I.

INTRODUCTION

UPPER GASTROINTESTINAL BLEEDING

Originates in the GI tract from the mouth to the ligament of Treitz where the duodenum, the
first part of the small intestine, ends. Bleeding from the esophagus may occur from esophageal
varices, dilation of the veins in the esophagus. One of the symptoms of upper GI bleeding is
vomiting of blood (hematemesis).If the blood travels
through the GI tract, the stool may appear tarry and black (melena) because of digested blood,
though the stool can still be stained with red blood (hematochezia). About 75% of patients
presenting to the emergency room with GI bleeding have an upper source. The diagnosis is
easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of
patients in the emergency room with GI bleeding have an upper source. Determining whether a
patient truly has an upper GI bleed versus lower gastrointestinal bleeding is difficult. Mortality
is about 11% in patients admitted with an UGIB.2 It is as high as 33% in patients who
develop bleeding whilst in hospital. A score of less than 3 using the Rockall system above is
associated with an excellent prognosis, whereas a score of 8 or above is associated with high
mortality.3 Most deaths occur in elderly patients with co-morbidity. Mortality is reported to be
lower in specialist units possibly because of adherence to protocols rather than because of
technical advances.2 The prognosis in liver disease relates significantly to the severity of the
liver disease rather than to the magnitude of the haemorrhage

Upper gastrointestinal bleeding is commonly caused by bleeding varices (varicose veins) in the
esophagus, peptic ulcers or a Mallory- Weiss tear at the esophageal gastric junction from severe
retching .Otherwise, bleeding over time results in anemia, characterized by lower than normal
blood hemoglobin and hematocrit with symptoms like weakness, fatigue, and fainting.

The most important step to evaluate upper GI bleeding is upper endoscopy. During this
procedure, performed by a gastroenterologist, a tube with a camera (endoscope) is passed
into the mouth and down the esophagus. The gastroenterologist can proceed to the stomach
and duodenum and localize the source of the bleeding, if possible. Other examination to
determine UGIB are Vital signs, in order to determine the severity of bleeding and the timing of
intervention. Abdominal and rectal examination, in order to determine possible causes of
hemorrhage. Assessment for portal hypertension and stigmata of chronic liver disease in order
to determine if the bleeding is from a variceal source.
Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio.

Emergency treatment for upper GI bleeds includes aggressive replacement of volume

with intravenous solutions, and blood products if required. As patients with esophageal
varices typically have coagulopathy, plasma products may have to be administered. Vital signs
are continuously monitored.Early endoscopy is recommended, both as a diagnostic and
therapeutic approach, as endoscopic treatment can be performed through the endoscope.
Therapy depends on the type of lesion identified, and can include:injection of adrenaline or
other sclerotherapy, electrocautery, endoscopic clipping, or banding of varices. Stigmata of high
risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the
bleeding lesion are usually removed in order to determine the underlying pathology, and to
determine the risk for rebleeding. Pharmacotherapy includes the following: Proton pump
inhibitors (PPIs), which reduce gastric acid production and accelerate healing of certain gastric,
duodenal and esophageal sources of hemorrhage. These can be administered orally or
intravenously as an infusion depending on the risk of rebleeding. Octreotide is
a somatostatin analog believed to shunt blood away from the splanchnic circulation. It has
found to be a useful adjunct in management of both variceal and non-variceal upper GI
hemorrhage. It is the somatostatin analog most commonly used in North America.
Terlipressin is a vasopressin analog most commonly used in Europe for variceal upper GI
hemorrhage. Antibiotics are prescribed in upper GI bleeds associated with portal hypertension.

If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy

with antibiotics and a PPI is suggested.
II. OBJECTIVES

 General objectives:

This case study focuses on the advancement of my skills in managing and

administering the extensive range of my intervention to my client with Upper
Gastrointestinal Bleeding (UGIB). This study will further help me to expand my knowledge
about the said disease.

 Specific objectives:

1. To established good rapport to the client and to get the physical assessment.
2. To define what is Upper Gastrointestinal Bleeding (UGIB).
3. To trace the pathophysiology of UGIB.
4. To enumerate the different signs and systems of UGIB.
5. To formulate and apply necessary nursing care plans utilizing the nursing process.
III. DEMOGRAPHIC DATA
Name: Mrs. E.M.C

Age: 47 y/o

Gender: Female Spouse: Armando A. Cacho

Status: Married Chief Complaint: Change in Sensoruim

Nationality: Filipino Date admitted: November 11, 2010

Religion: INC Time admitted: 10:30 am

Blood type: O+

Address: BKL3 LOT 10 PH Dela Costa Homes 3, SJDM, Bulacan

Final Diagnosis: Upper Gastrointestinal Bleeding (UGIB)

 CLINICAL ABSTRACT

This is the case of EMC 47 y/o female from BKL3 LOT 10 PH Dela Costa Homes 3, SJDM, Bulacan. She
was born on September 15, 1963. She is married for 22 years now and has 6 children. Mrs. EMC is a
non smoker and non alcoholic beverages drinker.

