Acute G.

I Bleeding
Peptic Ulcer
 Acute G.I Bleeding
Peptic Ulcer
Name: Patient MR
Age: 56 years old
Admitting diagnosis: Chest Pain

• Has an intermittent 2-month history of chest tightness with substernal burning that radiates through
to the mid-back intermittently, in a stabbing fashion.
• Symptoms occur after a large meal; with heavy lifting at the construction site; and in the middle of
the night when he awakens from sleep with coughing, shortness of breath, and a foul, bitter taste in
his mouth.
• Recently, he has developed nausea, without emesis, which is worse in the morning or after
skipping meals.
• He complains of "heartburn" three or four times a day. When this happens, he takes a couple of
Rolaids or Tums. He keeps a bottle at home, at the office, and in his truck.

VITAL SIGNS:
BP = 130/80 lying, 120/72 standing
Temp = 98.6° F (37° C), Sp02 92% on room air
A 12-lead ECG showed normal sinus rhythm
 CMP Result
Na 140 mEq/L
CBC Result
K 3.7 mEq/L
WBC 6,000/mm3
BUN 20 mg/dL
Hgb 15.0 g/dl
Creatinine 1.0 mg/dL
Hct 47% à 32% after emesis
Lipase 20 u/l
Plt 22,000/mm3
Amylase 18 u/l
PT 12.0 sec
INR 1.0
H. Pylori Antibody Test- 20 units/mL

• The chest x-ray showed no abnormalities

• He smoked one pack of cigarettes a day for the past 35 years, drinks two or three
beers on most nights, and has noticed a 20-pound weight gain over the past 10
years.
• He feels "so tired and old now." Has dark circles under his eyes and complains of
constant daytime fatigue.
He also reinjured his lower back a month ago at work, lifting a pile of boards, so his
physician prescribed ibuprofen (Motrin) 800 mg bid or tid for 4 weeks.
• Suddenly, M.R. begins to complain of nausea; and he promptly vomits coffee-ground
emesis with specks of bright red blood. VS remain stable.
 CAUSED BY MEDICAL MANAGEMENT
NSAIDS (Ibuprofen) TESTED THROUGH (COLLABORATIVE CARE MGT.)
Smoking and Alcohol
Age SURGICAL PROCEDURES
ACUTE G.I BLEEDING: • Esophagogastroduodenoscopy (EGD)
⚬ Cautery
PEPTIC ULCER
Breaks down defense MEDICATIONS:
system of the stomach • Pantoprazole (Protonix)
lining
SIGNS AND SYMPTOMS DIAGNOSTIC AND LAB TESTS Start oxygen therapy.
• Esophagogastroduodenoscopy • Oxygen by nasal cannula
Block prostaglandin Fever and Pain (EGD). Ulcer is oozing blood in the
stomach antrum, duodenal bulb is
normal.
• Biopsy. Negative for H. pylori
Cell in the stomach is bacteria. NURSING MANAGEMENT
damaged due to • H. Pylori Antibody Test. Normal.
penetration of acid • Complete Blood Count. • Assess client’s physiological response to hemorrhage.
⚬ WBC- 6000/mm3. Normal • Monitor laboratory findings of hemoglobin, hematocrit,
⚬ Hgb- 15.0 g/dL. Normal BUN and creatinine, as well as for clotting studies.
Histamine released ⚬ Hct- 47-->32% after vomit • Measure central venous pressure if indicated and
⚬ Platelets 220,000/mm3 available
PATHOPHYSIOLOGY

• Chest X-Ray. No abnormalities • Monitor vital signs every 1 hour.

