The Pathophysiology of GI Bleeding: Case Study Assessment 1 Answer

INTRODUCTION

Gastrointestinal bleeding is common issues encountered in the intensive care or emergency department of primary health care settings. Acute GI bleeding is clinically presented in the form of hematemesis, melena or haematochezia. In the individual case of acute GI bleeding accurate clinical diagnosis is crucial to form an appropriate care plan and interventions. There are certain risk factors which predispose an individual toward the development of ulcer formation and eventually occurrence of gastrointestinal bleeding. In this paper, the pathophysiology of Gi bleeding is discussed under the case scenario connecting the probable risk factors. The essay also describes the holistic assessment in a case considering the vital signs and factors which might affect the health outcomes.  The essay also emphasis on the responsibility and accountability of the registered nurse while administering the medication to the patient.  The essay assesses the probable risk behaviour of the patient appeared in the case scenario and how it affects her current health status. The essay also defines the health promotion which can be provided to the patient given the risk behaviour pattern in the case under the registered nurse standard of practice.

PATHOPHYSIOLOGY RELATED TO CASE SCENARIO

Acute upper GI bleeding usually originates from oesophagus, stomach and duodenum.  The pathological process of GI bleeding includes disruption of the mucosal barrier and the direct inflammatory effect on the GI mucosa. The disruption reaction may appear secondary to various causes including H. pylori infection, stress, NSAID, aspirin and Mallory-Weiss tears. The bleeding source is categorized pathologically into ulcerative, vascular, traumatic, iatrogenic and secondary to portal hypertension.  The commonest cause of GI bleeding is ulcerative which is peptic ulcer disease as the result of drug intake like aspirin and SSRI (Kim et al., 2014). As Ms O’Sullivan is taking anti-depressant and anticoagulant drug-induced upper gastrointestinal bleeding may occur. Prolonged use of the drug when combined with alcohol acts as the irritant causing the mucosal ulcers.  Ulcers are known to be caused by inhibition of cyclooxygenase which decreases the mucosal prostaglandin synthesis resulting in impaired mucosal defence mechanism. The ulcer then burrows down into the mucosal layer causing weakening and necrosis of the arterial wall leading to the development of pseudoaneurysm, when ruptures may cause haemorrhage. 

The antidepressant drug like citalopram is a selective serotonin reuptake inhibitor which inhibits the reuptake of serotonin into platelets, enhancing the risk of bleeding. The medication is known to have an additive effect if taken along with other drugs like anticoagulants which concomitantly known to cause bleeding. Aspirin is a commonly used anticoagulant for prevention and treatment of stroke, pulmonary embolism, deep venous thrombosis and thromboembolism. Aspirin has direct damaging effects on the gastrointestinal mucosa and also reduce the effectiveness of the clotting mechanism (Quinn et al., 2018). Upper endoscopy examination is advised for investigating the oesophagus, stomach and duodenum. it is mostly advised due to its therapeutic as well as diagnostic benefits. In Ms O’Sullivan case endoscopy is advised for the hemostatic bleeding control. It is advised in the first 24 hours of acute bleeding (Gralnek et al.,2015). The therapeutic role of endoscopy include management of the GIB through injection, contact thermal devices and mechanical devices. Endoscopy is used to provide the hemostasis with effective success in limiting the episodes of rebleeding resulting in a better prognosis. In diagnostic role endoscopy act as a screening tool for distinguishing location, nature of the lesion and further course of treatment including the requirement of hospitalization (Jung & Moon, 2019).

A holistic multidisciplinary approach is required in treating Ms O’Sullivan. This includes intensivist, surgeon, radiologist, cardiologist and primary health care provider in key essential roles depending on the severity, complications, clinical course and comorbidities.

