GI Bleed/Hypovolemic Shock
UNFOLDING Reasoning
Jim Olson, 45 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
•
•
•
NCLEX Client Need Categories
Clotting
Clinical Judgment
Patient Education
Percentage of Items from Each
Category/Subcategory
Safe and Effective Care Environment
✓ Management of Care
✓ Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Physiological Integrity
✓ Basic Care and Comfort
✓ Pharmacological and Parenteral Therapies
✓ Reduction of Risk Potential
✓ Physiological Adaptation
© 2018 Keith Rischer/www.KeithRN.com
Covered in
Case Study
17-23%
9-15%
6-12%
6-12%
✓
6-12%
12-18%
9-15%
11-17%
✓
✓
✓
✓
✓
✓
UNFOLDING Reasoning
History of Present Problem:
Jim Olson is a 45-year-old male with a history of cirrhosis and ETOH abuse who has not had any medical care the last
ten years. He began vomiting large amounts of bright red blood when he woke up this morning. He was found on the
floor of the bathroom by Sheila, his girlfriend, when he became lightheaded and fell on the floor and was too weak to get
up. Sheila called 911.
Paramedics report that there was a large dark red/black stool in the toilet. They were able to get an 18-gauge IV in
the right antecubital vein, and Jim received 500 mL of 0.9% NS. His initial BP was 80/40 at the scene, and his most
recent BP is 82/44 with a current heart rate of 128, sinus tachycardia.
Personal/Social History:
Jim recently lost his job as a construction laborer and was divorced six months ago. His ex-wife has full custody of his
two children. Jim’s girlfriend states that he has been more depressed lately and has been drinking more heavily since his
divorce. He takes ibuprofen daily for chronic back pain.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem:
Clinical Significance:
jyHx of cirrhosis and alcohol abuse, no
medical care in the past 10 yrs, vomiting large
amounts of blood, passed out due to being
weak and lightheaded, hypotensive, sinus
tachycardia, patients take ibuprofen daily
untreated cirrhosis and continuous alcohol abuse leads to liver damage
and failure, no early detection bc pt never sees the dr., alcohol abuse can
cause severe scarring of the tissue and lead to vomiting blood, syncope
occurs when there is insufficient blood flow to the brain, very low bp may
indicate shock, sinus tachycardia may be caused by low bp, ibuprofen
causes GI bleeding
RELEVANT Data from Social History:
Clinical Significance:
Pt recently lost his job
Pt divorced six months ago and wife
has custody of 2 children
Pt has been drinking more heavily
- Financial stress
- Emotional stress and depression
- Depression leading to alcoholism
Patient Care Begins:
Current VS:
T: 98.2 F/36.8 C (oral)
P: 138 (regular)
R: 28 (regular)
BP: 74/30 MAP: 45
O2 sat: 95% room air
P-Q-R-S-T Pain Assessment:
Provoking/Palliative:
Denies
Quality:
Region/Radiation:
Severity:
Timing:
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data:
Clinical Significance:
HR 138, R 28, BP
74/30,
Clients in shock may experience tachycardia as a compensatory mechanism
due to vasoconstriction and to compensate decreased cardiac output.
Tachypnea occurs when the body is trying to remove excess CO2 due to
shock.
Hypotension is due to dilation of blood vessels. The heart is then overworked
and may lead to HF.
© 2018 Keith Rischer/www.KeithRN.com
Current Assessment:
GENERAL
Lethargic, body tense, appears uncomfortable but denies pain
APPEARANCE:
RESP:
Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort
CARDIAC:
Pale, extremities cool, no edema, heart sounds regular with no abnormal beats, pulses weak,
equal to palpation at radial/pedal/post-tibial landmarks, 1-2 second capillary refill
NEURO:
Alert & oriented to person, place, time, and situation (x4), whispers responses
GI:
Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four quadrants, feels
nauseated
GU:
No urine output present
SKIN:
Skin integrity intact, skin turgor elastic, no tenting present
What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion & Maintenance)
RELEVANT Assessment Data:
Clinical Significance:
-no urine output
- pt is lethargic and body is tense
- pt is pale, pulses are weak
- pt feels nauseated
- Lethargy can be due to low blood pressure but it is also a symptom seen
in chronic liver diseases.
- Patient may be tense due to stress and anxiety of being in the hospital.
- Weak pulse and paleness may be due to insufficient blood flow. There
might be decreased blood flow to vitalorgans.
