CASE PRESENTATION

PRESENTED BY BSN III - A2

UPPER GASTROINTESTINAL BLEEDING
SECONDARY TO DUODENAL ULCER
ANEMIA SEVERE SEC TO UGIB
REFLUX ESOPHAGITIS GRADE A
 DEMOGRAPHIC PROFILE

Patient RMM, 48 Year-old Male, Filipino, Married, from Tambis

St, Banawa, Cebu City came to Sacred Heart Hospital on 11-18-
2020 at 4:45 PM with a complaint Melena and Dizziness. He
was admitted to 4th central wing Bed 7 under Dr. Avila, Charlie
with the diagnosis of Upper Gastrointestinal Bleeding sec to
Duodenal ulcer. Anemia severe sec to UGIB, reflux esophagitis
grade A.

BP-120-60 mmHg; PR-96 bpm; RR-24 cpm; T-36.2 C

PATHOPHYSIOLOGY OF UPPER
GASTROINTESTINAL BLEEDING
SEC TO
DOUDENAL ULCER
PATHOPHYSIOLOGY OF
ANEMIA SEVERE SEC TO
UGIB
PATHOPHYSIOLOGY OF
REFLUX ESOPHAGITIS
GRADE A
 Hospitals should be prepared whenever patients arrive
especially when admitted. A covid rapid test and RT-PCR test are
required in order to find out if the patients are positive with
COVID-19.

COVID RAPID TEST

this test determines if the human body consist of antibody of
COVID-19. The patient is negative with COVID-19. The result was
taken on November 18, 2020.
RT-PCR TEST
swab specimen collected done by prime care on November
19, 2020, results were not available.

Urinalysis
There were no unusualities displayed in the result of the
urinalysis. Chemical results were all negative and normal.
TEST FOR SODIUM,
POTASSIUM, CREA, BUN AND ALT.

Sodium and potassium was in the normal range. Creatinine is

slightly above the normal range of 0.51-0.55 with the result of
1.04 mg/dL. Though BUN is in the normal range of 6.0 to 20 it is
slightly low. Maybe because the patient is diagnosed with
duodenal ulcer and experiencing symptoms like diarrhea, vomiting
and bleeding so the BUN level decreases because of low protein in
the body. ALT (sgpt) is in the normal range of 0-41 U/L with 17.

LIPID PANEL TEST

Only triglycerides is above the normal range of 25-148 mg/dL
with the result of 168.6 mg/dL. Patient undergone fasting in order
to get FBS with the normal range of 70-100 mg/dL with the result
of 92.53 mg/dL.
 Prothrombin time
Prothrombin time is a test that measures how long it takes blood to
clot. The patient’s result is 11.9 seconds and is within the normal
range

Blood typing
Blood typing is a method to determine what type of blood you have.
Based on the results, the patient is blood type O+
Echocardiogram

ECG is a test that’s used to check the heart’s rhythm and electrical
activity. There were no unusualities displayed in the result of the
ECG performed on November 18,2020
Vent. Rate (bpm): 86
PR Intervals (ms): 178
QRS Duration (ms): 104
QT/QTc Interval (ms): 356/402
P/QRS/T Axes (deg): 64/45/8

Normal sinus rhythm

Inferior T wave abnormality is nonspecific
Borderline ECG Unconfirmed Diagnosis
Gastroscopy
A gastroscopy can help rule out the presence of medical conditions like
gastritis or peptic ulcers. The physician confirms two diagnoses here;
1) Duodenal Bulb Ulcers Forest II and, 2) Reflux Esophagitis Grade A

Esophagus. The esophagus was distensible with air insufflation and with good
peristalsis. The esophageal mucosa was smooth and pinkish. The Z was obliterated due
to mucosal breaks.

Stomach. The cardia was hugging the scope on retroflexed view. The fundus and body
had normal looking mucosa. The antrum was hyperemic. The pylorus was incompetent

Duodenum. The 1st portion has two deep ulcers measuring 1cm each with clean base.
The 2nd portion was hyperemic.

Performed: November 20, 2020

· CHEST X-RAY

Date performed: Nov. 18, 2020

Results:

- The lung fields are clear. Heart is not enlarged.

The tracheal air column is at the midline. Both
hemidiaphragms and costophrenic sulci are intact.
Osteophytes are seen rising in the lateral articulating
margins of the thoracic.

Impression:

- Clear lung fields & spondylosis of the thoracic

spine
·
 Amoxicilli
n
Dosage:
Brand Name: 500mg
Amoxil
Route:
Classification: P.O.
Aminopenicillin /penicillin-
type antibiotic. Frequency:
b.i.d.

