Hello! Welcome to my tumblr! I am a Nursing student and hope that my Nursing related posts will be helpful to all my fellow student nurses! I am also a writer (not a pro) :) But poetry brings great joy and serenitity to my being. please see the page "writing/poems by trilife" I am pretty much an open book to those who take the time to ask and care to know me. I am open-minded and feel caring for others ANYONE is a priority in my life. I don't wanna just ramble about myself but please feel free to ask me anything. I do not claim to be a person who "knows everything," But I have been delt a few jokers in my life so who know's maybe we can relate! ;0
NCLEX Tip:
On NCLEX, heart sounds can appear in a multiple-choice format question or a hot spot question.
5 areas to remember: APETM
Here’s another illustration by Nursing Education Consultants, Inc. (2007):
Mnemonics (input by various people)
- APE To Man
- All People Enjoy Time Magazine
- All Physicians Earn Too Much
- All Patients Enjoy Taking Meds
- All Pigs Eat Too Much
- All Pimps/Prostitutes Enjoy Taking Money
NCLEX RN Q: Therapeutic Communication; pt with psychosis
A client says to the nurse, "The federal guards were sent to kill me." What is the best nursing response to the client's concern?
1."I don't believe this is true."
2."The guards are not out to kill you."
3."Do you feel afraid that people are trying to hurt you?"
4."What makes you think the guards were sent to hurt you?"
Test-Taking Strategy:
Note the strategic word best. Use therapeutic communication techniques. Eliminate options that show disagreement with the client or encourage any discussion regarding the delusion
ANSWER:3
RATIONALE:It is most therapeutic for the nurse to empathize with the client's experience. The remaining options lack this connection with the client. Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. Encouraging discussion regarding the delusion is inappropriate.
Appears fresh, bright red blood or “coffee grounds”
Melena
Black, tarry stools
Caused by digestion of blood in GI tract
The black color is caused by oxidation of the iron in hemoglobin during its passage through the ileum and colon.
Occult bleeding “hidden”, not so obvious
Very small amounts of blood in gastric secretions, vomitus, or stools
Not very obvious by just visual inspection
Detectable by guaiac test
Bleeding (hematochezia) that is from an arterial source is profuse, and the blood is bright red
The bright red color indicates that the blood has not yet been in contact with the stomach’s acid secretions long enough to make it begin to coagulate
“Coffee ground” vomitus reveals that the blood has been in the stomach for a longer time and has been changed by gastric secretions
Melena: Slow bleeding from an upper GI source including gastric ulcer, gastritis, esophageal varices
Longer the passage of blood through intestines, the darker the stool color due to breakdown of Hb—release of iron. If the transit time is greater than 14 hours, then melena is noted.
Hematochezia describes bright red blood
If less than 14 hours, then hematochezia or bright red blood is noted.
Cause of bleeding is not always easy to discover…
Variety of areas in GI tract may be involved
Objectives
Identify the etiology & clinical manifestations of GI bleeding
Identify the collaborative care & nursing management of GI bleeding
Upper GI Bleeding
150,000 to 200,000 hospital admissions each year for UGI bleeding
Mortality rate 6% to 10% for past 40 years
Increased incidence of UGI bleeding in older adults, especially women, and use of NSAIDs
Etiology and Pathophysiology
Most serious loss of blood from Upper GI is characterized by sudden onset
Insidious occult bleeding can also be a major problem
Severity depends of bleeding origin:
Venous
Capillary
Arterial
Common Causes:
Esophageal origin
Stomach and duodenal origin
Drug-induced origin
Systemic disease origin
Esophageal Origin
Chronic esophagitis- causes
GERD: reflux of acid
Mucosa-irritating drugs: ASA, NSAIDS
Alcohol: alcoholic liver cirrhosis
Cigarette/tobacco use: promotes ulcers
Mallory-Weiss tear
Tear in mucosa of the stomach or esophageal wall
Related to severe retching/vomiting
Tears also can occur after seizures, forceful coughing or laughing, lifting, straining, hyperemisis gravidarum, and childbirth. Physicians often find tears in people who have recently binged on alcohol.
