INTRODUCTION

DEFINITION
Upper gastrointestinal (GI) bleeding is hemorrhage in the upper GI tract includes the esophagus, stomach, and first part of the small intestine.

The common causes for upper GI hemorrhage include the following: Esophagitis Gastritis Esophageal ulcer Gastric ulcer Duodenal ulcer Excessive use of NSAID

Risk factors
Helicobacter pylori infection poor dietary habit Use of NSAID Smoking Drinking alcohol Family history Stress Personality A Blood type O Age between 40 to 60 years old

Signs and Symptoms

Chronic abdominal pain especially when stomach is empty Recurrent vomit Hematemesis ( vomiting with blood) Melena (black stool) Chronic anemia Abdominal tenderness

PATIENTS PROFILE
Name: Mr. RJ Case no. : 100657 Address: Sitio 5, Santo Angel Central Sta. Cruz (26) Laguna Gender: Male Civil Status: Single Birthdate: January 24,1972 Age: 41 y/o Birthplace: Sta. Cruz Nationality: Filipino Religion: Aglipay Occupation: Ice dealer Admission: August 1, 2013 (4:10 pm) Admission Diagnosis: UGIB prob secondary to BPUD

Medical History: Chief complaint: vomiting x2 weeks History of present illness: 2 weeks prior to admission + pallor + loss of appetite +vomiting post prandial +epigastric pain +Occasional dizziness 2nd day prior to admission + epigastric pain

Past medical history:

HPN x1month Catapres OD maintenance s/p appendectomy 2008 @ LPH

Personal / social history: Alcohol beverage + Smoking+ Family history: none Allergy: none

Physical examination: Vital sign T 36.7 CR 78 RR 21 BP 140/100

General data: conscious and coherent SHEENT: pale looking, ambulatory not in cardio respiratory distress, anicteric sclerae, pale palpebral conjunctiva Heart: NPR, (-) murmur Abdominal: Flat, soft, epigastric tenderness, (+) pale nail beds, (-) edema

NUTRITIONAL-METABOLIC PATTERN
Typical daily food intake: AM-bread NN- rice, meat (e.g kaldereta) PM- same as nn appetite change when vomiting occur vomit any food after meal gnawing, burning sensation at epigastric area burping, sour taste

Typical daily fluid intake: 5-7 glasses of water, 2 glass of soda x3 a week
Weight: 72 kg to 66kg

ELIMINATION PATTERN Void 3-4 times a day Urine color is yellow No burning sensation felt during urination Moves bowel ever morning and afternoon With brown and formed stool but recently he had x2 melena 2weeks PTA.

ACTIVITY/EXERCISE Ice dealer

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

Predisposing factor Age (40-60) Gender Alcohol Smoking Blood type o Consume caffeinated beverages

Precipitating factor irritating foods

Increase HCl acid production Irritation of lining of stomach Damage mucosal barrier Low function of mucosal cell Low quality of mucus Loss of tight junction between cells Further mucosal erosion ulceration Bleeding Decrease o2 crrying capacity Pallor, lightheadness, weakness epigastric pain black tarry/ hematemesis

DIAGNOSTIC AND LABORATORY STUDIES

Radiology 8-1-13

Chest PA
ROENTENOLOGY Mild Cardiomegaly

CBC 8-1-13 RESULT Hgb Hct RBC Mcv MCH MCHC RDW-CV PLT CT PCT MPV PDW WBC Segmented neutrophil Lymphocytes Monocytes Eosinophil 57 .17 2.01 79 28.6 364 11.01 284 .214 7.6 14.8 6.0 70 21 07 02 NORMAL VALUE 130-180 40-50 4.5-6.2 80-100 27-32 360 11.0-16.0 170-400 .15-.50 6-11 11-18 4-10 55-65 25-35 3-6 2-4 decrease decrease decrease slightly decrease normal slightly increase normal normal normal normal normal normal slightly increase slightly decrease slightly increase normal

BT FROM Patient blood type : O+ Source of Blood: PRC Component : PRBC Amount: For modification (y/N) N Serial no. 4009-0043690 ABO/ RH type :O+ Extraction date: 7-31-13 Expiration date: 9-4-13 Cross matching method: Diaclon Result of cross matching Testing: compatible (unit is fit for transfusion) Cross transfusion done by: lyne M. Aliamirano Transfusion Started 8-3-13 (4:55 am) Vital sign Prior Post T36.9 36.7 P72 83 R20 21 BP120/80 120/70