Mrs. EMC was admitted to East Avenue Medical Center on November 11, 2010, 10:30 in the morning.
She was admitted due to dizziness, loss of consciousness and change of sensorium.

 HISTORY OF PRESENT ILLNESS

One week prior to admission the patient had experienced dizziness and vomiting of previous ingested
food but still conscious and able to communicate. Three days prior to admission Mrs. EMC had
experienced anorexia and abdominal pain. Few hours prior to admission Mrs. EMC still in the previous
symptoms, and rushed to the ER of EAMC.

November 11, 2010 the physician ordered CBG monitoring, serum glucose control which revealed type
2 DM, start of empiric antibiotic which revealed complicated UTI and had her laboratory examinations
like blood chemistry, hematology test and urinalysis. On the same day she undergone upper
endoscopy with biopsy which revealed gastric ulcer. On the 13 th day of Nov. she had her cross
matching which revealed her blood type which is type ”O” positive. Nov. 21 she had undergone to IJ
catheter insertion for dialysis.

 PAST MEDICAL HISTORY

According to the patient she has a hypertension, DM and BA (last attack 20 vq). She is negative to PTB
and thyroid disease. She had no maintenance on her HPN, for her DM she took Metformin.

 FAMILY MEDICAL HISTORY

(+) Hypertension (-) PTB

(+) DM (-) Thyroid disease

(+) BA

 LIFE STYLE

A. Personal Habit

The patient does not smoke nor drinks alcoholic beverages.

B. Diet

She eats three times a day and drinks 6-8 glass of water per day and sometimes
she also drinks soft drinks. The patient’s usual diet includes rice, meats like pork,
beef, chicken and fish. According to the patient, she seldom eats vegetables. She is
fond of eating sweets and lechon. She also drinks coffee often (4x a day).

C. Recreational Activity

She watch television during her free time after she had finish the household
choirs.

D. Sleep and Rest

She said that she spends 6 hours of sleep every night and she takes naps if she
had free time. She usually sleeps at 11:00 in the evening and wakes up at 5:00 in
the morning she said that it is continuous and she feels refreshed after waking up.

E. Activities of Daily Living

The patient works everyday in their house and sometimes she accepts laundry.
Every weekend she allotted time to rest and to have bonding with her family. She
said she do the household choirs before she starts washing her accepted laundry
from her neighbors.
 PATIENT’S SOCIAL HISTORY

A. Family Relationship and Friends

The patient’s family is nuclear type together with her husband Armando A.
Cacho, her six children. According to her she has a good relationship with each
member of her family and also with her friends. She allotted time to bond with
her family.

B. Occupational History

The patient is self employed.

C. Economic History

According to the patient her husband is a constructor and an OFW before. Her
husband is the one who brings income in their family. According to her
husband work is enough to support their children’s need. Her accepted laundry
from their neighbors helps them in their needs and it is an additional income to
them and it satisfies their needs.

IV. PHYSICAL ASSESSMENT

 Actual Findings Normal Findings Interpretation
 Head
 Skull -Normocephalic -Normocephalic -Normal
-No lumps -Smooth
-No lumps
-Absence of modules or masses
-No area of tenderness
-Symmetrical with protrusions
on the lateral part of parietal
forehead and occipital bone.

 Scalp -No nits, lice and dandruff -Whitish -Normal

-no baldness -No nits, lice and dandruff
-no baldness

 Hair -Black or brown in color -Normal

-Straight, Black with white hair,
oily hair
-Hair is evenly distributed
-No area of baldness
-Thick
-Fine
-Curly/kinky/straight
-Dry/oily/shiny hair

 Face -Symmetrical with movement -Symmetrical with movement -Normal

-Expressions appropriate to -Expressions appropriate to
situations situations

 Eyes -Symmetrical -Symmetrical -Normal

-No cloudiness -No protrusions
-No Lacrimation -Dear or no Cloudiness
-No excessive Lacrimation

 Eyebrows -Symmetrical -Moves symmetrically -Normal

-Hair evenly distributed
-Skin Intact

 Eyelashes -Equally distributed -Equally distributed -Normal

-Curved slightly outward -Curved slightly outward

 Eyelids -Skin intact -Skin intact -Normal

-No discharge -No discharge
-No discoloration -No discoloration
-Lids close symmetrically -Lids close symmetrically
 -approximately 15-20 -approximately 15-20
involuntary blinks per minute; involuntary blinks per minute;
bilateral blinking bilateral blinking

-No secretions -No scaling -Normal

 Lid margins -No erythema -No secretions
-No redness -No erythema
-No redness

-Pink, shiny, with visible blood -Pink, shiny, with visible blood -Normal
 Lower palpebral vessels vessels
conjunctiva -No discharges -No discharges

-White in color -White/yellowish in black -Normal

 Sclera -Clear Americans
- No redness -Clear, No cloudiness
-No redness

-Flat -Flat -Normal

 Iris -Brown -Brown
-Round -Even coloration
-Transparent/Shiny -Symmetrical
-Round
-Transparent/Shiny