• Electrocardiogram. Normal sinus • Type and cross-match for packed red blood cells
Signal parietal and Heartburn and nausea rhythm. (PRBC), coagulation studies and anticipate blood
chief cell to release • Complete metabolic panel (CMP). transfusion as ordered.
more pepsin and HCl ⚬ Na -140 mEq/L, NORMAL
⚬ K-3.7 mEq/L, NORMAL • Position the patient in the left lateral decubitus position
⚬ BUN- 20 mg/dL, NORMAL to minimize aspiration, encourage adequate rest
⚬ Creatinine-1.0 mg/dL, NORMAL periods to prevent fatigue.
↓ Mucous Production ⚬ Lipase- 20 units/L, NORMAL • Administer oxygen by nasal cannula with titrate to
⚬ Amylase- 18 units/L, LOW maintain Sp02 over 92%
⚬ Prothrombin time- 12.0 sec, • Administer NS at 100mL/hr as ordered by the doctor
NORMAL • Administer Pantoprazole (Protonix) drip at 8mg/hr,
↓ Bicarbonate secretion Erosion of inner lining ⚬ INR- 1.0. NORMAL preceded by an 80-mg bolus IV over 8 minutes as
prescribed
• Anticipate the use of a vasopressin drip as ordered.
↓ Mucosal blood flow PATIENT PROBLEMS
• Fluid volume deficit related to
blood volume loss secondary to GI
bleeding as evidenced by coffee
Gastric acid permeate ground emesis with specks of PATIENT OUTCOMES
mucosal barrier Painful sore
bright red blood, orthostatic • Participate in procedures and treatments
hypotension*** necessary for patient’s assumption of adequate
• Acute pain related to fluid volume.
Gastric lesion compromised stomach lining • Maintain adequate fluid volume and absence of GI
secondary to gastrointestinal bleeding with a normal hct level
pathology • Maintain vital signs within normal limits and no
GI Bleeding Coffee ground emesis • Risk for injury (aspiration) related occurrence of emesis
to acid reflux as evidenced by
coffee-ground emesis, heartburn
and chest tightness
ACUTE G.I BLEEDING:
PEPTIC ULCER
NSAIDS (Ibuprofen) CAUSED BY
Smoking and Alcohol
Age
ACUTE G.I BLEEDING:
PEPTIC ULCER
 NSAIDS (Ibuprofen) CAUSED BY
Smoking and Alcohol
Age
ACUTE G.I BLEEDING:
PEPTIC ULCER
Breaks down defense
system of the stomach
lining
SIGNS AND SYMPTOMS

Block prostaglandin Fever and Pain

PATHOPHYSIOLOGY
 NSAIDS (Ibuprofen) CAUSED BY
Smoking and Alcohol
Age
ACUTE G.I BLEEDING:
PEPTIC ULCER
Breaks down defense
system of the stomach
lining
SIGNS AND SYMPTOMS

Block prostaglandin Fever and Pain

Cell in the stomach is

damaged due to
penetration of acid

Histamine released
PATHOPHYSIOLOGY

Signal parietal and Heartburn and nausea

chief cell to release
more pepsin and HCl
 NSAIDS (Ibuprofen) CAUSED BY
Smoking and Alcohol
Age
ACUTE G.I BLEEDING:
PEPTIC ULCER
Breaks down defense
system of the stomach
lining
SIGNS AND SYMPTOMS

Block prostaglandin Fever and Pain

Cell in the stomach is

damaged due to
penetration of acid

Histamine released
PATHOPHYSIOLOGY

Signal parietal and Heartburn and nausea

chief cell to release
more pepsin and HCl

↓ Mucous Production

↓ Bicarbonate secretion Erosion of inner lining

↓ Mucosal blood flow

 NSAIDS (Ibuprofen) CAUSED BY
Smoking and Alcohol
Age
ACUTE G.I BLEEDING:
PEPTIC ULCER
Breaks down defense
system of the stomach
lining
SIGNS AND SYMPTOMS

Block prostaglandin Fever and Pain

Cell in the stomach is

damaged due to
penetration of acid

Histamine released
PATHOPHYSIOLOGY

Signal parietal and Heartburn and nausea

chief cell to release
more pepsin and HCl

↓ Mucous Production

↓ Bicarbonate secretion Erosion of inner lining

↓ Mucosal blood flow

Gastric acid permeate

mucosal barrier Painful sore
 NSAIDS (Ibuprofen) CAUSED BY
Smoking and Alcohol
Age
ACUTE G.I BLEEDING:
PEPTIC ULCER
Breaks down defense
system of the stomach
lining
SIGNS AND SYMPTOMS

