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: Lanie S. Bawanta

Age: 35 y/o

Gender: Female

Status: Single Chief Complaint: Change in Sensoruim

Nationality: Filipino Date admitted: January 3, 2011

Religion: Catholic Christian Time admitted: 12:15am

Blood type:

Address:

Final Diagnosis: Upper Gastrointestinal Bleeding (UGIB)

 CLINICAL ABSTRACT

This is the case Lanie S. Bawanta 35 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 13th 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 is evenly distributed
hair -No area of baldness
-Thick
-Fine
-Curly/kinky/straight
-Dry/oily/shiny hair
• Face -Symmetrical with movement -Symmetrical with movement -Normal
-Expressions appropriate to situations -Expressions appropriate to situations

-Symmetrical -Symmetrical
• Eyes -No cloudiness -No protrusions -Normal
-No Lacrimation -Dear or no Cloudiness
-No excessive Lacrimation

-Symmetrical -Moves symmetrically

• Eyebrows -Hair evenly distributed -Normal
-Skin Intact

-Equally distributed -Equally distributed

• Eyelashes -Curved slightly outward -Curved slightly outward -Normal

-Skin intact -Skin intact

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

-No secretions -No scaling

-No erythema -No secretions
-No redness -No erythema -Normal
• Lid margins
-No redness

-Pink, shiny, with visible blood vessels -Pink, shiny, with visible blood vessels
-No discharges -No discharges
-Normal
• Lower palpebral
conjunctiva -White in color -White/yellowish in black Americans
-Clear -Clear, No cloudiness
- No redness -No redness
-Normal
• Sclera -Flat
-Flat -Brown
-Brown -Even coloration
-Round -Symmetrical
-Transparent/Shiny -Round -Normal
• Iris -Transparent/Shiny

-PERRLA(Pupils Equally Round,

-PERRLA Reactive to Light & Accommodation

-Normal
• Pupils -Moves in unison
-coordinated
-Moves in unison
-coordinated
-Good peripheral vision
• Eye Movement -20/20 in both eyes -Normal
 -Parallel with outer canthus of the eyes
• Field of vision -Same as the color of the face -Normal
*Visual acuity -Same as the color of the face -No swelling
-No swelling -No tenderness
-Shell shape -Shell shape
• Ear -Firm cartilage -Normal

-Yellowish
-Dry/waxy cerumen
-Presence of cilia
- Waxy cerumen -No foreign body
-Presence of cilia

• Ear Canal -With good hearing acuity in both ears

-Normal

-With good hearing acuity in both ears -Symmetric and straight

-No discharge or flaring
-Uniform color
• Hearing acuity -No lesions -No tenderness -Normal
-Presence of cilia -No lesions
-Presence of cilia
• Nose
-Uniform pink color(darker, e.g,Bluish -Normal
hue, in Mediterranean groups and dark-
skinned clients)
-Darker lips -Soft, moist, smooth texture
-Ability to purse lips -Symmetry of contour
-Ability to purse lips
-No tenderness
• Lips
-Decrease of
-Pink, moist oxygen supply
-No swelling
-No tenderness
-Pink, moist -No discharges
-No swelling -No retraction(lower and upper)
-No tenderness
-No discharges -32 in number
• Gums -White -Normal
-Upper teeth over-rides lower teeth
-white

-Pink, even, rough dorsal surface and

moist
• Teeth -Normal

-Pink, even, rough dorsal surface and -Midline

moist -pinkish
-With visible veins
• Tongue
-Midline -Pink, moist, no swelling/No tenderness -Normal
-pinkish
-With visible veins
• Frenulum -Bony, Light pink in color, moist
-Pink, moist, no swelling/No tenderness -Normal
 -Pink, moist
-Bony, Light pink in color, moist -Midline moves when the client says
• Soft Palate “Aah” -Normal

-Midline moves when the client says

“Aah”
• Hard Palate -Pinkish -Normal
-No discharge
-No inflammation
• Uvula
-Pinkish -Normal
-No discharge -Erect & midline
-No inflammation -Same as the skin color
-No tenderness
• Tonsils -No lymphs, No mass
-Same as the skin color -Symmetrical -Normal
-No lymphs, No mass -Muscles equal in size; head centered
-Coordinated, smooth movements with
no discomfort
 Neck
-Normal

-Varies from light to deep brown; from

ruddy pink to light pink; from yellow
overtones to olive
-No edema
-No abrasions or other lesions
-No abrasions or other lesions -Freckles, some birthmarks, some flat
-When pinched, skin springs back to and raised nevi
previous state -When pinched, skin springs back to
- with edema previous state
 Upper Extremities
-Convex curvature -accumulation of
•Skin -Smooth texture excess fluid
-Highly vascular and pink in light-
skinned clients; dark-skinned clients
may have brown or black pigmentation
in longitudinal streaks
-Intact epidermis
-Prompt return of pink or usual
-Convex curvature color(generally less than 4 seconds)
-white