-PERRLA -PERRLA(Pupils Equally Round, -Normal

 Pupils Reactive to Light &
Accommodation

 Eye Movement -Moves in unison -Moves in unison -Normal

-coordinated -coordinated

 Field of vision -Good peripheral vision -Normal

*Visual acuity -20/20 in both eyes

 Ear -Same as the color of the face -Parallel with outer canthus of -Normal
-No swelling the eyes
-Shell shape -Same as the color of the face
-No swelling
 -No tenderness
-Shell shape
-Firm cartilage

- Waxy cerumen -Yellowish

 Ear Canal -Presence of cilia -Dry/waxy cerumen -Normal
-Presence of cilia
-No foreign body

-With good hearing acuity in -With good hearing acuity in -Normal

 Hearing acuity both ears both ears

 Nose -No lesions -Symmetric and straight -Normal

-Presence of cilia -No discharge or flaring
-Uniform color
-No tenderness
-No lesions
-Presence of cilia

 Lips -Darker lips -Uniform pink color(darker, -Decrease of

-Ability to purse lips
e.g,Bluish hue, in Mediterranean oxygen supply
groups and dark-skinned clients)
-Soft, moist, smooth texture
-Symmetry of contour
-Ability to purse lips
-No tenderness

 Gums -Pink, moist -Pink, moist -Normal

-No swelling -No swelling
-No tenderness -No tenderness
-No discharges -No discharges
-No retraction(lower and upper)

 Teeth -white -32 in number -Normal

-White
-Upper teeth over-rides lower
teeth

 Tongue
-Pink, even, rough dorsal surface -Pink, even, rough dorsal surface -Normal
and moist and moist
  Frenulum -Midline -Midline -Normal
-pinkish -pinkish
-With visible veins -With visible veins

-Pink, moist, no swelling/No -Pink, moist, no swelling/No -Normal

 Soft Palate tenderness tenderness

-Bony, Light pink in color, moist -Bony, Light pink in color, moist -Normal
 Hard Palate

-Midline moves when the client -Pink, moist

 Uvula says “Aah” -Midline moves when the client -Normal
says “Aah”

 Tonsils -Pinkish -Pinkish -Normal

-No discharge -No discharge
-No inflammation -No inflammation

 Neck -Same as the skin color -Erect & midline -Normal

-No lymphs, No mass
-Same as the skin color
-No tenderness
-No lymphs, No mass
-Symmetrical
-Muscles equal in size; head
centered
-Coordinated, smooth
movements with no discomfort

 Upper Extremities -No abrasions or other lesions
 Skin -When pinched, skin springs
back to previous state
- with edema
-Varies from light to deep -accumulation
brown; from ruddy pink to light of excess fluid
pink; from yellow overtones to
olive
-No edema
-No abrasions or other lesions
-Freckles, some birthmarks,
some flat and raised nevi
-When pinched, skin springs
 back to previous state

-Convex curvature
 Nails -Smooth texture
-Convex curvature -Highly vascular and pink in -Decrease O2
-white light-skinned clients; dark- supply
skinned clients may have brown
or black pigmentation in
longitudinal streaks
-Intact epidermis
-Prompt return of pink or usual
color(generally less than 4
seconds)

 Chest and back -Chest symmetric

 Posterior -Skin Intact; uniform
Thorax temperature -Normal
-No tenderness -Chest wall intact
-No masses -No tenderness
-No masses
-Full and symmetric chest
expansion
-Vesicular and bronchovesicular
sounds

 Anterior Thorax
-Quiet, rhythmic, and effortless
-Full expansion respirations -Difficulty of
-Tachypnea -Full symmetric excursion breathing
-Bronchial and tubular breath
sounds in the trachea
-Vesicular and bronchovesicular
breath sounds
 Abdomen
-Unblemished skin
-Unblemished skin -Uniform color -Normal
-Uniform color -Silver-white striae or surgical
scars
-Flat, rounded(convex),or
scaphoid (concave)
- Symmetric movements caused

 Lower extremities
 Skin
-Brown in color
- with edema
- No abrasions or other lesions
- with edema
 Nails
- Concave curvature
-Brown pigmentation in
longitudinal streaks
 Motor
functions:
- Repeatedly and rhythmically
touches the nose
- Rapidly touches each finger to
thumb with each hand
- Can readily determine the
position of fingers and toes
by respiration
- Audible bowel sounds
- No tenderness
- Relaxed abdomen with
smooth, consistent tension
- Varies from light to deep
brown; from ruddy pink to light - accumulation
pink; from yellow overtones to of excess fluid
olive
- No edema
- No abrasions or other lesions
- Freckles, some birthmarks,
some flat and raised nevi
- when pinched, skin springs
back to previous state
- Concave curvature
- Smooth texture
- highly vascular and pink in -Normal
light-skinned clients; dark-
skinned clients may have brown
or black pigmentation in
longitudinal streaks
- Intact epidermis
- Prompt return of pink or usual
color (generally less than 4
secs.)
- Has upright posture and steady
gait with opposing arm swing;
walks unaided, maintaining -Normal
balance
- May sway slightly but is able to
maintain upright posture and
foot stance.
- Maintain stance for at least 5
secs
- maintains heel-toe walking
along straight line
- Repeatedly and rhythmically
 touches the nose
- Rapidly touches each finger to
thumb with each hand
- Can readily determine the
position of fingers and toes