Timing:
8am, 8pm
Mechanism of Action

Inhibits cell wall synthesis during

bacterial multiplication.
Indication/s

❏ Helicobacter pylori infection

Contraindication/s

❏ Contraindicated in patients hypersensitivity to drug

or other penicillins.
❏ Use cautiously in patients with other drug allergies
especially to cephalosporins
❏ Use cautiously in those with mononucleosis because
of high risk of maculopapular rash.
 Side Effects/Adverse Reactions

❏ CNS: Seizures, lethargy, hallucinations, anxiety, confusion, agitation,

depression, dizziness, fatigue.

❏ GI: diarrhea, nausea, pseudomembranous colitis, vomiting,

stomatitis, gastritis, abdominal pain, black hairy tongue.

❏ GU: interstitial nephritis, nephropathy, vaginitis.

❏ Hematologic: agranulocytosis, leukopenia, thrombocytopenic

purpura, anemia, eosinophilia, hemolytic anemia.

❏ Other:anaphylaxis, hypersensitivity reactions. Overgrowth of

nonsusceptible organisms.
 Nursing Responsibilities

⮚ Check and verify the right drug to be administered.

⮚ Administer the drug to the right patient.
⮚ Administer drug with the right dosage and route.
⮚ Administer drug at the right time and frequency.
⮚ Instruct patient to take entire quantity of drug exactly as
prescribed, even after he feels better.
⮚ Instruct patient to take the medication with food or after
meals.
⮚ Tell the patient to immediately notify the physician if rash,
fever or chills develop.
⮚ Monitor therapeutic effects.
 Clarithromycin
Dosage:
Brand Name: 500mg
Biaxin
Route:
Classification: P.O.
macrolide
Frequency:
b.i.d.

Timing:
8am,8pm
Mechanism of Action

Binds to the 50S subunit of bacterial

ribosomes, blocking protein synthesis;
bacteriostatic or bactericidal depending
on concentration.
Indication/s

❏ Helicobacter pylori, to reduce risk of duodenal ulcer

recurrence.
Contraindication/s

❏ Contraindicated in patients hypersensitivity to

clarithromycin, erythromycin or other macrolides.
❏ Use cautiously in patients with hepatic or renal
impairment.
 Side Effects/Adverse Reactions

❏ CNS: headache
❏ GI: pseudomembranous colitis, diarrhea, nausea, taste perversion,
abdominal pain or discomfort.
❏ Hematologic: leukopenia, coagulation abnormalities.
❏ Skin: rash.
 Nursing Responsibilities

⮚ Check and verify the right drug to be administered.

⮚ Administer the drug to the right patient.
⮚ Administer drug with the right dosage and route.
⮚ Administer drug at the right time and frequency.
⮚ Tell patient to take drug as prescribed even he feels better.
⮚ Instruct patient to report persistent adverse reactions.
⮚ Inform patient to take the drug with meals or after meals.
⮚ Monitor therapeutic effects.
 Omeprazole
Dosage:
Brand Name: 40mg/cap
Omepron
Route:
Classification: PO
PROTON PUMP INHIBITOR
Frequency:
BID

Timing:
8:00 AM, 6:00 PM
Mechanism of Action

Suppresses Gastric acid secretion by

specific inhibition of the hydrogen
potassium ATP as enzyme system at the
secretory surface of the gastric parietal
cells blocks the final step of acid
production.
Indication/s

❏ used to reduce the amount of acid in your stomach. It’s used to treat
gastric or duodenal ulcers, gastroesophageal reflux disease (GERD),
erosive esophagitis, and hypersecretory conditions. This drug is also used
to treat stomach infections caused by Helicobacter pylori bacteria
Contraindication/s

❏ Contraindicated with hypersensitivity to omeprazole

or its components.
 Side Effects/Adverse Reactions

❏ CNS: Headache, dizziness, vertigo, insomnia, apathy, anxiety,

paresthesia

❏ DERMATOLOGY: Rash, inflammation, urticaria, pruritus, alopecia, dry

skin

❏ GI: Diarrhea, Abdominal pain, Nausea, vomiting, constipation, dry

mouth, tongue atrophy

❏ RESPIRATORY: URI symptoms, cough, epistasis

❏ Others: Cancer in preclinical studies, back pain and fever

 Nursing Responsibilities

⮚ Verify doctor’s order.