Clinical Chemistry (electrolytes) 8-1-13 Na K Cl 133.5 4.21 106.8 135-145 mmol/L 3.5-5.0 mmol/L 97-107 mmol/L LOW NORMAL NORMAL

URINALYSIS 8-1-13
Physical properties color: yellow Transparency: hazy Ph: 6.0 (5-9) Specific gravity: 1.020 (1.005-1.030) Sugar: negative Protein: 1+ negative (<10 mg/dL/100Ml) RBC: 0-1/hpf WBC: 6.10/hpf Epithelial cells: some Bacteria: some

8-2-13 ALT BUN kinetic UV Crea kinetic

22.9U/L 40.8 mmol/L 201.1 mmol/ L

4.0-36.0 2.5-6.4 35.4-123.8

NORMAL HIGH HIGH

Hematology 8-5-13

Result
Hbg Hct 8.0 24%

normal value
13-18 40-50%

Department of radiology ROENTGENOLOGY REPORT

8-6-13

RU: 7.4X2.7 cm
LU: 7.4X4.2 CM Small sized right kidney with clearance

Parenchymal change
Normal sized left kidney with clearance Normal prostate gland/U. bladder

Fecalysis

8-8-13

Color : Brown Consistency: loose Occult blood: negative

Ova or parasite: no parasite

seen Others: Blastocystis hominis

BT FROM 8-5-13 Patient blood type : O+ Source of Blood: PRC Component : PRBC Amount: For modification (y/N) N Serial no. 4009-00600080 ABO/ RH type :O+ Extraction date: 8-6-13 Expiration date: 9-6-13 Cross matching method: Diaclon Result of cross matching Testing: compatible (unit is fit for transfusion) Transfusion Started Vital sign Prior T36.8 P98 R24 BP140/90 8-6-13 (6:15 am)

BT FROM 8-5-13 Patient blood type : O+ Source of Blood: PRC Component : PRBC Amount: For modification (y/N) N Serial no. 4009-0060040 ABO/ RH type :O+ Extraction date: 8-2-13 Expiration date: 9-6-13 Cross matching method: Diaclon Result of cross matching Testing: compatible (unit is fit for transfusion)
Transfusion Started Vital sign Prior T36.6 P75 R21 BP120/80 8-6-13 (9:40 am)

BT FROM 8-9-13 Patient blood type : O+ Source of Blood: PRC Component : PRBC Amount: For modification (y/N) N Serial no. 4009-004170-0 ABO/ RH type :O+ Extraction date: 8-1-13 Expiration date: 9-5-13 Cross matching method: Diaclon Result of cross matching Testing: compatible (unit is fit for transfusion) Transfusion Started Vital sign Prior T37.3 P90 R23 BP140/80 8-10-13 (1:15 Pm)

MEDICATION

Captopril 25 mg; 1 tab PRN for >

160/100 given 12:28 an ACE inhibitor and a common antihypertensive. Captopril works by competitively inhibiting the conversion of angiotensin I to angiotensin II. Classification ACE inhibitor, Antihypertensive Adverse effect: Hypotension, tachycardia, chest pain, palpitations, pruritus, hyperkalemia.

Nursing consideration:
Take drug 1 hour before meals; do not take with food

Ranitidine 1 amp IV now Ranitidine blocks histamine h2- receptors in the stomach and prevents histamine-

mediated gastric acid secretion

Classification Histamine2 (H2) antagonist Adverse effect: Headache, dizziness, hypersensitivity Nursing consideration: Take drug wit meals and at bed time

Omeprazole 40 mg IV OD 6am 8/2-8/3 and shifted to omeprazole 40mg/tab 1 tab OD 8/4-8/10 An antisecretory compound that is a gastric acid pump inhibitor. Suppresses gastric acid secretion by inhibiting the H+, K+-ATPase enzyme system [the acid (proton H+) pump] in the parietal cells Classifications: gastrointestinal agent; proton pump inhibitor Adverse effects Headache, dizziness, fatigue, Diarrhea, abdominal pain, nausea, mild transient increases in liver function tests Nursing consideration: Give before food, preferably breakfast; capsules must be swallowed whole (do not open, chew, or crush).

Tranxemic acid 500g IV q8 given 8/1 8pm to 8/3 4am and revised to tranxemic acid 500g q8 x3 more doses used for the prompt and effective control

of haemorrhage
Classification: Anti-fibrinolytic, antihemorrhagic Adverse Effects: Nausea, vomiting, visual disturbance Nursing consideration: The medication can be taken with or without meals.