 GORDONDS
Before During Interpretation Analysis
hospitalization hospitalization

a. activity- According to her During her She was not able Exercise is very
exercise pattern she does the hospitalization to perform the important to our
- hobbies household she is in activities body because it
choirs and at the complete bed because of the promotes good
same time it is rest. disease process. health and helps
her way of us build and
exercising and maintain healthy
she can perform muscles, bones,
different and joints and it
activities. reduces
depression and
anxiety.

Elimination Prior to For the period of The patient’s Good

pattern hospitalization hospitalization elimination elimination
she defecates her defecation pattern changed pattern reduces
every day. She does not vary during the risk of
urinates normal but her urine hospitalization having cancer. It
amount and output because she is helps us to
normal color. decreases. under detoxify waste
urinates medication. in our body to
free ourselves
from
complications
Sleep and rest Before she Throughout her Due to Enough and
pattern sleeps 6 hours hospitalization confinement the good sleep and
every day sleeps 12 hours patient has no rest pattern can
and can take problem with reduce stress,
naps. her sleep. helps us to think
better.

Cognitive- The patient is a Same Due to Good education

perceptual 2nd year college confinement the is important to
pattern undergraduate. patient has no overcome
She is literate. problem with poverty.
understanding

Self –perception Prior to During her Even she is in Good self-

and self-concept hospitalization hospitalization the hospital perception and
pattern she is a happy she is still a herself self-concept
person and positive thinker. perception does pattern helps us
positive thinker. not change. She to overcome
stayed the same problems and
as she was trials.
before.

Role- The patient’s Throughout her Due to her Good

relationship family is nuclear hospitalization hospitalization relationship to
pattern type. They are 8 her family is the family each member of
in the family. with her side at becomes closer the family
They have 6 all times to to one another creates unity
children and she support her. and become and compact
allotted time for stronger. relationship with
her family to each other.
bond. She is Good
sociable to relationship with
everyone. other people can
gain trust,
acceptance,
support, and
someone to Call
On When You
Need a Hand.
Coping-stress Ever time she During her Her coping Having a good
tolerance encounters hospitalization stress is the coping to stress
pattern difficulties she she just prays same as what can overcome
asks guidance every time she’s she is doing stressors and
and help from in pain. before. depressions.
God.

Good health
Health According to her During her Her health perception can
perception health is very hospitalization perception is the maintain health,
important she still believes same as what the body can
because it is that health is she believes function
wealth. wealth. before. properly and it
acts as personal
strength.

Good sexuality-
Sexuality- Before Same Her reproductive reproductive can
reproductive hospitalization system works easily determine
pattern she menstruates properly. the fertilization
regularly. and can prevent
cancers in
reproductive
system.

Strong values-
Values- belief She is an INC. During her Her values- beliefs help us to
pattern They go to hospitalization belief pattern overcome
church every her husband and does not change difficulties and
Thursday and her always prays and her faith to trials.
Sunday. for her health. God become
stronger.

V. ANATOMY AND PHYSIOLOGY

UPPER GI
The upper GI tract consists of the mouth, pharynx, esophagus, and stomach. This is where ingestion
and the first phase of digestion occur.

MOUTH

The mouth includes the tongue, teeth, and buccal mucosa or mucous membranes containing the ends
of the salivary glands, continuous with the soft palate, floor of the mouth and under side of the
tongue. Chewing (mastication) is the mechanical process by which food, constantly repositioned by
muscular action of the tongue and cheeks, is crushed and ground by the teeth through the muscular
action of the lower jaw (mandible) against the fixed resistance of the upper jaw (maxilla).

Saliva excreted in the oral cavity by three pairs of exocrine glands (parotid, submandibular, and
sublingual) is mixed with chewed food to form a bolus, or ball-shaped mass. There are two types of
saliva: a thin watery secretion that wets the food and a thick mucous secretion that lubricates and
causes the food particles to stick together to form the bolus.

Digestive enzymes in saliva begin the chemical breakdown of food, primarily starches at this
point, almost immediately.

PHARYNX
The pharynx is contained in the neck and throat and functions as part of both the digestive
system and the respiratory system. The human pharynx is divided into three sections: the
nasopharynx behind the nasal cavity and above the soft palate;

The oropharynx behind the oral cavity and including the base of the tongue, the tonsils, and the
uvula; the hypopharynx or laryngopharynx includes the junction with the esophagus and the
larynx, where respiratory and digestive pathways diverge. The swallowing reflex is initiated by touch
receptors in the pharynx as the bolus of chewed food is pushed to the back of the mouth.