Block prostaglandin Fever and Pain

Cell in the stomach is

damaged due to
penetration of acid

Histamine released
PATHOPHYSIOLOGY

Signal parietal and Heartburn and nausea

chief cell to release
more pepsin and HCl

↓ Mucous Production

↓ Bicarbonate secretion Erosion of inner lining

↓ Mucosal blood flow

Gastric acid permeate

mucosal barrier Painful sore

Gastric lesion

GI Bleeding Coffee ground emesis

 NSAIDS (Ibuprofen) CAUSED BY TESTED THROUGH
Smoking and Alcohol
Age
ACUTE G.I BLEEDING:
PEPTIC ULCER
Breaks down defense
system of the stomach
lining
SIGNS AND SYMPTOMS DIAGNOSTIC AND LAB TESTS
• Esophagogastroduodenoscopy
Block prostaglandin Fever and Pain (EGD). Ulcer is oozing blood in the
stomach antrum, duodenal bulb is
normal.
• Biopsy. Negative for H. pylori
Cell in the stomach is bacteria.
damaged due to • H. Pylori Antibody Test. Normal.
penetration of acid • Complete Blood Count.
⚬ WBC- 6000/mm3. Normal
⚬ Hgb- 15.0 g/dL. Normal
Histamine released ⚬ Hct- 47-->32% after vomit
⚬ Platelets 220,000/mm3
PATHOPHYSIOLOGY

• Chest X-Ray. No abnormalities

• Electrocardiogram. Normal sinus
Signal parietal and Heartburn and nausea rhythm.
chief cell to release • Complete metabolic panel (CMP).
more pepsin and HCl ⚬ Na -140 mEq/L, NORMAL
⚬ K-3.7 mEq/L, NORMAL
⚬ BUN- 20 mg/dL, NORMAL
⚬ Creatinine-1.0 mg/dL, NORMAL
↓ Mucous Production ⚬ Lipase- 20 units/L, NORMAL
⚬ Amylase- 18 units/L, LOW
⚬ Prothrombin time- 12.0 sec,
NORMAL
↓ Bicarbonate secretion Erosion of inner lining ⚬ INR- 1.0. NORMAL

↓ Mucosal blood flow

Gastric acid permeate

mucosal barrier Painful sore

Gastric lesion

GI Bleeding Coffee ground emesis

 NSAIDS (Ibuprofen) CAUSED BY TESTED THROUGH
Smoking and Alcohol
Age
ACUTE G.I BLEEDING:
PEPTIC ULCER
Breaks down defense
system of the stomach
lining
SIGNS AND SYMPTOMS DIAGNOSTIC AND LAB TESTS
• Esophagogastroduodenoscopy
Block prostaglandin Fever and Pain (EGD). Ulcer is oozing blood in the
stomach antrum, duodenal bulb is
normal.
• Biopsy. Negative for H. pylori
Cell in the stomach is bacteria.
damaged due to • H. Pylori Antibody Test. Normal.
penetration of acid • Complete Blood Count.
⚬ WBC- 6000/mm3. Normal
⚬ Hgb- 15.0 g/dL. Normal
Histamine released ⚬ Hct- 47-->32% after vomit
⚬ Platelets 220,000/mm3
PATHOPHYSIOLOGY

• Chest X-Ray. No abnormalities

• Electrocardiogram. Normal sinus
Signal parietal and Heartburn and nausea rhythm.
chief cell to release • Complete metabolic panel (CMP).
more pepsin and HCl ⚬ Na -140 mEq/L, NORMAL
⚬ K-3.7 mEq/L, NORMAL
⚬ BUN- 20 mg/dL, NORMAL
⚬ Creatinine-1.0 mg/dL, NORMAL
↓ Mucous Production ⚬ Lipase- 20 units/L, NORMAL
⚬ Amylase- 18 units/L, LOW
⚬ Prothrombin time- 12.0 sec,
NORMAL
↓ Bicarbonate secretion Erosion of inner lining ⚬ INR- 1.0. NORMAL

↓ Mucosal blood flow PATIENT PROBLEMS

• Fluid volume deficit related to
blood volume loss secondary to GI
bleeding as evidenced by coffee
Gastric acid permeate ground emesis with specks of
mucosal barrier Painful sore
bright red blood, orthostatic
hypotension***
• Acute pain related to
Gastric lesion compromised stomach lining
secondary to gastrointestinal
pathology
GI Bleeding Coffee ground emesis • Risk for injury (aspiration) related
to acid reflux as evidenced by
coffee-ground emesis, heartburn
and chest tightness
 CAUSED BY MEDICAL MANAGEMENT
NSAIDS (Ibuprofen) TESTED THROUGH (COLLABORATIVE CARE MGT.)
Smoking and Alcohol
Age SURGICAL PROCEDURES
ACUTE G.I BLEEDING: • Esophagogastroduodenoscopy (EGD)
⚬ Cautery
PEPTIC ULCER
Breaks down defense MEDICATIONS:
system of the stomach • Pantoprazole (Protonix)
lining
SIGNS AND SYMPTOMS DIAGNOSTIC AND LAB TESTS Start oxygen therapy.
• Esophagogastroduodenoscopy • Oxygen by nasal cannula
Block prostaglandin Fever and Pain (EGD). Ulcer is oozing blood in the
stomach antrum, duodenal bulb is
normal.
• Biopsy. Negative for H. pylori
Cell in the stomach is bacteria.
damaged due to • H. Pylori Antibody Test. Normal.
penetration of acid • Complete Blood Count.
⚬ WBC- 6000/mm3. Normal
⚬ Hgb- 15.0 g/dL. Normal
Histamine released ⚬ Hct- 47-->32% after vomit
⚬ Platelets 220,000/mm3
PATHOPHYSIOLOGY

