Saint Francis of Asissi College

045, Admiral Village, Talon III, Las Pinas City

COLLEGE OF NURSING

A Case Study of a 58-year-old Male with Admitting Diagnosis

Hypovolemic Shock secondary to Massive Upper
Gastrointestinal Bleeding

A Case Study Presented to the Faculty of the College of Nursing of Saint Francis of Assisi College, Las Pinas
City

In Partial Fulfillment of the requirements in Related Learning Experience (NCM-113) for the Degree of
Bachelor of Science in Nursing

Submitted to: Miss Carolyn Calupitan

Submitted by: Elinne Mhe Ballon

Bianca Mae H. Carnate

Marie Flor L. Lugo

Roselyn M. Deduque
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

Introduction

Upper gastrointestinal bleeding is a common medical emergency worldwide and refers to bleeding from the esophagus,
stomach, or duodenum. Patients present with hematemesis (bloody or coffee ground emesis) or melena, although hematochezia
can occur in the context of a major bleed and is typically associated with hemodynamic instability. Patients with melena present
with lower hemoglobin values than patients with hematemesis, probably because presentation is more likely to be delayed.
Therefore, patients with melena more often require transfusion, although mortality is lower in patients with melena than in those
with hematemesis in some series. Numerous improvements in the management of upper gastrointestinal bleeding have been
incorporated into clinical practice in recent years. However, many patients now have risk factors for a poorer outcome,
including increasing age and major medical comorbidities.

Although the cause of a bleeding episode is uncertain until endoscopy is undertaken, guidelines often separate upper
gastrointestinal bleeding into variceal and non-variceal bleeding because management and outcomes differ. This article covers
the acute management of patients with overt upper gastrointestinal bleeding, summarizing evidence for risk assessment,
resuscitation, blood transfusion, medical and endoscopic therapy, and early post-endoscopic management.

This medical condition is one of the most important cause of hospitalization and mortality worldwide. In Asia, with a high
prevalence of Helicobacter pylori infection, a potential difference in drug metabolism, and a difference in clinical management
of UGIB due to variable socioeconomic environments, it is considered necessary to re-examine the International Consensus of
Non-variceal Upper Gastrointestinal Bleeding with emphasis on data generated from the region.
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

General Objectives:

The aim of the study is to conduct a case review and to provide a nursing health care to the client who diagnosed with
Hypovolemic Shock secondary to Massive Upper Gastrointestinal Bleeding.

Specific Objectives:

 Identification of the disease, its clinical manifestations, risk variables, pathophysiology and disease diagnostic
procedures.
 Identify different medical and nursing management of hypovolemic shock secondary to massive upper gastrointestinal
bleeding
 Learn on how to effectively evaluate and manage gastrointestinal bleeding in the critically ill patient
 Formulation of nursing care plan and apply it to the client
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

I. Case Abstract
A case scenario of a 54-year-old male admitted at Emergency Department for Hypovolemic shock secondary to
Massive Upper Gastrointestinal Bleeding with a chief complaint of “general chest discomfort and nausea with massive
hematemesis” as verbalized by the client.
The client has several treatment modalities that includes the following: Hydrochlorothiazide 25mg once a day, IV NS
Fluid Bolus, Blood Transfusion 2U, Massive Transfusion Protocol Activation, IV PPI (Bolus and Infusion),
Intubation, Vasopressin Intubation, Sengstaken – Blakemore tube, IV Antibiotic (Ceftriaxone), and PCC Vitamin K.
The patient will undergo intubation to suction the blood in the upper gastrointestinal and an Electrocardiogram to
determine the rhythm of the heart.
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

A. Theoretical Framework

Johnson’s Behavioral System Model is a nursing care model that advocates the fostering of efficient and effective behavioral
functioning in the patient to prevent illness. The patient is identified as a behavioral system composed of seven behavioral subsystems:
affiliative, dependency, ingestive, eliminative, sexual, aggressive, and achievement. Each subsystem’s three functional requirements
include protection from noxious influences, provision for a nurturing environment, and stimulation for growth. An imbalance in any of
the behavioral subsystems results in disequilibrium. It is nursing’s role to assist the client in returning to a state of equilibrium.