Swallowing automatically closes down the respiratory or breathing pathway as an anti-choking reflex.
Failure or confusion of reflexes at this point can result in aspiration of solid or liquid food into  the
trachea and lungs.

ESOPHAGUS

The esophagus is the hollow muscular tube through which food passes from the pharynx to the
stomach. It is also lined with mucous membrane continuous with the mucosa of the mouth and into
which open the esophageal glands.

The esophagus is surrounded by relatively deep muscles that move the swallowed bolus of masticated
food through peristaltic action, piercing the thoracic diaphragm to reach the stomach.
STOMACH

The stomach is a hollow muscular organ, located below the diaphragm and above the small intestine
that receives and holds masticated food to begin the next phase of digestion. Two smooth muscle
valves, the esophageal sphincter above and the pyloric sphincter below, keep stomach contents
contained.

The stomach is surrounded by stimulant (parasympathetic) and inhibitor (orthosympathetic) nerve

plexuses which regulate both secretory and muscular activity during digestion. With a volume of as
little as 50 mL when empty, the adult human stomach may comfortably contain about a liter of food
after a meal, or uncomfortably as much as 4 liters of liquid.

DUODENUM
The duodenum precedes the jejunum and ileum and is the shortest part of the small intestine, where most
chemical digestion takes place. The nameduodenum is from the Latin duodenum digitorum, or twelve

fingers' breadths.

In humans, the duodenum is a hollow jointed tube about 10–12 in long connecting the stomach to

the jejunum. It begins with the duodenal bulb and ends at the ligament of Treitz.

The duodenum is largely responsible for the breakdown of food in the small intestine, using

enzymes. Brunner's glands, which secrete mucus, are found in the duodenum. The duodenum wall is

composed of a very thin layer of cells that form the muscularis mucosae. The duodenum is almost entirely

retroperitoneal.

The duodenum also regulates the rate of emptying of the stomach via hormonal

pathways. Secretin and cholecystokinin are released from cells in the duodenal epithelium in response to

acidic and fatty stimuli present there when the pylorus opens and releases gastric chyme into the duodenum

for further digestion. These cause the liver and gall bladder to release bile, and the pancreas to release

bicarbonate and digestive enzymes such as trypsin,lipase and amylase into the duodenum as they are

needed.

VI. PATHOPHYSIOLOGY
Precipitating factors Contributing factors Predisposing factors

old NSAIDs use Stress

Diet: spicy foods and coffee

 Elicit their effects on
cyclooxegenase

Disruption of mucous
barrier

Inflammatory effect on
gastric mucusa Neutrophils – 86%

Ulcers burrows deep

Weakening and necrosis of

arterial

Peripheral vasoconstriction Development of pseudo

anuerysms

Pale nail beds and Weakened wall raptures leading

conjuctivitis

UGIB

-Generalized body weakness BP: 180/90 RR:25 PR:90

-Dizziness

VII. LABORATORY
 URINALYSIS

Definition:
 Is an array of tests performed on urine and one of the most common methods of medical
diagnosis.

Indication:

It is used to detect the presence of UTI, Proteinuria,Glucosuria, Ketonuria, presence of urinary

sediments which indicates renal pathology.

Nursing Responsibility:

 Instruct the patient perform perineal care prior to the procedure

 Collect urine from the first voiding in the morning and examine within 30 mins.
 Label specimen properly
 Instruct patient to keep labia majora separated while urinating
 Instruct the patient to collect specimen by a midstream catch

Parameters Results
Color Light yellow
Transparency Slightly cloudy
Reaction 5.0
Sp gravity 1,020
Albumin +2
Glucose (-)
RBC count 1-2
WBC count 25-30
Epithelial cells Few
Mucus threads 0 cc’l
Bacteria Moderate
Amorphous
Urates
Casts none
Analysis and interpretation

Laboratory results revealed that there is presence of Albumin in the blood, this indicates that
the glomerular cannot filter large molecules such as that of Albumin. It also revealed that
there is infection as evidence by presence of bacteria and red cells in the urine.

Hematology

Definition

Is the branch of internal medicine, physiology, pathology, clinical laboratory work,

and pediatrics that is concerned with the study of blood, the blood-forming organs, and blood
diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis,
and prevention of blood diseases. The laboratory work that goes into the study of blood is
frequently performed by a medical technologist. Hematologists physicians also very frequently do
further study in oncology - the medical treatment of cancer.

Indication

This test determines the concentration of hemoglobin in whole blood.

Nursing responsibility:

 Explain the procedure to the patient

 Collect blood sample by extraction from the vein in arm using needle or finger prick
 Label the specimen properly.