• Chest X-Ray. No abnormalities

• Electrocardiogram. Normal sinus
Signal parietal and Heartburn and nausea rhythm.
chief cell to release • Complete metabolic panel (CMP).
more pepsin and HCl ⚬ Na -140 mEq/L, NORMAL
⚬ K-3.7 mEq/L, NORMAL
⚬ BUN- 20 mg/dL, NORMAL
⚬ Creatinine-1.0 mg/dL, NORMAL
↓ Mucous Production ⚬ Lipase- 20 units/L, NORMAL
⚬ Amylase- 18 units/L, LOW
⚬ Prothrombin time- 12.0 sec,
NORMAL
↓ Bicarbonate secretion Erosion of inner lining ⚬ INR- 1.0. NORMAL

↓ Mucosal blood flow PATIENT PROBLEMS

• Fluid volume deficit related to
blood volume loss secondary to GI
bleeding as evidenced by coffee
Gastric acid permeate ground emesis with specks of
mucosal barrier Painful sore
bright red blood, orthostatic
hypotension***
• Acute pain related to
Gastric lesion compromised stomach lining
secondary to gastrointestinal
pathology
GI Bleeding Coffee ground emesis • Risk for injury (aspiration) related
to acid reflux as evidenced by
coffee-ground emesis, heartburn
and chest tightness
 CAUSED BY MEDICAL MANAGEMENT
NSAIDS (Ibuprofen) TESTED THROUGH (COLLABORATIVE CARE MGT.)
Smoking and Alcohol
Age SURGICAL PROCEDURES
ACUTE G.I BLEEDING: • Esophagogastroduodenoscopy (EGD)
⚬ Cautery
PEPTIC ULCER
Breaks down defense MEDICATIONS:
system of the stomach • Pantoprazole (Protonix)
lining
SIGNS AND SYMPTOMS DIAGNOSTIC AND LAB TESTS Start oxygen therapy.
• Esophagogastroduodenoscopy • Oxygen by nasal cannula
Block prostaglandin Fever and Pain (EGD). Ulcer is oozing blood in the
stomach antrum, duodenal bulb is
normal.
• Biopsy. Negative for H. pylori
Cell in the stomach is bacteria. NURSING MANAGEMENT
damaged due to • H. Pylori Antibody Test. Normal.
penetration of acid • Complete Blood Count. • Assess client’s physiological response to hemorrhage.
⚬ WBC- 6000/mm3. Normal • Monitor laboratory findings of hemoglobin, hematocrit,
⚬ Hgb- 15.0 g/dL. Normal BUN and creatinine, as well as for clotting studies.
Histamine released ⚬ Hct- 47-->32% after vomit • Measure central venous pressure if indicated and
⚬ Platelets 220,000/mm3 available
PATHOPHYSIOLOGY

• Chest X-Ray. No abnormalities • Monitor vital signs every 1 hour.