-Chest symmetric
•Nails -Skin Intact; uniform temperature
-Chest wall intact -Decrease O2
-No tenderness supply
-No masses
-Full and symmetric chest expansion
-Vesicular and bronchovesicular
sounds

-No tenderness
 -No masses -Quiet, rhythmic, and effortless
 Chest and back respirations
• Posterior Thorax -Full symmetric excursion
-Bronchial and tubular breath sounds in -Normal
the trachea
-Vesicular and bronchovesicular breath
sounds

-Unblemished skin
-Uniform color
-Silver-white striae or surgical scars
-Full expansion -Flat, rounded(convex),or scaphoid
-Tachypnea (concave)
• Anterior Thorax - Symmetric movements caused by
respiration
- Audible bowel sounds
- No tenderness -Difficulty of
- Relaxed abdomen with smooth, breathing
consistent tension
-Unblemished skin
-Uniform color
 Abdomen
- Varies from light to deep brown; from
ruddy pink to light pink; from yellow -Normal
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

- Concave curvature
- Smooth texture
 Lower extremities -Brown in color - highly vascular and pink in light-
- with edema skinned clients; dark-skinned clients
- No abrasions or other lesions may have brown or black pigmentation
• Skin
- with edema in longitudinal streaks
- Intact epidermis
- Prompt return of pink or usual color - accumulation of
(generally less than 4 secs.) excess fluid

- Has upright posture and steady gait

with opposing arm swing; walks
unaided, maintaining balance
- Concave curvature - May sway slightly but is able to
-Brown pigmentation in longitudinal maintain upright posture and foot
streaks stance.
• Nails - Maintain stance for at least 5 secs
- maintains heel-toe walking along
straight line
- Repeatedly and rhythmically touches -Normal
the nose
- Rapidly touches each finger to thumb
with each hand
 - Can readily determine the position of
fingers and toes
- Repeatedly and rhythmically touches
the nose
- Rapidly touches each finger to thumb
 Motor functions: with each hand
- Can readily determine the position of
fingers and toes
-Normal

 GORDONDS

Before During Interpretation Analysis

hospitalization hospitalization

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

Prior to
hospitalization she For the period of The patient’s Good elimination
Elimination pattern defecates every hospitalization her elimination pattern pattern reduces the
day. She urinates defecation does not changed during risk of having
normal vary but her urine hospitalization cancer. It helps us
amount and output decreases. because she is to detoxify waste in
normal color. under medication. our body to free
urinates ourselves from
complications

Enough and good

Throughout her Due to confinement sleep and rest
Before she sleeps 6 hospitalization the patient has no pattern can reduce
Sleep and rest hours every day sleeps 12 hours and problem with her stress, helps us to
pattern can take naps. sleep. think better.

Good education is
Same Due to confinement important to
The patient is a 2nd the patient has no overcome poverty.
year college problem with
Cognitive- undergraduate. She understanding
perceptual pattern is literate.
Good self-
Even she is in the perception and self-
During her hospital herself concept pattern
Prior to hospitalization she perception does not helps us to
Self –perception hospitalization she is still a positive change. She stayed overcome problems
and self-concept is a happy person thinker. the same as she was and trials.
pattern and positive before.
thinker.

Due to her Good relationship

hospitalization the to each member of
family becomes the family creates
Throughout her closer to one unity and compact
The patient’s hospitalization her another and relationship with
Role-relationship family is nuclear family is with her become stronger. each other. Good
pattern type. They are 8 in side at all times to relationship with
the family. They support her. other people can
have 6 children and gain trust,
she allotted time acceptance,
for her family to support, and
bond. She is someone to Call On
sociable to When You Need a
everyone. Hand.

Having a good
coping to stress can
Her coping stress is overcome stressors
the same as what and depressions.
she is doing before.
During her
Ever time she hospitalization she
Coping-stress encounters just prays every Good health
tolerance pattern difficulties she asks time she’s in pain. perception can
guidance and help Her health maintain health,
from God. perception is the the body can
same as what she function properly
believes before. and it acts as
During her personal strength.
According to her hospitalization she
Health perception health is very still believes that
important because health is wealth.
it is wealth. Good sexuality-
reproductive can
Her reproductive easily determine
system works the fertilization and
properly. can prevent cancers
in reproductive
Same system.
Before
Sexuality- hospitalization she
reproductive menstruates
pattern regularly.
Strong values-
 beliefs help us to
overcome
Her values- belief difficulties and
pattern does not trials.
change and her
faith to God
During her become stronger.
She is an INC. hospitalization her
Values- belief They go to church husband and her
pattern every Thursday always prays for
and Sunday. her health.
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 Stress

use
Diet: spicy foods and
 Elicit their effects
on
cyclooxegenase

Disruption of
mucous barrier

Inflammatory
effect on gastric Neutrophils –
mucusa 86%

Ulcers burrows
deep

Weakening and
necrosis of arterial

Peripheral Development of pseudo

vasoconstriction anuerysms

Pale nail beds Weakened wall raptures

and 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 score

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