Parameters Normal Values Results

Hemoglobin M- 130- 180 g/l 60
F – 120-160 g/l
Hematocrit M- 0.42-0.52 0.181
F- 0.37- 0.48
WBC count 4.3-10.8x 10/l
Segments 0.45-.0.74 0.83
Lymphocytes 0.16-0.45 0.15
Eosinophils 0-0.07
Monocyte 0.04-0.10 0.02
Basophils 0-0.02
Bands 0.02-0.04
Platelets 130-400x 10 /l 239
ESR M- 0.15 mm/hr
F- 0.20 mm/hr
RDW= 14.7 Normal MCV= 85.2 Normal MCH-= 28.3 Normal

MCHC= 332 Normal

Interpretation:

This test showed that the hemoglobin is less than the normal value therefore it indicates a
decrease of oxygen in the blood.

Blood chemistry

Definition

A blood test is a laboratory analysis performed on a blood sample that is usually extracted from

a vein in the arm using a needle, or via finger prick.
Indication

Blood tests are used to determine physiological and biochemical states, such

as disease, mineral content, drug effectiveness, and organ function. They are also used in drug
tests. Although the term blood test is used, most routine tests (except for most haematology ) are
done on plasma or serum, instead of blood cells.

Nursing responsibility

 Explain the procedure to the patient

 Collect blood sample by extraction from the vein in arm using needle or finger prick.

 Label specimen properly

Parameters Normal values Results

Glucose 3.9-8 + mmol/l
Uric acid .16-.43
Urea nitrogen 2.5-6.1 1.2
Creatinine 53-115 umol 61
Cholesterol 0-5.2 mmol/l
Triglycerides .23-1.71 mmol/l
HDL .91 mmol/l
Total bilirubin 0.17-1 umol/l
Direct bilirubin .5 umol/l
Indirect bilirubin 0-12.1umol/l
Total protein 61-82 g/l
Albumin 34-50 g/l
Globulin 25-35 g/l
A/G ratio 1.5-2.5
SGOT 15-37 u/l
SGPT 30-65 u/l
Alkyl phosphate 50-136 u/l
Na 140-148 mmol/l 126
K 3.6-5.2 mmol/l 3.9
CHON Value control secs
APPT Value control secs
24 hr urine ECC M- .78-1.155 ml/sec
F- 1.03-1.81 ml/sec
24 hr urine CHON 28-41 mg/24hr
Glycosylated Hgb Up to 66%
Total Hgb

B/C 4.87

ECC 111

Interpretation

Sodium and potassium are normal which means there is still fluid and electrolyte balance.

IX. Discharge plan

Clients with Upper Gastrointestinal Bleeding are instructed to take the following
plan for discharge.
M- Medications should be taken regularly as prescribed, on exact dosage, time,
& frequency, making sure that the purpose of medications is fully disclosed by
the health care provider.
 Losartan 50 mg/tab 1tab OD
 Hydrocortisol 50 mg/tab 1tab
 FeSo4 + folic acid 1tab TID
 CaCo3 1tab
 NaHCo3 1tab TID
 Kalium durule 1tab x 2 days
 Nefidipine 30 mg/tab BID

E- Exercise should be promoted in a way by stretching hand and feet every

morning. Encourage the patient to keep active to adhere to exercise program and
to remain as self –sufficient as possible
- bed rest

T- Treatment after discharge is expected for patients and watcher with UGIB to
fully participate in continuous treatment.

H- Health teachings regarding the importance of proper hygiene and hand

washing, intake of adequate water and vitamins especially vitamin C-rich foods to
strengthen the immune response and increasing of oral fluid intake should be
conveyed. Avoid spicy foods, carbonated beverages and coffee.

O- OPD such as regular follow-up check-ups should be greatly encouraged to

clients with UGIB as ordered by physician to ensure the continuing management
and treatment.

D- Diet which is prescribed should be followed.

S- Pray for faster healing and don’t losses hope.
Endoscopy: Risk assessment in upper gastrointestinal bleeding
Ernst J. Kuipers  About the author

Abstract

Endoscopy is the mainstay for diagnosis and therapy of upper gastrointestinal bleeding. Early
risk assessment is crucial for effective timing of endoscopy and determination of the need for
other measures to be taken—scoring systems should be used for this purpose. A new prospective
study suggests that the Blatchford score can identify patients who do not need endoscopic
intervention.

Acute upper gastrointestinal bleeding (UGIB) is the gastrointestinal tract condition most likely to result in a medical
emergency. The estimated incidence of acute UGIB is 50–150 per 100,000 population per year: 40–60% of these bleeds are
caused by a peptic ulcer, 10% are related to varices, 10% are attributable to erosive esophagitis and the remainder are
caused by a variety of conditions. Endoscopic treatment is the main therapy for patients with UGIB. However, risk
assessment is necessary to determine whether endoscopic treatment is required; a study by Pang et al. has now assessed the
predictive value of two risk assessment scoring systems.

Endoscopic treatment, either with clips or thermocoagulation with or without epinephrine injection,  can stop the initial
bleed and reduce the risk of rebleeding considerably. This treatment improves outcome, as it can shorten the hospital stay,
decrease the need for a blood transfusion, further endoscopic or surgical intervention, and reduce mortality. After adequate
endoscopic therapy, the outcome for high-risk patients (such as those with a visible vessel) can be further improved by
profound acid suppressive therapy by means of a PPI given intravenously.

