INTRODUCTION:

Gastrointestinal bleeding refers to any bleeding that starts in the gastrointestinal tract, which extends from the mouth to the large bowel. It is a potentially life-threatening abdominal emergency that remains a common cause of hospitalization.

Upper gastrointestinal bleeding is characterized by the sudden onset of bleeding from the GI tract at a site (or sites) proximal to the ligament of Treitz. Most upper GI bleeds are a direct result of peptic ulcer erosion, stress related- mucosal disease, that may evidence as superficial erosive gastric lesion to frank ulcerations, erosive gastritis (secondary to use or abuse of NSAIDs, oral corticosteroids, or alcohol) or esophageal varices (secondary to hepatic failure).The incidence of upper gastrointestinal bleeding (UGIB) is approximately 100 cases per 100,000 population per year1.

The degree of bleeding can range from nearly undetectable (the amount of blood is so small that it can only be detected by laboratory testing) to acute, massive, and life-threatening. Prolonged microscopic bleeding can lead to massive loss of iron, causing anemia. Acute, massive bleeding can lead to hypovolemia, shock, and even death.

Bleeding from the upper GI tract is approximately 4 times as common as bleeding from the lower GI tract and is a major cause of morbidity and mortality. Mortality rates from UGIB are 6-10% overall.

In the case of this patient, his UGIB is due to history of chronic gastritis, peptic ulcer disease, use of NSAID, ASA, coffee and alcohol intake. This case study aims to discuss UGIB disease process, nursing and medical management, health teaching and diagnostic exams to enhance our knowledge regarding this disease in order to provide quality care to patients with UGIB.

I. HEALTH HISTORYA. DEMOGRAPHIC (BIOGRAPHICAL) DATA

o Client’s Initials: S.L.P

o Gender: Male

o Age: 88 y/o

o Birth Date: April 22, 1924

o Birthplace: Cavite

o Civil Status: Widower

o Nationality: Filipino

o Religion: Roman Catholic

o Address: Dasmariñas, Cavite

o Occupation: Farmer

B. SOURCE AND RELIABILITY OF INFORMATIONo The source of information is from the Client himself.

C. REASON FOR SEEKING CAREo Presence of abdominal pain which occurs often and ranges from mild to

severe in intensity.

D. HISTORY OF PRESENT ILLNESSTwo weeks prior to admission PS has been complaining of stomach pain

increasingly at the epigastric region, and ranges from mild to moderately severe. Pain was rated 6 over 10. This was associated with nausea and vomiting and dark colored stool. Stomach pain has increased in frequency and now occurs often every day. NSAID medication provides relief he said. He thinks that the reason for why his stomach aches is because of not taking meals on time and he disregards his feeling of hunger. He had a history of kidney problem. He remembers having a similar kind of stomach pain that began at age 42, and then diminished to once every day, when he takes pain relievers. PS admitted at MITU due to Upper Gastrointestinal Bleeding with hypotension, BP of 80/50, intake of NSAIDs increased due to gout attacks.

E. PAST MEDICAL HISTORYPS has no serious illnesses, only experiencing measles and chickenpox

during his childhood. He received complete immunizations, but experienced an illness/hospitalization which occurred last year 2011. He had a kidney problem and was diagnosed with Chronic Kidney Disease 3 times during his hospitalization at University Medical Center at Dasmariñas Cavite. He received injection medication of EPO 4,000IU via the subcutaneous route every 2 weeks.

Psychiatric Illnesses/Hospitalizations: None Operations: None Injuries/Accidents: None Transfusions: 2 units PRBC on June 29, 2012

F. FAMILY HISTORYPS is an 88 years old, male and widowed veteran of Philippine Guerilla on

the time of World War II. He is a farmer and was born on April 22, 1924. He’s wife died of hypertension that led to cardiac arrest. They have a son and six daughters.