Esophageal varices
Usually occurs secondary to cirrhosis of liver
Branches of vena cava and azygos vein combine with smaller vessels of lower esophagus
Vessels are not elastic, engorged, and tortuous due to high pressure often secondary to portal hypertension related to cirrhosis
Anything that increases pressure (coughing, sneezing) or causes irritation (vomiting) may cause massive bleeding
Stomach and Duodenal Origin
Gastric cancer
Steady blood loss as tumor grows and ulcerates
Hemorrhagic gastritis
Peptic ulcer disease
Bleeding ulcers account for 50% of Upper GI bleeding cases
Related to H. pylori: bacteria has evolved to survive in the acidic environment of the stomach
Also related to drug use (NSAIDs)
Polyps
Stress-related mucosal disease
Also called physiologic stress ulcers
Occurs in patients with severe burns, trauma, ICU, or after major surgery
Erosion of more superficial blood vessels occurs
Peptic Ulcers
Drug-Induced Origin
OTC or prescribed drugs: Major cause of Upper GI bleeding
Irritate and disrupt gastric mucosal barrier
Aspirin
Excedrin
Alka-Seltzer
Pepto-Bismol
NSAIDs
Ibuprofen, Aleve, Toradol
Corticosteroids: prednisone
Careful history of all commonly used drugs required
Systemic Disease Origin
Systemic diseases must be considered when Upper GI bleeding occurs
Diseases that interfere with normal blood clotting
Blood dyscrasias
Leukemia
Aplastic anemia
Hemophilia
Renal failure
Uremia, erythropoietin production
Laboratory studies
CBC
BUN and CR
Serum electrolytes
Blood glucose
Platelets, PT, PTT
U/A and Specific Gravity (1.005 to 1.025) to assess level of hydration
Liver enzymes
ABGs
Type/cross-match for possible blood transfusions
Other laboratory studies
Vomitus/stools
Tested for the presence of gross and occult blood
Urinalysis
Specific gravity: Indication of the patient’s hydration status (1.005 to 1.025)
Emergency Assessment & Management
Immediate physical examination with emphasis on
BP
LOC, pulse ox readings, respiratory status
Rate and characteristics of pulse
Peripheral perfusion with capillary refill
Observation of neck vein distention (JVD)
V/S every 15 to 30 minutes
Signs and symptoms of shock must be evaluated
Treatment as soon as possible
Respiratory status assessed
Abdominal exam
Listen for presence or absence of bowel sounds
Palpate for tense, rigid abdomen: may indicate perforation and peritonitis
Once immediate interventions have started
Complete history of events leading to bleeding episode
Previous bleeding episodes
Weight loss
Received blood transfusion
Other illnesses (liver disease, cirrhosis)
Sengstaken-Blakemore Tube
It consists of a multiluminal plastic tube with two inflatable balloons. It is passed down into the esophagus and the distal balloon is inflated in the stomach. Distension of the proximal balloon is used to stop bleeding from the varices. The gastric portion of the double lumen is for aspirating and removing bloody stomach contents.
Medication use
Religious preferences regarding blood or blood product usage
Significant blood loss is indicated by
Pallor
Tachycardia
Tachypnea
Orthostatic Hypotension
Restlessness
Confusion
Poor capillary refill
Prioritization
Protection of the airway: a cuffed ET tube can be placed to prevent aspiration of blood. HOB elevated!
Oxygen administration
IV line & Immediate volume replacement with Ringer’s lactate or normal saline: 3cc fluid for every 1cc blood lost.
Use LR for liver patients to avoid ascites, NS for all others
Transfusion of whole blood or packed cells
Fluid replacement
IV lines
Priority! Access line should be established for fluid and blood replacement
Preferably two IVs
16 or 18 gauge
Generally best to begin with Lactated Ringer’s or NS for volume expansion
Foley insertion to monitor output and renal status and hydration status
Blood replacement
Whole blood, packed RBCs and fresh frozen plasma
Used for replacement of lost volume in massive hemorrhage
Packed RBC are preferred over whole blood because of fluid overload and immune reactions
Hgb and Hct provide baseline for further treatment
Normal Values
Hct 36 to 44% females 41 to 50% males
Hgb 12.1 to 15.1 g/dl females
Hgb 13.6 to 17.7 g/dl males
**Initial Hct may be normal and not reflect loss until 4 to 6 hours after fluid replacement
Diagnostic Studies
Endoscopy
Primary tool for diagnosing source of bleeding and to determine upper GI vs. lower GI bleeding
Endoscopy is preferably performed at the bedside in the ICU, to allow for an early view of the upper tract. Positioning the patient in a left lateral decubitus position will help prevent aspiration of GI contents. Sedate pt. and anesthetize back of throat to make procedure tolerable
Before the procedure begins, make sure that you have oral-tracheal suction equipment at the bedside and that the patient is on a heart-monitoring device and pulse oximeter.
May need to lavage with for clearer view
NG or orogastric tube placed and room-temperature water used for lavage
Do not advance against resistance
Aspiration of stomach contents through a large-bore tube (Ewald tube) to remove clots. Sengstaken-Blakemore tube can also be used to remove clots
Angiography
Used to diagnose only when endoscopy cannot be done
Invasive procedure
May not be appropriate for high-risk or unstable patient
Catheter placed into left gastric or superior mesenteric artery until site of bleeding discovered
Barium contrast
Limited use in identification of bleeding sites during acute phase of treatment
After acute bleeding phase, can document an actual lesion but cannot verify source
Collaborative Care
Endoscopic hemostasis therapy: surgery
Goal: To coagulate or thrombose bleeding artery
Useful for gastritis, Mallory-Weiss tear, esophageal and gastric varices, bleeding peptic ulcers, and polyps
Gastric lavage is usually performed to remove blood from the stomach prior to endoscopy. The goal of endoscopic therapy is to “seal” the bleeding vessel
Several techniques are used including
Thermal (heat) probe
Coagulates tissue by directly applying heat to site
Electrocoagulation probe (multi- and bipolar)
LASER photocoagulation: 2 Types
1. Argon plasma coagulation (APC)
Noncontact coagulation delivers a monopolar current to tissue
Neutralize HCl acid that is present: Nexium drip, can be continuous
Injection therapy during endoscopy for acute hemostasis
Bleeding due to ulceration
Epinephrine
Produces tissue edema → pressure on bleeding source
A form of sclerotherapy, which involves injecting the bleeding ulcer with a necrotizing agent; this traumatizes the endothelial layer of the GI mucosa, causing necrosis and eventual sclerosis of the bleeding vessel.