The case presenters chose the theory of Dorothy Johnson’s because it is related to the case scenario of the patient.
The seven subsystems of the theory were reflected to his behavior in his daily activities in life. As what he posses
while he is in the hospital, he even got to think that he just needs some beer.
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

II. Assessment
A. Client Profile

Patients Initial: Mr. FJ Gender: Male Age: 58 Marital Status: Single

Educational Attainment: Occupation: Religion:Catholic Place of
High School Graduate Fish vendor Birth:Mandaluyong
Health Care Usual Source of Source of
Financing:Philhealth Medical Information:
Care:N/A N/A
Date of Date of Date of Admitting Diagnosis:
Admission:10/03/2015 Interview:N/A Discharge: N/A Hypovolemic shock
secondary to massive
upper gastrointestinal
bleeding

B. Nursing Health History

Chief Complaint
“general chest discomfort and nausea with massive hematemesis” as verbalized by the client.

C. History of Present Illness

Forty years prior to hospitalizationpatientfirst tried drinking alcohol and cigarette with the influenced of his friends.
He consumed two bottles of beer and one stick of cigarette in the entire gathering because according to him he
doesn’t like the taste of cigarette.

Thirty-nine years prior to hospitalization the patient got broken hearted for the first time of his entire life. That’s
the time that he abuses himself and he often drink a beer as a way of coping up to the breakup he experienced.
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

Thirty-five years prior to hospitalization, according to the patient he consumed five to six bottles of beer a day. He
drinks with his friends most of the time after his work.

Twenty-five years prior to admission the client was able to drink 10 bottles of beer as his maximum and half of a
packed of cigarette.

Fifteen years prior to hospitalization the drinking behavior of the client and the use of cigarette get worsened
because he is broken hearted. The client was 43 years old way back then and he is very much hopeless to have
someone with him when he gets old. The woman that he liked rejected him because of his bad habits in life.

Ten years prior to hospitalization the patient complaint of abdominal pain but he insists that he just needs to drink
some beer to cure it and just eat a lot of food. The patient is able to finish 10 to 20 bottles per day and one packed
of cigarette.

Five years prior to hospitalization he experiences headache that he never been before and went to a Health Center
and he diagnosed of hypertension. The physician prescribed him a medication but the client didn’t take it seriously
because he believes that he is healthy and only needs to avoid fatty foods.

Two days prior to the client experience of vomiting which began as coffee grounds and progressed to bright red.

Three hours prior to admission the client drinks 3 bottles of beer until such time that he feels chest discomfort and
nausea. His neighbors immediately brought him to the nearest hospital because they saw him fell down in front of
his house with a blood to his mouth.
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

D. Past Medical History

Childhood Illness(s) Not stated in the case scenario

Childhood / Adult Immunization(s) Not stated in the case scenario
Accidents and Injuries Not stated in the case scenario
Previous hospitalization / Surgery Hypertension
Medication(s) prior to confinement hydrochlorothiazide

E. Family History of Illness

Patient FJ grandfather and grandmother in both sides were already dead due to unknown reason or old age. Both
parents of the patient are deceased due to unknown reason. The eldest brother of the patient was already died due
to Heart Disease three years ago.
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

GENOGRAM

FATHER SIDEMOTHER SIDE

GRANDFATHER GRANDMOTHER GRANDFATHER

GRANDMOTHER
Decease Decease Decease
decease
unknown unknown reason unknow
unknown

FATHER MOTHER
Decease decease
unknown reason unknown

2. 3. 4.
1.
Patient 50 yrs.old 43 yrs. old
59 yr. old
58 yrs. Old No illness No illness
decease
heart Disease
LEGEND:
PATIENT FJ

MALE

FEMALE
F. Developmental History
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