⮚ Instruct patient to rest and provide therapeutic environment.
⮚ Follow ten rights.
⮚ Monitor urinalysis for hematuria and proteinuria.
⮚ Instruct family member to assist giving Fiber once allowed to
eat by the physician.
⮚ Increase fluid intake once allowed by the physician
⮚ Report severe diarrhea, drug may need to need discontinued
⮚ Report any changes in urine elimination such as pain or
discomfort, or blood in urine.
 Rebamipide
Dosage:
Brand Name: 100 mg
Mucosta
Route:
Classification: PO
Antiulcerant; Antacid
Frequency:
TID

Timing:
8-1-6
Mechanism of Action

Prostaglandin Increasing Effect:

Rebamipide increased the endogenous
prostaglandin E2 (PGE2) content in the
gastric mucosa in rats. The drug also
increased PGE2 and PGI2 content in the
gastric juice, as well as the content of 15-
keto-13, 14-PGE2, a metabolite of PGE2
Indication/s

❏ Gastric ulcers
❏ Treatment of gastric mucosal lesions
(erosion, bleeding, redness, and edema) in
the following conditions; acute gastritis and
acute exacerbation of chronic gastritis.
❏ Prevention of NSAID-induced gastropathy.
Contraindication/s

❏ Rebamipide is contraindicated in elderly and

children and adult patients with chronic illness
including cancer.
❏ Rebamipide should not be prescribed to patients
allergic to synthetic formulations, dye and
chemicals and with a history of hypersensitivity
to any ingredient of this drug.
❏ Should be used by pregnant or possibly pregnant
women only if the anticipated therapeutic benefit
is thought to outweigh any potential risk.
 Side Effects/Adverse Reactions

❏ Hypersensitivity: Rash, pruritus and eczematous drug eruption

may rarely occur. If such signs of hypersensitivity reactions
develop, Mucosta should be discontinued.
❏ Gastrointestinal: Dry mouth, constipation, sensation of abdominal
enlargement, diarrhea, nausea, vomiting, heartburn, abdominal
pain and belching may rarely occur.
❏ Hepatic: Signs of hepatic function disorder including increased
GOT, GPT, γ-GTP and alkaline phosphatase levels may rarely
occur.
❏ Hematologic: Leukopenia may rarely occur.
❏ Others: Mammary gland expansion, nonpuerperal lactation,
menstrual disorder, dizziness, increase in BUN level, edema and
sensation of foreign body in the pharynx may rarely occur.
 Nursing Responsibilities

⮚ Consider 10 rights of medication.

⮚ Do not give more than 3 tablets per day.
⮚ Monitor for any adverse effects. Monitor vital signs after
administration and encourage patient to verbalize any discomforts.
⮚ Instruct patient to take in fiber rich foods to prevent or alleviate
constipation.
⮚ Encourage patient to use lip balm and increase fluid intake for dry
lips and mouth.
⮚ Instruct patient to verbalize relief from hyperacidity and report
presence of rash. Inform patient of the possible side effects.
⮚ Watch out for abdominal distention.
⮚ Monitor intake and output.
Nursing Diagnosis:

Deficient Fluid Volume related to blood volume loss secondary to GI

bleeding as evidenced by melena.
Defining Characteristics

Subjective Data:
“I feel weak” as verbalized by the patient

Objective Data:
- Weakness
- Decreased skin turgor
- Vital signs as follows:
Bp: 120/60
PR: 96 bpm
RR: 24 cpm
Temp: 36.2
Scientific Analysis

Loss of blood from the gastrointestinal tract is most often the result of
erosion or ulceration of the mucosa but it may also be a result of arteriovenous
(AV) malformation or increased pressure in the portal venous bed pr direct
trauma in the GI tract.

Upper GI bleeding may manifest as blood tinged, bright red or coffee ground
emesis. The client may also experience dark tarry stools.

Reference:
Gulanick, M., & Meyers, J.L. (2017). The Nursing Care Plans: diagnoses interventions & outcomes. 9th edition. St.
Louis, Missouri: Mosby, an imprint of Elsevier Inc.
Plan of Care