HOLISTIC APPROACH TO ASSESSMENT

The approach to treat her should be holistic with vigilance to potential deterioration of concomitants which can affect the overall health beyond bleeding episodes. The optimal management of acute upper gastrointestinal bleeding requires a timely observation and overview of vital sign and clinical condition (Strate & Gralnek, 2016). Signs and symptoms including abdominal pain, light-headedness, dizziness, syncope, hematemesis, and melena should be closely observed. Physical examination of hemodynamic stability, abdominal pain, rebound tenderness and stool colour conclude the overall assessment. Laboratory tests evaluating complete blood count, liver profile, metabolic panel, coagulation panel, and the type and crossmatch should be done (Wilkins, Wheeler & Carpenter, 2020). As Ms O’Sullivan is having some critical changes in her vital sign she needs the earliest stabilization and resuscitation. Her blood pressure is low with a higher respiratory rate indicating clinical manifestation of haemorrhagic shock. Haemorrhagic shock increases the mortality rate to 30 percent with poor therapeutic outcomes. A thorough care plan must be prepared to provide adequate fluids and blood transfusion if needed.  The hypovolemic shock may appear in cases of upper GI bleeding hence haemoglobin concentration should be assessed and maintained to at least 7-8 g/dL (Gaiani et al., 2018). Early haemodynamic interventions and intensive resuscitation in her case will decrease the chances of mortality. However, aggressive resuscitation with blood products and crystalloid can increase the risk of rebleeding and have poor outcomes. All possible signs of hypovolemia must be checked including Tachycardia, Tachypnoea, pallor, low body temperature and augmented capillary refill time. Also check for signs of central hypoperfusion including lethargy, coma, oliguria. As soon as she is a stable most adequate diagnostic and therapeutic approach based on the differential diagnosis and suspected aetiology should be followed (Kamboj, Hoversten & Leggett, 2019). 

A complete blood count with platelet count should be done to assess the level of loss of blood. The complete blood count should be checked within a frequency of four hours depending on the severity of bleeding.  A platelet count below 50 X 109 cells/L requires platelet transfusion (Barkun et al., 2019). Coagulation profile assessment like prothrombin time, international normalized ratio and activated thromboplastin time should be done to document coagulopathy. This could appear secondary to thrombocytopenia. Prolonged PT in decreased fibrinogen level indicates liver impairment. Antithrombotic agents like aspirin are reconsidered due to the risk of thromboembolic events and rebleeding and should be discontinued (Aoki et al., 2019). Upper gastrointestinal bleeding can elevate the blood urea nitrogen BUN signalling possible renal comorbidity. Assessing the calcium level helps monitor the hypercalcemia in case of multiple transfusion of citrated blood. Assessment of gastrin level should be identified to evaluate gastrinoma as well as multiple ulcers. Gastrin levels could be probably high in Ms O’Sullivan as she was taking proton pump inhibitors. Ms O’Sullivan case management should include a holistic approach focusing on diagnosing the cause and foci of bleeding with monitoring for haemorrhage and volume resuscitation to avoid end-organ injury, hypotension, hypovolemia and myocardial infraction.

NURSING MEDICATION ADMINISTRATION: RESPONSIBILITY AND ACCOUNTABILITY

All aspects of medication administration including responsibility and accountability are governed by the standard of practice, code of ethics, medication management practice guidelines and competency profile where competencies specific to administration of medication are outlined. While caring for Ms O’Sullivan a registered nurse is required to abide with nursing practice guidelines to be professionally accountable and responsible (Kerr et al., 2012). The nurse must show competency to prepare, initiate, administer, monitor, evaluate, titrate and discontinue medication if required to ensure the safety of the client. A nurse is responsible to understand the pharmacodynamics and pharmacokinetics of the drug for management, assessment and safe preparation; accountable to monitor and teach client; documenting the response of the client to medication and communicating it further. A practice nurse in the gastro-intestinal bleeding requiring endoscopic setting is often required to administer I.V medication to sedate the patient, hence it becomes the responsibility of the nurse that although the same standard dose might be required a specific order for each patient should be taken. While administering medicine nurse should exercise critical judgment and evidence-based practice in carrying out the medically prescribed regime.  For example, the nurse would question the patient regarding allergies before administering medication as ordered by the physician. Being responsible and accountable nurse should protect the rights of the individual such as privacy, beliefs, confidentiality and values. 

