysts

o Walled-off collection of tissue debris, fluids, pancreatic juices

 o Pancreatic abscess

o An infected pseudocyst

CLASSROOM ACTIVITY

1. Discuss normal hemoglobin and hematocrit (H&H).

2. What disorders are indicated by increased or decreased H&H?

3. Discuss how the H&H is affected by a gastrointestinal bleeding?

4. Review the risk factors and causes of gastrointestinal bleeding.

5. List the predisposing factors for pancreatitis.

6. Describe the manifestations of mild and severe pancreatitis.

CLINICAL ACTIVITY

1. Obtain appropriate permission and observe an upper endoscopy and /or a colonoscopy of a

patient experiencing gastrointestinal bleeding.

2. Learn how to use the slides to test for occult blood in feces or gastric contents.

3. Seek out a patient assignment with the diagnosis of pancreatitis.

4. Determine the cause of the pancreatitis. Did this patient have any of the predisposing factors

for it?
Solution Manual for Understanding the Essentials of Critical Care Nursing : 0131722107

5. Follow this patient’s lab tests, especially those related to the pancreatitis. Do the results follow

the clinical presentation?

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