Theory Ag Development Task Client Description Interpretation

e
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

Psychosexual by 58 Genital Stage Pt. is single. He had a partner The client experiences his
Sigmund Freud Puberty to death when he was 19 years old but heartbreak that will change
The onset of puberty allows the leaved him after her working his perception of love.
libido to once again become contract expired without any
engaged. The person develops a traces. They met at their
strong sexual interest in the perspective work, she was a
opposite sex during the final sales lady and he was a
stage of psychosexual delivery man at that time. He
development. During puberty, had an idea of having a child
this stage starts but last for the before the woman leaved him.
rest of the life of a child. He and their neighbor noticed
the changes of her body. Until
then, he lost interest to the
women.
Psychosocial by 58 Generativity vs. Stagnation Pt. have a good relationship Pt. able to have a good
Erik Erikson During this stage, middle-aged with his friends and neighbor. relationship with his
adults begin contributing to the His friends are his backrest neighbors.
next generation, often through during his needs, they are his
childbirth and caring for others; ally when it comes to his
they also engage in meaningful problem
and productive work which
contributes positively to society.
Those who do not master this
task may experience stagnation
and feel as though they are not
leaving a mark on the world in a
meaningful way; they may have
little connection with others and
little interest in productivity and
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

self-improvement.
Cognitive by 58 Formal Operational Pt. has been working for his The patient able to use his
Jean Piaget Theoretical, hypothetical, and needs and helping out his critical thinking despite of his
age.
counterfactual thinking. neighbor in terms of financial
Abstract, logic, and reasoning. matter if he can handle.
Strategy and planning become Though he has a bad habit of
possible. Concepts learned in drinking alcohol, he doesn’t
one context can be applied to need anyone for this habit, he
another worked hard to sustain his
needs.
Moral by 58 Post- conventional individual Patient is 40 years active smoker The pt. moral value greatly
Lawrence An individual able to understand and alcoholism. Even though he is influenced by his friends.
Kohlberg alcoholic but he isn’t aggressive, it
the morality of having
is his way to have a good sleep.
democratically establishment.
The person understands the
principles of human rights and
personal conscience.
Spiritual by 58 Universalizing Faith prior to admission the patient was the patient has a strong
James Fowler The individual would treat any able to attend Sunday service development of spiritual
occasionally, most especially when despite of his bad habits in life.
person with compassion as
it his birthday is approaching.
he/she views people as form of Despite of being alcoholism he still
universal community, and believes in God.
should be treated with universal
principles of love and justice.

G. Personal / Social History

 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

Patient FJ. 58 years old is a fish vendor in a wet market near in his area. He loves to eat fruits and vegetables every
day. He preferred to wake when going to work, as per him walking is his exercise every day. Patient FJ is a smoker
since he is high school student, he consumed 1 pack per day, and he also drinks alcohol since high school student,
can consume ten to twenty bottles of beer per day. As his educational attainment he is high graduate, as per him
there’s a lot of problem like his family and financial problem that he cannot pursued his college education.

H. Environmental History
Patient FJ was leaving in Mandaluyong City since birth. He doesn’t usually go to outside Mandaluyong. Their
house is bungalow type; he is leaving there alone, no hazard precautions. Public market is near to their home that
can supply their basic needs. They have friendly neighborhood, and the houses is close to each other. Also, they
have Barangay center not too far from their house.

I. Gordon’s Typology of 11 Functional Health Pattern

a. Health Perception / Health Management Pattern

Prior to hospitalization, patient was aware that being an alcoholism is bad to his health but he insists that he
only live once and just wanted to enjoy his existence while he can. Patient FJ is aware of having a hypertension
but he doesn’t comply to the prescribed medication

During hospitalization, patient experience active hematemesis and complains of general chest discomfort and
insists that will be fine and just needs a beer.
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

Analysis: Health is a state of complete physical, mental, and social well-being, and not merely the absence of
disease of infirmity (WHO, 1948)
Interpretation:Patient FJ has a bad health perception and didn’t practice what is best for him.

