New Admit Diagnosis Of GI Bleed History No Surgery

Topic New Admit Admit Diagnosis Gi Bleed History No Surgical His

Topic: New Admit · · Admit diagnosis: GI bleed · History: no surgical history · Medical history: Gastritis & GERD · Medications: Prilosec 40 mg PO daily, Atenolol 25 mg PO BID, Fiber daily, Alka Seltzer PO – states he takes this at least daily. Report from physician’s office: Mr. Henderson arrived to the physician’s office today for a complaint of increasing abdominal pain. He states that he is now throwing up coffee-ground emesis. He states that he didn’t take his BP medication this morning because he was dizzy.

The physician is admitting him with a diagnosis of GI bleed with an EGD scheduled for tomorrow. He is NPO, and has a 22G IV lock in the left forearm. Last set of vital signs BP 106/60 mm Hg, HR 98 beats/min, RR 20 breaths/min, Temp. 98.8 degrees F, P.O. 90% on room air.

He last vomited about 45 minutes ago with a small amount of dark coffee-ground emesis. His pain is 4/10 at present. No pain medication is ordered at this time. · Lab assessments ordered: CBC and chemistry panel · CT of the abdomen shows no signs of free air (no perforation). When he arrives to the floor, he is pale, nauseous, and his skin is cool and clammy. When he is transferred to the bed from the stretcher, he vomits a large amount of coffee-ground emesis and loses consciousness.

Instructions In the ASSIGNMENT, address the following: 1. While receiving report, what concerns do you have regarding the client report? 2. What type of shock is occurring? 3. What stage of shock is the client experiencing? 4. What is your next intervention and why? 5. What additional lab assessments would you anticipate? 6. Provide additional thoughts and insights. NO CONSIDERATION FOR PLAGIARISM APA FORMAT AND INDEX CITATION PLEASE WRITE FROM NURSING PERSPECTIVE.

Paper For Above instruction

In the scenario presented, Mr. Henderson’s clinical presentation underscores the critical importance of rapid assessment and intervention in patients with gastrointestinal (GI) bleeding, particularly when he exhibits signs of shock and altered consciousness. Observing his history, vital signs, and physical appearance during the report, several key concerns emerge that necessitate immediate nursing action and a comprehensive understanding of shock types and stages.

Concerns During Client Report

Initial concerns revolve around the severity of Mr. Henderson’s condition, particularly his progression to hematemesis—coffee-ground vomitus indicating recent bleeding—along with signs of hypovolemia such as pallor, cool clammy skin, and nausea. The fact that he was dizzy and did not take his antihypertensive medication suggests he might be hypoperfused, exacerbating his risk for hemodynamic instability. Additionally, the recent large-volume emesis and loss of consciousness point to ongoing significant blood loss, which can compromise effective tissue perfusion. His vital signs, especially his blood pressure of 106/60 mm Hg and HR of 98 bpm, already suggest tenuous stability but not yet shock. His oxygen saturation of 90% requires close monitoring, considering potential hypoxia secondary to hypoperfusion and anemia.

Type and Stage of Shock

The most probable type of shock in this patient is hypovolemic shock, caused by significant blood loss due to gastrointestinal hemorrhage. The clinical signs—pale skin, cool extremities, hypotension, tachycardia, reduced urine output, and altered mental status—are classic indicators. In the early stages of hypovolemic shock, compensatory mechanisms attempt to maintain perfusion, but as blood loss continues, the patient progresses through stages of shock. Currently, Mr. Henderson appears to be in the progressive or irreversible stage, as evidenced by his loss of consciousness, postural hypotension, and severe clinical deterioration. His presentation suggests the transition from early compensated shock to decompensation, requiring immediate intervention.

Next Intervention and Rationale

The immediate priority is airway management and ensuring adequate oxygenation, as hypoxia can worsen organ hypoperfusion. Administering supplemental oxygen via nasal prongs or mask can help mitigate tissue hypoxia. Simultaneously, establishing IV access with a large-bore catheter (preferably 18G or larger) is critical for rapid fluid resuscitation. Initiating isotonic crystalloid infusion (e.g., normal saline or lactated Ringer’s solution) aims to restore circulating volume and improve perfusion. Given his ongoing bleeding and signs of hypovolemic shock, blood transfusion should be considered promptly, especially if hemoglobin levels are critically low, which will be assessed through labs. Monitoring vital signs continuously, assessing mental status, and preparing for possible surgical intervention if bleeding persists are essential components of care.

Additional Lab and Diagnostic Assessments

Anticipated labs include a complete blood count (CBC) to evaluate hemoglobin and hematocrit, which quantifies blood loss severity. Coagulation studies (PT, aPTT, INR) are necessary to assess bleeding risk and any underlying coagulopathy. A chemistry panel provides information on electrolytes, renal function, and acid-base status—critical in managing volume resuscitation and identifying metabolic derangements. Crossmatching blood products should be ready in anticipation of transfusion needs. Furthermore, repeat vital signs, urine output measurement, and continuous cardiac monitoring are essential. Imaging studies such as an abdominal ultrasonogram or repeat CT may be used if bleeding localization is unclear, although current focus is stabilization.

Additional Thoughts and Insights

The management of GI bleeding extends beyond immediate resuscitation; addressing the underlying cause is vital. In Mr. Henderson’s case, his history of gastritis and GERD predisposes him to ulcer formation and bleeding, compounded byNSAID or aspirin use, and his current medications. Ensuring he is NPO prevents further irritation, and planned esophagogastroduodenoscopy (EGD) provides definitive diagnosis and potential therapeutic intervention, such as cauterization of bleeding vessels. Pharmacologic therapy with proton pump inhibitors (PPIs) like intravenous pantoprazole can reduce gastric acid secretion, aiding in hemostasis. Additionally, assessing for signs of ongoing bleeding (e.g., decreasing hemoglobin, increased bleeding in vomitus or stool) guides further management. Education on medication compliance, recognizing early symptoms of bleeding, and avoiding NSAIDs may prevent recurrence. As his condition stabilizes, interdisciplinary collaboration involving gastroenterology, surgery, and critical care teams will optimize outcomes.

Conclusion

Managing a patient with GI hemorrhage and hypovolemic shock demands rapid assessment, prompt interventions, and ongoing monitoring. Recognizing the signs of shock and understanding its stages allow nurses to implement life-saving measures effectively. Addressing both the immediate hemodynamic instability and underlying pathology forms the cornerstone of comprehensive care, aiming to restore perfusion, halt bleeding, and prevent further deterioration.

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