Early risk assessment is crucial in patients presenting with UGIB to ensure optimal timing of endoscopy, and to determine
whether other measures (such as hospital admission, blood transfusion and treatment in an intensive care unit) are
required. Several risk assessment scales have been developed over the past 15 years that are based on retrospective
analyses of cohorts of patients presenting with UGIB. Prospective cohort studies are required to assess the validity and
usefulness of these scoring systems. For that purpose, Pang and colleagues compared two frequently used risk assessment
scales—the Blatchford and pre-endoscopic Rockall scoring systems—for their ability to predict the need for endoscopic
therapy.3

Early risk assessment is crucial in patients presenting with UGIB...

Both the Blatchford and pre-endoscopic Rockall scoring systems are based on parameters that can be assessed during first
presentation. The pre-endoscopy Rockall scoring system is based on the patient's age, comorbidities, and signs of shock on
presentation. By contrast, the Blatchford scale does not consider age, but does assess urea and hemoglobin levels. The
Blatchford scale is also more focused on symptoms than the Rockall scoring system.
Pang and colleagues assessed the two scoring systems prospectively in 1,087 patients presenting with UGIB. Endoscopic
therapy was given to 297 (27.3%) of the patients. The decision to apply endoscopic treatment was made by the individual
endoscopist, who was guided by an in-hospital protocol that required such treatment for all actively bleeding lesions, as well
as for visible vessels and adherent clots.
Patients requiring endoscopic treatment were divided fairly equally over all the Rockall score categories. The pre-endoscopic
Rockall score was thus unable to predict the need for endoscopic treatment. By contrast, the Blatchford score was able to
make this prediction, as none of the patients with a score of 0 needed endoscopic intervention. The investigators conclude
that the Blatchford score, but not the pre-endoscopic Rockall score, is a useful predictor of the need for endoscopic
intervention. The Blatchford score can, therefore, be used to immediately discharge the subgroup of patients that present
with UGIB who are at low risk and so can return to the hospital at a later date for outpatient endoscopic treatment. 3

The results of this study provide valuable confirmation of the usefulness of the Blatchford score for the identification of low-
risk patients, enabling the targeted use of resources. Pang et al.'s findings support the recommendation of the latest
international guidelines that strongly advise the use of pre-endoscopic risk assessment scores in patients with nonvariceal
UGIB. Several other reports also confirmed that patients with a Blatchford score of 0 rarely require endoscopic intervention.

The clinical impact of these important observations is, however, limited by two closely related factors. First, a minority of
cases have a Blatchford score of 0. In Pang et al.'s study, 4.6% (n = 50) of patients were given this score.3 In other studies the
proportion of patients given a Blatchford score of 0 varied between 1% and 15%.Second, the positive predictive value of a
Blatchford score >1 for the need for intervention is low. For these reasons, the next question that needs to be addressed is
whether the clinical impact of the Blatchford score can be augmented. In contrast to the pre-endoscopic Rockall score, the
probability of the need for intervention increases with increasing Blatchford scores.

In a UK study to validate the Blatchford scoring system, approximately 20% of the participants had a score of 1 or 2, and 5%
of these patients required intervention. 5Similarly, Pang and colleagues found that one-fifth of patients had a score of 1 or 2,
but 16% required endoscopic treatment. 3 This difference in the need for endoscopic treatment is remarkable because Pang
and colleagues' study only used endoscopic intervention as the outcome parameter, whereas the UK study also included
other interventions, such as blood transfusion, in their outcome parameter. None of the available studies provided more
detailed information regarding the endoscopic appearance of the bleeding lesion and the type of intervention provided. Such
information is needed from future studies to enable the selection of a more sizable proportion of patients with UGIB for
endoscopy on an outpatient basis. This strategy would better reflect the fact that only a minority of patients with UGIB
require endoscopic treatment.3,5

Together, these data support the use of prognostic scores for rapid assessment of patients with UGIB, as recommended by
international guidelines. Unfortunately, this strong recommendation is not routinely followed. In a nationwide survey of
6,750 patients with UGIB in more than 200 UK hospitals, pre-endoscopic risk assessment did not influence timing of
endoscopy in hospitalized patients and 42% of high-risk patients did not undergo endoscopy within 24 h, as recommended
by the international guidelines. 9The results of this audit probably reflect the situation in many other countries around the
world. These results also show that studies, such as the one by Pang et al., are urgently required to assess the performance
of prognostic scales and stress the need for their use in the treatment of patients with UGIB—a condition associated with
serious comorbidity and mortality.

In conclusion, international guidelines strongly recommend the use of pre-endoscopic risk assessment scores to stratify
patients as either low-risk or high-risk, and thus determine the use of resources and timing of endoscopy. Pang and
 colleagues' findings suggest that the Blatchford score is more useful for this purpose than the pre-endoscopic Rockall score.
A low Blatchford score is adequate for the selection of patients who are unlikely to require endoscopic intervention. In some
series, these patients are identified by a score of 0, in others by a score of <2. Further studies are now required to improve
the predictive value of the Blatchford scoring system.