b. Nutritional / Metabolic Pattern

Prior to hospitalization, patient was an alcoholism that he can consumed ten to twenty bottles of beer a day
thoughhe has a good appetite in everything that food being served in the carinderia. He usually ate vegetables
and pork steak.
During hospitalization, patient doesn’t eat anything due to his esophageal varices that caused vomiting.
Analysis:Malnutrition was related to the intensity of ethanol intake, development of social or familial problems,
irregularity of feeding habits and cirrhosis with ascites. Irregularity of feeding habits was also related to heavy
drinking and to social or familial derangement. (www.researchgate.net)
Interpretation:Patient FJ has a good appetite prior to hospitalization though he has excessive alcohol intake
that triggers day by day his condition and he is not able to eat because he can’t due to massive gastrointestinal
bleeding.

c. Elimination Pattern
Prior to illness, Patient FJ frequently urinated with little amount of urine during the day and at bed time with
dark yellow in color with bubbles as per him because of alcohol. He defecated every other day or sometimes
once a day with dark brown in color depending on what he ate. The patient doesn’t used any laxative or diuretic
in order to facilitate excretion.
During hospitalization, Patient FJ urination pattern does not change though he is using diaper in order to avoid
going to the toilet because of active hematemesis.
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

Analysis:Alcohol use disorders in elderly people are associated with widespread impairments in physical,
psychological, social, and cognitive health. Age related changes in body composition means that, while
absorption, metabolism, and excretion of alcohol are largely unchanged, equivalent amounts of alcohol produce
higher blood alcohol concentrations in older people.www.ncbi.nlm.nih.gov
Interpretation: Patient FJ is alcohol abuse which is the cause of his frequent urination.

d. Activity – Exercise Pattern

Prior to hospitalization, patient way of exercise was walking every day from his house into the market where his
work at and preparing all the heavy equipment that he needed for his space. According to patient FJ working
daily is his way to have an active physical body because once that he stayed at his househe fells weak.
During hospitalization, patient just lay in bed because of chest discomfort and nausea that he complaining when
he tries to.

Analysis: Activity- exercise refer to a person’s routine of exercise, activity, leisure, and recreation. It includes
activities in daily living that require energy expenditure such as hygiene, dressing, cooking, shopping, home
maintenance, and types of quality and quantity exercise. (Kozier and Erbs, Fundamental of Nursing 8th edition.
p.1106)
Interpretation:Patient activity and exercise pattern was change because of his illness

e. Sleep – Rest Pattern

 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

Prior to hospitalization, patient FJ had4-5 hours of sleep at night and 2-3 hours siesta. Usual hours of sleep
werestarted at 11: P.M to 3:00A.M. and 2-4 PM. He has no sleeping pills or other medications taken in order to
facilitate sleep and rest. However, according to the patient drinking beer help him to have a good sleep.

During hospitalization, patient FJ sleep pattern has change, he become uncomfortable because of nausea,
vomiting and chest discomfort.

Analysis:Alcohol consumption can induce sleep disorders by disrupting the sequence and duration of sleep
states and by altering total sleep time as well as the time required to fall asleep (i.e., sleep latency). The effects
of alcohol consumption on sleep patterns, the potential health consequences of alcohol consumption combined
with disturbed sleep, and the risk for relapse in those with alcoholism who fail to recover normal sleep patterns.
Interpretation: patient FJ sleep – rest pattern has change during hospitalization because of his condition.
Though, he can rest at hospital but with feeling of discomfort.

f. Cognitive – Perceptual Pattern

Prior to admission, patient FJ has no memory lapses and memory deficit. Patient wasn’t wearing an eye glasses
and he didn’t wear any device to facilitate hearing and speaking. He also knows how to understand and follow
instructions.
During admission, patient can understand and doesn’t have difficulty of hearing but he is drowsy and has mild
confusion due to his condition. Heinsists that beer is all he needs to feel good.