Short Term:
After 8 hours of Nursing interventions, the patient will be able to:
> Verbalize understanding of causative factors and purpose of
individual therapeutic interventions and medications.
> Demonstrate behaviours to monitor and correct deficit,
as indicated.
Long Term:
After 4 days of nursing interventions, the patient will be:
> Maintain fluid volume at a functional level as evidenced by a
normal skin turgor.
Nursing Interventions Rationale
1. Obtain a history of the use of 1. Drugs that can cause
abuse or substances known ulceration of the GI mucosa
to predispose to GI bleeding contribute to the
development of bleeding.
such as; aspirin, NSAIDs,
alcohol and steroids.
Nursing Interventions Rationale
2. Monitor color, amount, and 2. Careful assessment of GI
consistency of the hematemesis, bleeding can help determine the
melena or rectal bleeding. exact site of bleeding.
Nursing Interventions Rationale
3. Assess vital signs particularly 3. Hypovolemia due to GI
blood pressure level. bleeding may lower blood
pressure levels and put the
patient at risk for hypotensive
episodes that lead to shock.
Nursing Interventions Rationale
4. Monitor patient’s urine output. 4. Urine output at least 30ml/hr is
an indication of an adequate renal
perfusion.
Nursing Interventions Rationale
5. Discuss factors related to 5. To reduce the risk of
occurrence of fluid deficit as recurrence.
individually appropriate.
References:

Gulanick, M., & Meyers, J.L. (2017). The Nursing Care Plans: diagnoses
interventions & outcomes. 9th edition. St. Louis, Missouri: Mosby, an imprint
of Elsevier Inc.

https://nursestudy.net/gi-bleed-care-plan-nclex-review/
Nursing Diagnosis

Acute pain related to gastroesophageal reflux as evidenced by

verbalization of pain.
Defining Characteristics

Subjective Data:
“I feel pain in my chest every time after I eat and it’s painful to
swallow”, as verbalized by the patient.

Objective Data:
- Regurgitation of food
- Fatigue
- Patient appears restless
- Patient appears pale
- Pain score of 7 out of 10
Vital Signs:
● PR: 96 bpm
● RR: 24 cpm
● BP: 120/60 mmHg
● Temp: 36.2
Scientific Analysis

Acute pain is the state in which an individual experiences and

reports the presence of severe discomfort lasting from 1 seconds up to <6
months.
Reflux esophagitis in an inflammation of the lining of the esophagus
caused by chronic exposure to stomach acid.
In gastroesophageal reflux, there is an excessive or prolonged transient
LES relaxation that will lead to the HCl in the stomach to be pushed up by the
increase abdominal pressure which result in heartburn or chest pain after
eating and acid regurgitation. The esophagus may develop ulcer, which can
bleed and cause severe pain

Reference:
Doenges, M.E & Moorhouse, M.F, Murr, A. (2016). Nurse’s Pocket Guide. (14th Ed.) Philadelphia. F.A. Davis Company
Yu, Y. & Maghera, A. (2019, May 5) Gastroesophagel Reflux Disease. https://calgaryguide.ucalgary.ca/Gastroesophageal-
Reflux-Disease-(GERD)-Pathogenesis-and-Clinical-Findings/
Plan of Care
Short Term:
After 8 hours of nursing intervention, the patient will be able
to:
● Cooperate with the nursing interventions
● Verbalize understanding of the illness and therapy regimen
● Report relief of pain

Long Term:
After 2 weeks of nursing intervention, the patient will be able
to:
● Apply behavioural changes and demonstrate relax body
posture and have adequate rest
Nursing Interventions Rationale
1. Carefully assess pain location 1. Pain from esophageal spasm,
and discern pain from GERD resulting from reflux
and angina pectoris. esophagitis tends to be
chronic and may mimic
angina pectoris: radiating to
the neck, jaws, and arms.
Nursing Interventions Rationale
2. Instruct patient to chew food 2. Well-masticated food is easier
thoroughly and eat slowly. to swallow. Food should be cut
into small pieces.
Nursing Interventions Rationale
3. Instruct patient to avoid gas 3. These can reduce the
forming foods (e.g. coffee, esophageal sphincter pressure
softdrinks, beer, cabbage, highly and to lessen acidity.
seasoned foods, and foods high in
fat)
Nursing Interventions Rationale
4. Avoid restrictive clothing. 4 . Restrictive clothing can
increase intra-abdominal pressure.
Nursing Interventions Rationale
5. Administer medication as 5. To maintain acceptable level of
indicated. pain and to buffer acidity.
References:
Doenges, M.E & Moorhouse, M.F, Murr, A. (2016). Nurse’s Pocket
Guide. (14th Ed.) Philadelphia. F.A. Davis Company
 Nursing Diagnosis

Activity intolerance related to imbalance between

oxygen supply and demand as evidenced by
decreased Hgb and Hct levels
Defining Characteristics
Subjective Data:
“I feel tired all the time”as verbalized by the patient