IV or intraarterial vasopressin (Pitressin)
For variceal bleeding
Causes vasoconstriction, ↑ smooth muscle activity of GI tract
Used in patients who do not respond to other therapies and poor surgical risk
Pitressin constricts blood flow through the liver, reducing portal pressure. When giving this drug, monitor for side effects of systemic vasoconstriction, myocardial ischemia, and bradycardia. Administer nitroglycerin, titrated to maintain systolic blood pressure between 90 mm Hg and 100 mm Hg, to curb side effects and to further reduce portal pressure.
Acid reducers
Acidic environment can alter platelet function and clot stabilization
Histamine-2 receptor blockers (H2R)
Inhibits action of histamine at H2 receptors and decreases HCl acid secretion
Cimetidine (Tagamet)
Ranitidine (Zantac)
Proton pump inhibitors (PPIs)
Suppresses gastric secretion by inhibiting H+, K+, ATP-ase enzyme system
Inhibits gastric acid pump
pantoprazole (Protonix)
esomeprazole (Nexium)
No proven ability to control active bleeding
Part of standard treatment protocols
*Tx. for H. Pylori: PPI plus amoxicillin 1 gram plus clarithromycin 500 mg all twice daily for 7-14 days
Antidiarrheal
Somatostatin analog octreotide (Sandostatin)
Used with upper GI bleeding
Reduces blood flow to the gut and reduces acid secretion
Given in IV boluses up to 5 to 6 days after initiation of bleeding
Antacids
Neutralize HCl acid
Maintains gastric pH above 5.5
Elevated pH inhibits activation of pepsinogen
sodium bicarbonate (Alka-Seltzer)
calcium carbonate (Tums)
magnesium hydroxide (Mag-Ox)
Be careful: Calcium carbonate and sodium bicarbonate can lead to systemic alkalosis
Sedatives should be administered cautiously because they may mask s/s of hypovolemia such as decreased B/P and LOC changes. Monitor patient
Anticholinergic drugs (like atropine and belladonna) are contraindicated in acute UGI bleeding episodes,
but may be used after the bleeding has stopped to reduce GI motility
Nursing Management
Nursing assessment
LOC and Respiratory Assessment
VS
Orthostatic checks: a drop of B/P of 20/10 mmHg and an increase in HR of 20 BPM suggests orthostatic changes that may be related to blood loss check lying to sitting, standing may not be possible
Every 15 to 30 minutes
Appearance of neck veins (JVD)
Nursing diagnoses: ABCs
Risk for aspiration of blood (airway, breathing)
Ineffective tissue perfusion (breathing)
Fluid volume deficit (circulation)
Decreased cardiac output (circulation)
Anxiety
Ineffective coping
Skin color
Capillary refill
Abdominal distention, guarding, peristalsis
Signs/symptoms of hypovolemic shock
Low BP
Rapid, weak pulse
Increased thirst
Cold, clammy skin
Restlessness, LOC changes
Health promotion
Patient with a history of chronic gastritis or peptic ulcer disease is at high-risk
Patient who has had one major bleeding episode is more likely to have another
Patient with cirrhosis or previous Upper GI bleed is also at high-risk
Nurse education
Taking the medications with meals or snacks lessens the potential irritating effects
Small frequent meals
GERD: avoid coffee, chocolate, smoking, HOB 30 degrees at night, avoid restrictive clothing at stomach area, no eating within 3 hours of sleep
Acute intervention (cont’d)
IV maintenance
Accurate intake and output record
Urine output hourly
At least 0.5 ml/kg/hr indicates adequate renal perfusion
Urine specific gravity should be measured
Normal (1.005 to 1.025)
CVP line or PAC readings every 1 to 2 hours
Assess stools for blood
Menses and bleeding hemorrhoids should be ruled out
Monitor laboratory studies
Hb and Hct every 4 to 6 hours
BUN assessed
Oxygen management
Nutrition
Observed for symptoms of nausea and vomiting
Recurrence of bleeding
Feedings initially include clear fluids given hourly
Gradual introduction of food follows as tolerated
Ambulatory and home care
Nursing education
Patient/family taught how to avoid future bleeding episodes
Made aware of consequences of noncompliance with diet and drug therapy
Emphasis that no drugs other than those prescribed should be taken