Clonidine 75mcg tab PRN for BP>160/120 given 8/1 8pm and 8/6 5am stimulates alpha-2 receptors in brain stem which results in reduced sympathetic outflow from the CNS and a decrease in peripheral resistance leading to reduced BP and pulse rate. Classification: Antihypertensive

Adverse effect: dizziness, headache, constipation, urinary retention, itching, fluid or electrolyte imbalance, GI upset, orthostatic hypotension, weakness, sedation, Transient hypertension or profound hypotension
Nursing consideration: Monitor BP carefully when discontinuing clonidine; hypertension usually returns within 48 hr.

Ciprofloxacin 500mg tab BID given 8/2 6pm to 8/10 6pm an antibiotic that is used to treat bacterial infections Classification: quinolone antibiotics Side effect: Nausea, vomiting, diarrhea, abdominal, pain, ras, headache, and restlessness. Nursing consideration: Instruct patient not to take ciprofloxacin with dairy products such as milk or yogurt, or with calcium-fortified juice. He may eat or drink dairy products or calciumfortified juice with a regular meal, but do not use them alone when taking ciprofloxacin. They could make the medication less effective

Amvase( Amlodepine) 5mg tab OD given 8/2 6pm to 8/10 6am Inhibits the movement of calcium ions across the membranes of cardiac and arterial muscle cells; decreased cardiac work, decreased cardiac oxygen consumption Classification Calcium channel-blocker, Antihypertensive

Adverse effect: Dizziness, light-headedness, headache, fatigue, Flushing, rash, Nausea, abdominal discomfort Nursing consideration: Monitor patient carefully (BP, cardiac rhythm, and output) while adjusting drug to therapeutic dose Take with meals if upset stomach occurs.

Mucosta tab TID pre meals given 8/3 5:30 to 8/10 5:30 is a mucosal protective agent and is postulated to increase gastric blood

flow,prostaglandin biosynthesis and

decrease free oxygen radicals. Classification: Antacid Adverse Reaction: Rash, pruritus, constipation, diarrhea, nausea.

Nursing consideration:
May be taken with or without food

Diphenhydramine 1amp IV 30 mins prior BT given 8/6 5:45 , 9:00 and 8/10 12:45 blocks histamine H1-receptors on effector cells of the GI tract, blood vessels and

respiratory tract. It also causes sedation

and has some anticholinergic action. Classification: Antihistamine Adverse Reactions: Drowsiness, dizziness, anticholinergic effects.

Nursing consideration:
Administer with food if GI upset occurs.

Metronidazole 500 mg/tab 1 tab BID x 7 days given 8/10 6pm is used to treat bacterial infections of the vagina, stomach, skin, joints, and respiratory tract.

Classification: Anti-protozoals
Adverse effect: abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue, glossitis, unpleasant taste, vomiting Nursing consideration: Take on an empty stomach, at least 1 hour before or 2 hours after eating a meal. Do not crush, chew, or break an extended-release tablet. Your symptoms may improve before the infection is completely cleared. Skipping doses may also increase your risk of further infection that is resistant to antibiotics

NaHCO3 1tab TID given 8/10 12nn 6pm Sodium bicarbonate act as alkalinizing agent by releasing bicarbonate ions which capable of neutralizing gastric acid
Classification: Antiulcer agents, alkalinizing agent Adverse effect:Edema, flatulence, gastric distension, metabolic alkalosis, hypernatremia, hypocalcemia, hypokalemia Nursing consideration: Assess the clients fluid balance throughout the therapy, this assessment includes intake and output, daily weight Take medication 1 hour after meal and at bedtime

CaCO3 1tab TID given 8/10 12nn 6pm Decreases total acid load of GI tract. Increase esophageal sphincter tone
Classification: Antacid,calciumsupplement, osteoporosis Adverse effect: Constipation, flatulence, diarrhea, renal dysfunction Nursing consideration: Administer as antacid 1 hr after meal and at bed time

DISCHARGE PLANNING Health teaching: Assist the patient in understanding the condition and factors that help or aggravate it. Teach patient about prescribed medications, including name, dosage, frequency, and possible side effects. Also identify medications such as aspirin that patient should avoid. Instruct patient about particular foods that will upset the gastric mucosa, such as coffee, tea, colas, and alcohol, which have acid producing potential. Encourage patient to eat regular meals in a relaxed setting and to avoid overeating. Explain that smoking may interfere with ulcer healing; refer patient to programs to assist with smoking cessation. Alert patient to signs and symptoms of complications to be reported. These complications include hemorrhage penetration and), and pyloric obstruction