The nurse should exemplify the attributes of the patient care like anxiety, stress and fear associated with the condition itself and its interventional treatment. As a part of the healthcare, the team nurse should collaborate with other members of the team in all steps of the nursing care through proper communication channels. Likewise, the patient should be informed about the upcoming medication or procedure (Endacott et al., 2018). Similarly, communication with the physician regarding the requirement of condition change, care plan revisions and health care worker for infection control post medication administration is included. The nurse should also understand the need and objective specific for an individual patient care plan for better goal settings. Also, it is the key responsibility of the nurse to observe for any adverse outcome, evaluate the development and have adequate incidence reporting response. Registered nurse dealing with the administration of care and managing the GI bleeding have the responsibility to foster a professional practice environment respecting legal and ethical policies and well-being of the patient. This might include demonstrating caring, respect and commitment along with appropriate psychological support (Jones & Treiber, 2018).

HEALTH EDUCATION AND RISK BEHAVIOUR

Two major risk health behaviour in the daily lifestyle of Ms O’ Sullivan is the intake of aspirin and alcohol which has predisposed her to the upper GI bleeding and continuation may cause a rebleeding episode. Aspirin is known to increase the risk of GI bleeding to sixty per cent (García Rodríguez et al.,2016). Aspirin has also emerged as one of the most prominent cause of peptic ulcers with two to four-fold increase in GI bleeding (Cryer & Mahaffey, 2014). Alcohol is also strongly associated with the bleeding episodes of peptic ulcers, alcohol consumption is known to cause a four-fold increase in the bleeding ulcer in the individual drinking more than 42 drinks/week (Strate et al., 2016). 

The knowledge regarding the importance of health-promoting activities including stress management, physical activity, sleep, hygiene, healthy eating and addressing risk behaviour is crucial for nurses in managing the condition. It is also important in addressing self-care and self-management. In the forefront, nurses are responsible for engaging in healthy lifestyle behaviours (Ross et al., 2017).  Understanding the risk behaviour preventable and correctable allow nurses to develop care plans focusing on educating the client for better optimal goal achievement. A registered nurse should closely assess the lifestyle practices of the client to impact better health practices. As per the standard six of professional codes and guidelines in registered nurse standard of practice aiming to promote health, a registered nurse provides skill and timely care for promoting the involvement and independence of the client in care decision making ("Nursing and Midwifery Board of Australia - Enrolled nurse standards for practice", 2017). This includes providing education to promote the active engagement of Ms O’ Sullivan within the health care setting by involving her as an active participant. This involves assisting Ms O’ Sullivan in the identification of high-risk behaviour in her style which includes taking aspirin without prescription, alcohol consumption. As a nurse, the role in health promotion is extended to provide information for the prevention and treatment of high-risk behaviour as a part of health education. The nurse must motivate her to adopt no alcohol, smaller frequent meals with aspirin cessation lifestyle. She can be associated and linked with group or agencies working for individuals with alcohol dependency.

CONCLUSION

GI bleeding is a life-threatening condition which requires a holistic approach of treatment and intervention for the best health outcomes for the patient. The clinical case of Ms O’ Sullivan indicated toward certain risk behaviour in her lifestyle which has predisposed toward the formation of bleeding ulcers. Intake of alcohol and aspirin with the antidepressant drug are closely observed as the major cause of GI bleeding which can be seen in the case. As a nurse taking care of Ms O’ Sullivan a through the identification of role, responsibility and accountability required. In the intensive care unit GI bleeding episode requires stabilization of multiple body function which can be affected by several factors resulting in poor outcomes. These attributes are needed to be addressed for long term condition management. Soon after the stability of condition; care plan identifying the health promotion need, addressing the risky behaviour and intervention is required.