G. SOCIO-ECONOMICo Works as a farmer.

ANATOMY AND PHYSIOLOGY:

Function of the Digestive System:

The function of the digestive system is digestion and absorption. Digestion is the breakdown of food into small molecules, which are then absorbed into the body.

The digestive system is divided into two major parts:

The digestive tract (alimentary canal) is a continuous tube with two openings: the mouth and the anus. It includes the mouth, pharynx, esophagus, stomach, small intestine, and large intestine. Food passing through the internal cavity, or lumen, of the digestive tract does not technically enter the body until it is absorbed through the walls of the digestive tract and passes into blood or lymphatic vessels.

Accessory organs include the teeth and tongue, salivary glands, liver, gallbladder, and pancreas.

The treatment of food in the digestive system involves the following seven processes: Ingestion is the process of eating. Propulsion is the movement of food along the digestive tract. The major means of

propulsion is peristalsis, a series of alternating contractions and relaxations of smooth muscle that lines the walls of the digestive organs and that forces food to move forward.

Secretion of digestive enzymes and other substances liquefies, adjusts the pH of, and chemically breaks down the food.

Mechanical digestion is the process of physically breaking down food into smaller pieces. This process begins with the chewing of food and continues with the muscular churning of the stomach. Additional churning occurs in the small intestine through muscular constriction of the intestinal wall. This process, called segmentation, is similar to peristalsis, except that the rhythmic timing of the muscle constrictions forces the food backward and forward rather than forward only.

Chemical digestion is the process of chemically breaking down food into simpler molecules. The process is carried out by enzymes in the stomach and small intestines.

Absorption is the movement of molecules (by passive diffusion or active transport) from the digestive tract to adjacent blood and lymphatic vessels. Absorption is the entrance of the digested food (now called nutrients) into the body.

Defecation is the process of eliminating undigested material through the anus.

Pathophysiology

Diagnostic and Laboratory Exam:

Parameters Results NormalColor pale Amber yellowTransparency Slightly TurbidReactionSp GravityAlbumin positive 60-120 units/lGlucose 3.3-11mmOl/lRBC count 5 to 6 million per cubic

millimeterWBC count 4, 300 to 10,800 cells per

cubic millimeterEpithelial cellMucus Threads FewBacteriaAmorphusviatesCats

Analysis:

The causes of gross and microscopic hematuria are similar and may result from bleeding anywhere along the urinary tract. One cannot readily distinguish between blood originating in the kidneys, ureters (the tubes that transport urine from the kidneys to the bladder), bladder, or urethra. Any degree of blood in the urine should be fully evaluated by a physician, even if it resolves spontaneously

Infection of the urine, stemming either from the kidneys or bladder, is a common cause of microscopic hematuria. Kidney and bladder stones can cause irritation and abrasion of the urinary tract, leading to microscopic or gross hematuria. Trauma affecting any of the components of the urinary tract or the prostate can lead to bloody urine. Hematuria can also be associated with renal (or kidney) disease, as well as hematologic disorders involving the body's clotting system. Medications that increase the risk of bleeding, such as aspirin, warfarin (Coumadin), or clopidogrel (Plavix), may also lead to bloody urine. Lastly, cancer anywhere along the urinary tract can present with hematuria.

Blood chemistry

Parameters Normal Value ResultsGlucose 3.9 - 8mol/lUric acid 16 - 0.63Urea nitrogen 2.5 - 6.1Creatinine 53 - 115umolCholesterol 0 - 5.2umolTrigylecerides 0.23 - 1.71umol/lHDL 0.9 - 1umol/l 106Total Bilirubin 0.17 - 1umol/lDirect Bilirubin 0.5umol/lIndirect Bilirubin 0 -1 2.1umol/lTotal Protein 61 - 82g/lAlbumin 34 - 50g/lGlobulin 25 - 35g/lA/G ratio 1.5 - 2.5SGOT 15 - 37 g/lSGPT 30 - 65 u/l 14Alkyl Phosphate 50 - 136u/l 79Na 140 - 141umol/l 126K 3.6 - 5.2umol/lChon Value control secsAPPT Value control secs24 hrs urine ECC M- 78 - 1.16ml/sec