- Nausea may be a sign of digestive distress and shock
- decrease in urine output. The patient may also be dehydrated (BMP
should be checked) and may be in shock
Cardiac Telemetry Strip:
Interpretation:
Regular/Irregular:
Interpretation:
Reg
P wave present?
yes
PR:
QRS:
Sinus tachycardia
Clinical Significance:
Signifies sinus tachycardia
Lab Results:
Complete Blood Count (CBC:)
WBC (4.5–11.0 mm 3)
Neutrophil % (42–72)
Hgb (12–16 g/dL)
Platelets (150-450 x103/µl)
Current:
8.5
75
5.5
68
© 2018 Keith Rischer/www.KeithRN.com
High/Low/WNL?
normal
normal
low
low
QT :
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):
hgb and platelet is
low
Clinical Significance:
- indicates possible shock and loss of blood
Basic Metabolic Panel (BMP:)
Sodium (135–145 mEq/L)
Potassium (3.5–5.0 mEq/L)
Glucose (70–110 mg/dL)
Creatinine (0.6–1.2 mg/dL)
Current:
134
4.8
145
1.9
High/Low/WNL?
low
normal
high
high
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):
Clinical Significance:
sodium, glucose and beginning stages of hyponatremia, impaired glucose tolerance and insulin
creatnine are relevant resistance are seen in patients with chronic liver disease
Misc. Labs:
Magnesium (1.6–2.0 mEq/L)
Lactate (0.5–2.2 mmol/L)
Coags:
PT/INR (0.9–1.1 nmol/L)
Current:
1.3
3.4
8.5
High/Low/WNL?
low
high
high
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):
all three
Clinical Significance:
magnesium - malnourished and alcohol abuse
lactate - Increased lactate levels not related to low SaO2 levels may indicate an increase
demand for oxygen or metabolic problems, this may be caused by liver disease. High
lactate levels may also indicate shock from extreme blood loss.
Increased INR indicates a slower blood clotting time, can be caused by blood thinning
medications, liver problems, vitamin K deficiency.
Liver Function Test (LFT:)
Albumin (3.5–5.5 g/dL)
Total Bilirubin (0.1–1.0 mg/dL)
Alkaline Phosphatase
Current:
2.1
3.5
152
male: 38–126 U/l female: 70–230 U/l
ALT (8–20 U/L)
AST (8–20 U/L)
68
75
© 2018 Keith Rischer/www.KeithRN.com
High/Low/WNL?
low
high
high
high
high
What lab results are RELEVANT and must be recognized as clinically significant by the nurse?
(Reduction of Risk Potential/Physiologic Adaptation)
RELEVANT Lab(s):
all of them
Clinical Significance:
Decreased albumin levels are seen in patients with cirrhosis of the liver. Patient might be
malnourished.
High Total bilirubin level are seen in the later stages of cirrhosis.
Increased Alk Phos levels indicate that the liver is not working properly, seen in patients with
cirrhosis.
Liver disease is the most common reason for a patient to have increasedALT levels.
Increased AST may indicate liver damage and disease.
Lab Planning: Creating a Plan of Care with a PRIORITY Lab:
(Reduction of Risk Potential/Physiologic Adaptation)
Lab:
Normal
Value:
Hemoglobin
Value:
5.5
Critical
Value:
Clinical Significance:
Primary protein of erythrocytes that is
composed of heme (iron) and globin
(protein)
*Carries O2 to cells and CO2 back to
lungs
*Parallels Hematocrit, which is the % of
RBC in proportion to total plasma volume
Nursing Assessments/Interventions
Required:
THINK BLOOD LOSS/ANEMIA
*Identify early signs of blood loss:
tachycardia, then hypotension
*Assess for signs of tissue hypoxia
(see above) *Assess skin color as
well as tolerance to activity
Clinical Reasoning Begins…
1. What is the primary problem your patient is most likely presenting? (Management of Care/Physiologic Adaptation)
Acute upper GI bleed
2. What is the underlying cause/pathophysiology of this primary problem? (Management of Care/Physiologic Adaptation)
It could be a result of a bleeding gastric ulcer or ruptured esophageal varices. From a nursing perspective, it does not really matter because it will not
change how the nurse will manage this potential life-threatening crisis. Knowing that this patient has a history of cirrhosis, the nurse needs to recognize the
connection between chronic liver disease and portal hypertension that results in esophageal varices that can rupture and cause profuse bleeding as a
clinical red flag in this presentation.