Objective Data:
➔ Limited ROM
➔ Ambulatory with assistance
➔ Hct- 15.8
➔ Hgb- 5.7
➔ Restlessness
➔ Presence of body weakness and fatigue
Vital signs
➢ BP;120/60
➢ T;36.2
➢ HR;96
➢ O2; 99%
➢ RR;21
Scientific Analysis

insufficient physiological or psychological energy to continue or

complete necessary or desired activities
A patient who has undergone blood transfusion is usually under
bed rest for few days that hinders them to perform daily
activities.and due to decrease in Hgb levels which is the oxygen
carrier in the blood , transportation of oxygen to tissue was
impared and causing the client to develop hypoxia thus they will
experience fatigue and weakness
Plan of Care
SHORT TERM
After 8 hours of nursing intervention the patient will
report an increase in activity tolerance
LONG TERM
After 2 days of nursing intervention the patient will be
free from weakness and fatigue and display an
acceptable range of laboratory values of Hgb and Hct.
Nursing Interventions Rationale
1. Elevate the head of the bed 1. Enhances rest to lower
as tolerated and encourage body's oxygen requirement
deep breath exercises reducing body weakness
Nursing Interventions Rationale
2. Provide assistance with 2. Although help may be
activities and ambulation if necessary , self esteem is
necessary enhanced when patient does
things for self

3. Assess the patient's ability to

perform activities of daily living 3. This influences choice of
and normal tasks intervention and needed
assistance
Nursing Interventions Rationale
4. Monitor laboratory studies of 4. It enables identify deficiencies
Hgb and Hct levels in RBC components affecting
oxygen transport and treatment
response
Nursing Interventions Rationale
5. Provide oxygen as needed 5. Maximizing oxygen transport
to tissues improves ability to
function
Nursing Interventions Rationale
6. Transfuse whole packed RBCs 6. Increases in oxygen carrying
products as indicated and monitor cells hence correcting deficiencies
closely for transfusion reactions to reduce risks of hemorrhage in
actually compromised individuals
References:

Doenges M E, Moorhouse,M,F , Murr. A,C nursing care plans ,

guidelines for individualizing client care across the lifespan 9th
edition , (2014 ) F.A Davis company
Medication:
Instruct and educate the patient and SO about medications regarding
their use, dosage, timing, advantages, contraindications, side effects and
adverse effects. The patient and SO should report any symptoms of
adverse effects if there are any abnormal behaviors being experienced.
The patient must adhere to the following medications:
1. Omeprazole (Pantor) 40 mg/cap 1 cap PO once a day 30 mins to 1 hr
before breakfast for 2 months
2. Clarithromycin 500 mc/cap 1 cap PO 2x/day (8am; 6pm) after meals
for 10 days
3. Amoxicillin 500mg/cap 2 caps PO 2x/day (8am; 6pm) after meals for
10 days
4. Rebamipide (Mucosta) 100mg/tab 1 tab PO 3x/day (8am; 1pm; 6pm)
for 14 day
Environment:

Make sure that the environment is clean and must be a good place to
stay. Homemaking services and emotional and economic support
systems are in place
Treatment:

Encourage patient to have a special diet to help treat GI conditions and

prevent problems such as GI bleeding. Make sure that the family and
patient knows the purpose and action of their treatment. Emphasize
the importance of home medications prescribed by the physician.
Health Teachings:

The patient and the family is taught how to administer drugs and
treatments when necessary. Instructed the patient and his family to
monitor vital signs at all times and avoid strenuous activities. Isolation
for about 14 days upon arrival. The patient will be able to identify and
report signs and symptoms of potential health problems as well as drug
and treatments side effects
Outpatient Referral:

The patient and family members must have available telephone

numbers of referred physicians and agencies. A written discharge will
be provided. It will be reviewed and explained to the patient and
family. Follow up care in Dr. Avila’s clinic in Adventist Hospital (Miller
Hospital) on December 2, 2020 with all repeat laboratory results will
be arranged. The patient will be informed the time, date, and location
of appointments given by the physician.
Diet:

The bleeding may make you lose iron. So it's important to eat
foods that have a lot of iron. These include red meat, shellfish,
poultry, and eggs. They also include beans, raisins, whole-grain
breads, and leafy green vegetables.
Spiritual:

Provide emotional support coming from the family. Emphasize

the importance of hope for longevity of life, growth through
developing spiritual assessments from chosen religion, culture,
belief, or organizations and pray accordingly to the patient
needs.