Competing interests statement

The author declares no competing interests.

References

1. van Leerdam, M. E. et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and
outcome of acute upper GI bleeding between 1993/1994 and 2000. Am. J. Gastroenterol. 98, 1494–1499 (2003)
2. Article
3. PubMed
4. ChemPort
5. Barkun, A. N. et al. International consensus recommendations on the management of patients with nonvariceal
upper gastrointestinal bleeding. Ann. Intern. Med. 152, 101–113 (2010).
6. Pub Med
7. Pang, S. H. et al. Comparing the Blatchford and pre-endoscopic Rockall sc ore

SUMMARY

Originates in the GI tract from the mouth to the ligament of Treitz where the duodenum, the first part of the small
intestine, ends. Bleeding from the esophagus may occur from esophageal varices, dilation of the veins in the esophagus. One of
the symptoms of upper GI bleeding is vomiting of blood (hematemesis).If the blood travels
through the GI tract, the stool may appear tarry and black (melena) because of digested blood, though the stool can still be
stained with red blood (hematochezia). About 75% of patients presenting to the emergency room with GI bleeding have an
upper source. The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of
patients in the emergency room with GI bleeding have an upper source. Determining whether a patient truly has an upper GI
bleed versus lower gastrointestinal bleeding is difficult. Mortality is about 11% in patients admitted with an UGIB.2 It is as high
as 33% in patients who develop bleeding whilst in hospital. A score of less than 3 using the Rockall system above is associated
with an excellent prognosis, whereas a score of 8 or above is associated with high mortality.3 Most deaths occur in elderly
patients with co-morbidity. Mortality is reported to be lower in specialist units possibly because of adherence to protocols
rather than because of technical advances.2 The prognosis in liver disease relates significantly to the severity of the liver
disease rather than to the magnitude of the haemorrhage

Upper gastrointestinal bleeding is commonly caused by bleeding varices (varicose veins) in the esophagus, peptic ulcers or a
Mallory- Weiss tear at the esophageal gastric junction from severe retching .Otherwise, bleeding over time results in
anemia, characterized by lower than normal blood hemoglobin and hematocrit with symptoms like weakness,  fatigue, and
fainting.

The most important step to evaluate upper GI bleeding is upper endoscopy. During this procedure, performed by a

gastroenterologist, a tube with a camera (endoscope) is passed into the mouth and down the esophagus. The

gastroenterologist can proceed to the stomach and duodenum and localize the source of the bleeding, if possible. Other

examination to determine UGIB are Vital signs, in order to determine the severity of bleeding and the timing of intervention.
Abdominal and rectal examination, in order to determine possible causes of hemorrhage. Assessment for portal

hypertension and stigmata of chronic liver disease in order to determine if the bleeding is from a variceal source.

Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio.

Emergency treatment for upper GI bleeds includes aggressive replacement of volume with  intravenous solutions,

and blood products if required. As patients with esophageal varices typically have coagulopathy, plasma products may have to

be administered. Vital signs are continuously monitored.Early endoscopy is recommended, both as a diagnostic and therapeutic

approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the type of lesion

identified, and can include:injection of adrenaline or other sclerotherapy, electrocautery, endoscopic clipping, or banding

of varices. Stigmata of high risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the

bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding.

Pharmacotherapy includes the following: Proton pump inhibitors (PPIs), which reduce gastric acid production and accelerate

healing of certain gastric, duodenal and esophageal sources of hemorrhage. These can be administered orally or intravenously

as an infusion depending on the risk of rebleeding. Octreotide is a somatostatin analog believed to shunt blood away from the

splanchnic circulation. It has found to be a useful adjunct in management of both variceal and non-variceal upper GI

hemorrhage. It is the somatostatin analog most commonly used in North America. Terlipressin is a vasopressin analog most

commonly used in Europe for variceal upper GI hemorrhage. Antibiotics are prescribed in upper GI bleeds associated

with portal hypertension.

If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is

suggested.

Reaction:

Nowadays there are many technologies discovered to treat diseases like the Upper Gastrointestinal Bleeding. Before UGIB is

difficult to treat because of lack of equipments and high technology equipments and because of that the mortality of UGIB is

very high. Until they discovered endoscopy ( means looking inside and typically refers to looking inside the body for medical reasons using

an endoscope an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices,

endoscopes are inserted directly into the organ ) to treat UGIB. It is easier now to treat UGIB with the new way while maintaining the

medications prescribed, but still there is disadvantage with endoscopy like risk for infection due to sepsis. The mortality of

UGIB now is low unlike before.

 University of Perpetual Help College of Manila
214 V Concepcion Street Sampaloc Manila

Case Study of
Upper Gastrointestinal Bleeding

Submitted to: Submitted by: Racca, Freegie B.

Ms. Ma. Evelyn Lumio