Collaborative Care: Medical Management (Pharmacologic and Parenteral Therapies)
Care Provider Orders:
Establish two large bore IVs
0.9% NS 1000 mL bolus
Ondansetron 4 mg IV push
Octreotide 50 mcg IV push
Octreotide 50 mcg/hour IV
gtt
Phytonadione (vitamin K) 2
mg in 50 mL D5W IVPB
Rationale:
Will require aggressive fluid resuscitation to improve blood pressure. A large
bore IV, preferably greater than 18 gauge, allows fluids to flow more quickly into
the body than a smaller IV such as a 20 or 22-gauge.
Expected Outcome:
IV access successfully obtained
decrease in HR and increase in BP
to raise his BP
decrease nausea and vomiting
management of acute hemorrhage
He needs clotting factors and vitamin K helps clotting factors
© 2018 Keith Rischer/www.KeithRN.com
stops n/v
portal hypertension is decreased leading to
decreased amount of upper GI bleed
Bleeding decreases over time
Fresh frozen plasma (FFP) 4
units IV
Packed red blood cells
(PRBC) 2 units Type O Neg
Type and cross match. Have
four units PRBC available
it's rich in clotting factors which is good for bleeding
replenishes the blood products that he needs until the right match comes along
Because this is a crisis, having four units available is expected and
will likely be needed. Packed red blood cells (PRBCs) are made from
a unit of whole blood by centrifugation.
bleeding decreases over time
HR decreases and BP increases
Blood products increase, VS return to baseline
PRIORITY Setting: Which Orders Do You Implement First and Why? (Management of Care)
Care Provider Orders:
• Establish two large bore
IVs
• 0.9% NS 1000 mL bolus
• Ondansetron 4 mg IV push
• Octreotide 50 mcg/hour IV
gtt
• Phytonadione (vitamin K)
2 mg in 50 mL D5W IVPB
• Fresh frozen plasma (FFP)
4 units IV
• Packed red blood cells
(PRBC) 2 units Type O
Neg
• Type and cross match.
Have four units PRBC
available
Order of Priority:
1. Two large bolus of IV
2. NS 1000mL
3. PRBC 2 units type O
4. Octreotide
5. Phytonadione
6. FFP
7. Type and cross match
8. Ondansetron 4 mg IV push
Rationale:
Obtaining IV access is essential in this scenario. If the IV
infiltrates, everything stops and could directly impact the
patient outcome.
2. Since no blood is immediately available, the next best
alternative is normal saline.
3. When O negative blood is received from the blood bank
administer it. The patient requires it because it carries
oxygen to the cells, while normal saline does not.
4. Once fluid resuscitation and blood replacement are
taking place, getting to the source of the problem is now
the priority. Decreasing portal hypertension is essential.
5. Replacing clotting factors also is needed and is an
indirect circulation priority.
6. See above
7. This is a lab priority, but make sure that it has been done.
8. Though controlling nausea is important for comfort, it is
not a circulation priority, therefore it is last in this
Collaborative Care: Nursing
3. Review the following skills and essential knowledge that the nurse will use in this scenario to save Jim’s life:
(Management of Care)
Skill:
IV Insertion
What does the Nurse Need to KNOW to Be Safe in Practice:
make sure to get the air bubble out
Administer fresh frozen plasma (FFP)
make sure the adverse effects of FFP won't harm the patient
Administer PRBCs
Make sure not to practice good hygiene, give the right amount, monitor labs
© 2018 Keith Rischer/www.KeithRN.com
4. What nursing priority (ies) will guide your plan of care? (if more than one-list in order of PRIORITY)
(Management of Care)
Bleeding out, fluid volume deficit, ineffective tissue perfusion.
5. What interventions will you initiate based on this priority? (Management of Care)
Nursing Interventions:
Rationale:
- Give two large boluses of IVs
- 0.9% NS
- Reassess VS within 15 minutes after
each IV bolus is administered
Closely trend and monitor VS parameters of BP, HR, RR
as well as color/temp of skin.
Assess and trend creatinine and urine output closely.
Assess mentation closely for any changes from current
baseline.
Consider recommending placement of Foley catheter
placement.
Facilitate transfer to intensive care
Expected Outcome:
A second IV will be needed to administer blood products
while the first IV for medications. Early fluid resuscitation is
needed to restore blood volume. Looking for decrease in HR
and elevation in BP, trend to determine the effectiveness of
fluid resuscitation.