F- 1.03 - 1.81 ml/sec24 hrs urine CHON 18 to 41 mg/ hrGlycosylated HGB Up to 66%

Analysis:

Low levels of HDL may be a sign of liver disease, type 2 diabetes, hyperthyroidism, severe inflammatory disease, malnutrition or malabsorption. Cigarette smoking, obesity and physical inactivity can also lead to low HDL levels. A HDL of less than 40 mg/dL can put you at risk for heart disease. Studies have also linked low cholesterol levels to strokes, depression and premature births. If your SGPT is low you have a liver problem

Hyponatremia refers to a lower-than-normal level of sodium in the blood. Sodium is essential for many body functions including the maintenance of fluid balance, regulation of blood pressure, and normal function of the nervous system. Hyponatremia has sometimes been referred to as "water intoxication," especially when it is due to the consumption of excess water, for example during strenuous exercise, without adequate replacement of sodium.Sodium is the major positively charged ion (cation) in the fluid outside of cells of the body. The chemical notation for sodium is Na. When combined with chloride (Cl), the resulting substance is table salt (NaCl).

RDW=14.7 Normal MCV=85.2 Normal MCH28.3 Normal MCHC=332 Normal

The patient has a bleeding and suffering from anemia secondary to low hemoglobin and hematocrit levels. The patient has infection due high WBC count.

NURSING CARE PLAN:

DAY 1:

FOCUS: Impaired Mobility

DATA: Non-weight bearing bilaterally

Total assistance with ADL’s (activity daily living)

ACTION: Turn and position every 2 hour

Provide passive Range of Motion every shift

Provide regular skin care and avoid friction and shearing

RESPONSE: Minimal joint stiffness and flexibility

Prevented bed sore and skin tears

DAY 2:

FOCUS: Risk for impaired skin integrity

DATA:

•Complete bed rest

•Total activity daily living assistance

•Impaired sensory perception

ACTION:

• Turn and position every 2 hours

• Provide appropriate pressure relief to bony areas

• Provide regular skin care

• Avoid friction and shearing during assistance and care

• Keep skin moist and dry at all times

• Asses skin integrity every shift

RESPONSE: Skin remains dry and intact

DAY 3:

FOCUS: Pain

DATA: Swelling at the right knee

ACTION:

• Apply Warm compress and cold compress every 15 minutes interval in the right knee

• Elevate right knee

• Administer pain medication per Doctor’s order

RESPONSE: Decrease pain and swelling on the right knee

DAY 4:

FOCUS: Diarrhea

DATA:

Several episode of loose bowel movement Frequent visit to CR q hour 8X

ACTION:

Monitor frequency of BM Regulate IVF as ordered Advised to keep buttocks clean and dry Encouraged to increase oral fluid intake @ least 10 glasses a day Advised to avoid high fiber diet Encouraged to take BRAT diet like apple, banana, lugaw.

RESPONSE: BM reduced to 4X

DAY 5:

FOCUS: Body malaise

DATA: Verbalized “Masakit pa ma’am ang katawan ko”.

ACTION:

Administer analgesics as prescribed by the physician. Recommended quiet atmosphere and bed rest if indicated. Provided/recommended assistance with activities/ambulation as

necessary

RESPONSE: Cooperative to all advises

Discharge plan:

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

M - Medications should be taken regularly as prescribed, on exact dosage, time & frequency, making sure that the purpose of medications is fully disclosed by the health care provider.

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

(Range of Motion Exercises)

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

H - Health teachings regarding the importance of proper hygiene and hand washing, intake of adequate water and vitamins especially vitamin

o C -rich foods to strengthen the immune response and increasing of oral fluid

intake should be conveyed.o Avoid spicy foods, carbonated beverages and coffee.

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

D - Diet which is prescribed should be followed.

S - Pray for faster healing and don’t losses hope.