• Electrocardiogram. Normal sinus • Type and cross-match for packed red blood cells
Signal parietal and Heartburn and nausea rhythm. (PRBC), coagulation studies and anticipate blood
chief cell to release • Complete metabolic panel (CMP). transfusion as ordered.
more pepsin and HCl ⚬ Na -140 mEq/L, NORMAL
⚬ K-3.7 mEq/L, NORMAL • Position the patient in the left lateral decubitus position
⚬ BUN- 20 mg/dL, NORMAL to minimize aspiration, encourage adequate rest
⚬ Creatinine-1.0 mg/dL, NORMAL periods to prevent fatigue.
↓ Mucous Production ⚬ Lipase- 20 units/L, NORMAL • Administer oxygen by nasal cannula with titrate to
⚬ Amylase- 18 units/L, LOW maintain Sp02 over 92%
⚬ Prothrombin time- 12.0 sec, • Administer NS at 100mL/hr as ordered by the doctor
NORMAL • Administer Pantoprazole (Protonix) drip at 8mg/hr,
↓ Bicarbonate secretion Erosion of inner lining ⚬ INR- 1.0. NORMAL preceded by an 80-mg bolus IV over 8 minutes as
prescribed
• Anticipate the use of a vasopressin drip as ordered.
↓ Mucosal blood flow PATIENT PROBLEMS
• Fluid volume deficit related to
blood volume loss secondary to GI
bleeding as evidenced by coffee
Gastric acid permeate ground emesis with specks of
mucosal barrier Painful sore
bright red blood, orthostatic
hypotension***
• Acute pain related to
Gastric lesion compromised stomach lining
secondary to gastrointestinal
pathology
GI Bleeding Coffee ground emesis • Risk for injury (aspiration) related
to acid reflux as evidenced by
coffee-ground emesis, heartburn
and chest tightness
 CAUSED BY MEDICAL MANAGEMENT
NSAIDS (Ibuprofen) TESTED THROUGH (COLLABORATIVE CARE MGT.)
Smoking and Alcohol
Age SURGICAL PROCEDURES
ACUTE G.I BLEEDING: • Esophagogastroduodenoscopy (EGD)
⚬ Cautery
PEPTIC ULCER
Breaks down defense MEDICATIONS:
system of the stomach • Pantoprazole (Protonix)
lining
SIGNS AND SYMPTOMS DIAGNOSTIC AND LAB TESTS Start oxygen therapy.
• Esophagogastroduodenoscopy • Oxygen by nasal cannula
Block prostaglandin Fever and Pain (EGD). Ulcer is oozing blood in the
stomach antrum, duodenal bulb is
normal.
• Biopsy. Negative for H. pylori
Cell in the stomach is bacteria. NURSING MANAGEMENT
damaged due to • H. Pylori Antibody Test. Normal.
penetration of acid • Complete Blood Count. • Assess client’s physiological response to hemorrhage.
⚬ WBC- 6000/mm3. Normal • Monitor laboratory findings of hemoglobin, hematocrit,
⚬ Hgb- 15.0 g/dL. Normal BUN and creatinine, as well as for clotting studies.
Histamine released ⚬ Hct- 47-->32% after vomit • Measure central venous pressure if indicated and
⚬ Platelets 220,000/mm3 available
PATHOPHYSIOLOGY

• Chest X-Ray. No abnormalities • Monitor vital signs every 1 hour.

• Electrocardiogram. Normal sinus • Type and cross-match for packed red blood cells
Signal parietal and Heartburn and nausea rhythm. (PRBC), coagulation studies and anticipate blood
chief cell to release • Complete metabolic panel (CMP). transfusion as ordered.
more pepsin and HCl ⚬ Na -140 mEq/L, NORMAL
⚬ K-3.7 mEq/L, NORMAL • Position the patient in the left lateral decubitus position
⚬ BUN- 20 mg/dL, NORMAL to minimize aspiration, encourage adequate rest
⚬ Creatinine-1.0 mg/dL, NORMAL periods to prevent fatigue.
↓ Mucous Production ⚬ Lipase- 20 units/L, NORMAL • Administer oxygen by nasal cannula with titrate to
⚬ Amylase- 18 units/L, LOW maintain Sp02 over 92%
⚬ Prothrombin time- 12.0 sec, • Administer NS at 100mL/hr as ordered by the doctor
NORMAL • Administer Pantoprazole (Protonix) drip at 8mg/hr,
↓ Bicarbonate secretion Erosion of inner lining ⚬ INR- 1.0. NORMAL preceded by an 80-mg bolus IV over 8 minutes as
prescribed
• Anticipate the use of a vasopressin drip as ordered.
↓ Mucosal blood flow PATIENT PROBLEMS
• Fluid volume deficit related to
blood volume loss secondary to GI
bleeding as evidenced by coffee
Gastric acid permeate ground emesis with specks of PATIENT OUTCOMES
mucosal barrier Painful sore
bright red blood, orthostatic • Participate in procedures and treatments
hypotension*** necessary for patient’s assumption of adequate
• Acute pain related to fluid volume.
Gastric lesion compromised stomach lining • Maintain adequate fluid volume and absence of GI
secondary to gastrointestinal bleeding with a normal hct level
pathology • Maintain vital signs within normal limits and no
GI Bleeding Coffee ground emesis • Risk for injury (aspiration) related occurrence of emesis
to acid reflux as evidenced by
coffee-ground emesis, heartburn
and chest tightness