IV established. Fluid
balance
restored. HR
decrease, BP
increases. Creatnine
trending downward
and renal function
improves. u/o
>30mL/hr.
Confusion/sepsis
improves. Successful
placement of foley
and monitor for urine
output. Prompt
transfer to critical
care.
If condition improves, HR will decrease, and BP increase. RR should
be <20. To determine adequate renal perfusion. Confusion and
worsening change are not uncommon with sepsis/infection and must
be carefully trended. Monitor urine output due to critical status and
known acute on chronic renal failure. Transfer to ICU will provide the
definitive care that this patient requires because his critical status
could change very quickly.
6. What body system(s) will you assess most thoroughly based on the primary/priority concern and what specific
assessments need to be performed by the nurse? (Reduction of Risk Potential/Physiologic Adaptation)
HR, BP, color, strength of pulses in extremities, cap refill, warmth or temperature of extremities and core
7. What is the worst possible/most likely complication to anticipate? (Reduction of Risk Potential/Physiologic Adaptation)
Hypovolemic shock with loss of BP and pulse.
8. What nursing assessments will identify this complication EARLY if it develops?
(Reduction of Risk Potential/Physiologic Adaptation)
Close trending of both heart rate and blood pressure is essential. The trend of the heart rate will stay unchanged despite fluid resuscitation and
replacement of blood products and may even increase as shock worsens. The blood pressure will continue to drop despite fluid resuscitation and blood
product administration. This is a clinical red flag.
9. What nursing interventions will you initiate if this complication develops?
(Reduction of Risk Potential/Physiologic Adaptation)
Though blood products are typically administered through an IV pump, in the ED, implementing all aspects of the medical plan of care is essential and
needs to take place promptly to save this patient’s life.
10. What psychosocial needs will this patient and family likely have that will need to be addressed?
(Psychosocial Integrity/Basic Care and Comfort)
Knowledge and support for nursing priorities and education and answer patient concern in regards to his condition, address patient's emotional and
spiritual needs
11. How can the nurse address these psychosocial needs?
(Psychosocial Integrity/Basic Care and Comfort)
This patient recognizes that he is critical and potentially could die. As a result, he will be anxious and require empathetic care and brief
explanations of everything that the nurse is doing. This is done as you provide care, especially in a crisis. Patient education is especially available
in this case. Always be present and available because the patient is going through emotional distress and a crisis.
© 2018 Keith Rischer/www.KeithRN.com
Evaluation:
One hour later…
Two large bore IVs have been placed, fresh frozen plasma, octreotide, and vitamin
K have been administered. He has received the IV bolus of normal saline and his
first unit of type O negative blood just completed.
Current VS:
T: 98.8 F/37.1 C
P: 112
R: 20
BP: 94/56 MAP: 69
O2 sat: 95% RA
Most Recent:
T: 98.5 F/36.9 C
P: 120
R: 22
BP: 88/50 MAP: 63
O2 sat: 97% RA
Current PQRST:
Provoking/Palliative:
Quality:
Denies
Region/Radiation:
Severity:
Timing:
Current Assessment:
GENERAL
Appears more relaxed
APPEARANCE:
RESP:
Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort
CARDIAC:
Pale, extremities cool, no edema, heart sounds regular with no abnormal beats, pulses weak,
equal to palpation at radial/pedal/post-tibial landmarks, 1-2 second capillary refill
NEURO:
Alert & oriented to person, place, time, and situation (x4), whispers responses
GI:
Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four quadrants, feels
nauseated
GU:
No urine output present
SKIN:
Skin integrity intact, skin turgor elastic, no tenting present
1.
What data is RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data:
Temp 98.8 F/37.1 C
P: 112 R: 20 BP: 94/56 MAP: 69
RELEVANT Assessment Data:
Appears more relaxed
Pale, extremities cool, no edema, heart sounds
regular with no abnormal beats, pulses weak, equal
to palpation at radial/pedal/post-tibial landmarks,
1-2 second capillary refill.
Skin integrity intact, skin turgor elastic, no tenting
present
2.
Clinical Significance:
VS returned to baseline and status has improved.
Clinical Significance:
Client has stabilized compared to before and out of an emergency but still needs close monitoring and
intense care
Has the status improved or not as expected to this point? (Physiological Adaptation)
Status has improved.
3. Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment?
(Management of Care)
No, the plan remains unchanged.
4. Based on your current evaluation, what are your nursing priorities and plan of care? (Management of Care)
© 2018 Keith Rischer/www.KeithRN.com
Close and frequent assessment of his heart rate and blood pressure, and overall cardiovascular
status are essential. Administering the second unit of type O blood until the cross-matched blood is
available is also a priority. Facilitating transfer to intensive care is the next step to stabilize this
patient.
It is now the end of your shift. Effective and concise handoffs are essential to
excellent care and, if not done well, can adversely impact the care of this
patient. You have done an excellent job to this point; now finish strong and
give the following SBAR report to the ICU nurse who will be caring for this
patient: (Management of Care)
Situation:
Name/age:
Jim Olson is a 45-year-old male who has not had any medical care the last ten years.
BRIEF summary of the primary problem:
He began vomiting large amounts of bright red blood when he woke up this morning. He was found
on the floor of the bathroom by Sheila, his girlfriend, when he became lightheaded and fell on the
floor and was too weak to get up. Sheila called 911 and he was brought to the ED.
Background:
Primary problem/diagnosis:
Acute upper GI bleed
Past Medical History:
Cirrhosis and ETOH abuse
RELEVANT background data:
Recent divorce and loss of custody of his two children. Has been increasingly depressed and drinking more heavily
Assessment:
Most recent vital signs:
Most recent assessment:
RELEVANT lab values:
T: 98.8 F/37.1 C P: 112 R: 20 BP: 94/56 MAP: 69 O2 sat: 95% RA
Appears more relaxed, breath sounds clear and equal bilaterally, pale, extremities
cool, no edema, heart sounds regular with no abnormal beats, pulses weak, equal to palpation at
radial/pedal/post-tibial landmarks, 1-2 second capillary refill NEURO: Alert & oriented to person, place, time, and
situation (x4), whispers responses GI: Abdomen flat, soft/non-tender, bowel sounds audible per auscultation in all four
quadrants, feels nauseated GU: No urine output present
Creatinine: 1.9 K+: 4.8 Mg: 1.3 Hgb: 5.5 Lactate: 3.4
TREND of any abnormal clinical data (stable-increasing/decreasing):
Heart rate is decreasing. His initial rate was 138 sinus tachycardia. His blood pressure has improved from 74/30 upon
arrival to 94/56. His respiratory rate has decreased from 24 to 20.
How have you advanced the plan of care?
Patient response:
Two large bore IVs have been placed, an 18-gauge in both arms. The first unit of type O
negative blood has been administered; the second has just been started. Fresh frozen plasma,
vitamin K, and and octreotide drip have been given.
His blood pressure is increasing and his heart rate is decreasing. He appears more calm and relaxed.
INTERPRETATION of current clinical status (stable/unstable/worsening):
His condition is currently stable but remains critical.
Recommendation:
Suggestions to advance the plan of care:
© 2018 Keith Rischer/www.KeithRN.com
Transfer to intensive care. Continue to monitor response to blood products and trend
of hemoglobin and lactate recheck’s when ordered.
Education Priorities/Discharge Planning
1. What educational/discharge priorities will be needed to develop a teaching plan for this patient and/or family?
(Health Promotion and Maintenance)
The patient should be encouraged to attend a support group and perhaps go to a rehab for an alcohol detox, the
patient needs to cease drinking alcohol in a sustainable manner.
Patient needs to attend therapy to learn new coping methods and be screened for depression.
Patient needs to engage in healthy eating habits and increased protein intake. Patient must keep all medical
appointment.
Medications should be taken as directed and HCP should be contacted if any signs of GI bleeding occur again.
2. How can the nurse assess the effectiveness of patient and/or family teaching and discharge instructions?
(Health Promotion and Maintenance)
schedule a follow-up
Caring and the “Art” of Nursing
1. What is the patient likely experiencing/feeling right now in this situation? (Psychosocial Integrity)
severe depression
2. What can you do to engage yourself with this patient’s experience, and show that he/she matters to you as a
person? (Psychosocial Integrity)
Stay with the patient when he is in emotional distress
Use Reflection to THINK Like a Nurse
Reflection-IN-action (Tanner, 2006) is the nurse’s ability to accurately interpret the patient’s response to an intervention
at the moment as the events are unfolding to make a correct clinical judgment.
1. What did I learn from this scenario?
You have to look at all aspects to treat a patient including the psychosocial aspect
2.
How can I use what has been learned from this scenario to improve patient care in the future?
Labs can tell you a lot about a patient's condition. I learned a lot about what to do in an emergency situation. Prioritization
is most important.
© 2018 Keith Rischer/www.KeithRN.com