Analysis: in older, changes in cognitive abilities are more often a difference in speed than in ability. Overall,
the older maintain intelligence, problem solving, judgement, creativity, and other well- practiced cognitive
skills. (Kozier, Fundamental of Nursing, 2008)
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

Interpretation:though patient FJ is in the hospital already, he still thinks that he needs beers despite of how
severe is happening to him as of the moment.

g. Self – Perceptual Pattern

Prior to hospitalization patient FJ describe himself as a serious person but easy to be with especially when it
comes to drinking alcohol. the patient perceived that he used to be independent because his parents passed away
and his siblings has their own family. He also adds that after drinking alcohol he directly goes home to have a
sleep for the preparation of his work the next day.

During hospitalization patient FJ professed that there will be changes to his self – concept. He may used to be
independent before but now he said that he needs someone to look after him.
Analysis:self – esteem is one’s judgement of one’s worth. If a person’s self – esteem does not match with the
ideal self, the low self – concepts results.
Interpretation: His condition made him realize that being alone in times of what he is into right now is not
easy.

h. Role – Relationship Pattern

Patient FJ is a responsible son to his late parents and selfless when it comes to his siblings. Despite of his bad
habits in life he still gets compliments to the people whom he socializes with.

During hospitalization patient FJ’s friends and siblings all throughout his hospitalization. They encourage
patient FJ to fight and have courage to surpass his condition.
Analysis:Role is a set of expectations about how the person occupying one position behaves. Each person
usually has several roles, such as husband, wife, parents, sibling, and friend. Some roles are assumed for limited
periods such as client, patient, and students.
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045, Admiral Village, Talon III, Las Pinas City
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Interpretation: patient FJ didn’t expect that there are people who will be by his side and still portray concern
to him despite of being alcoholism.

i. Sexually – Reproductive Pattern

Prior to hospitalization patient FJ has no problem in his reproductive area. He also states that he is inactive
when it comes to coitus because he is single and old.
During hospitalization patient FJ does not complain about any changes in his reproductive area and nothing has
change.
Analysis:Sexuality is an individual expressed and highly phenomenon whose meaning evolves from life
experiences. Physiologic, Psychosocial and Cultural factors influence a person’s sexuality and lead to the wide
range of attitudes and behaviors seen in humans. (Fundamental of Nursing, Kozier and Erb, 8th edition, page
1019)
Interpretation:Patient is a single and does not complain about his reproductive area.

j. Coping and Stress Tolerance Pattern

Prior to admission the patient way of distressing is to drink some beer and have a sing along with his friends or
other acquaintance. But sometimes when he misses his parents and his favorite siblings to passed away, he goes
to the cemetery and visiting the tomb of his late loved ones.
Analysis:Stress is a condition in which the person experiences changes in the normal balanced state. Stress can
have physical, emotional intellectual, social and spiritual consequences. Usually the effects are mixed, because
stress affects the whole person. (Fundamental of Nursing, Kozier and Erb, 8th edition, page 1061)
Interpretation:His way of coping up with stress has a vital role to cope up with and divert for the mean time
his attention to other things. Though alcohol wouldn’t help patient FJ to distress in an acceptable manner.
 Saint Francis of Asissi College
045, Admiral Village, Talon III, Las Pinas City
COLLEGE OF NURSING

k. Value – Belief Pattern

Prior to admission, patient admitted that he occasionally goes to the church if he had time for it. And strongly
believes in God.
During the hospitalization, patient stated that his faith still remains the same.
Analysis:Spiritual distress refers to a challenge to the spiritual well-being or to the belief system that provides
strength, hope and meaning to life. Some factors that may associated with or contribute to a person’s spiritual
distress includes physiologic problems, treatment-related concern, and situational concern. (Fundamental of
Nursing, Kozier and Erb, 8th edition, page 1043)
Interpretation:patient didn’t often go to church but despite of that he still believes in God

Physical Assessment

Physical Examination

GENERAL SURVEY
Body Built Proportionate
Posture and Gait Drowsy
Hygiene and Grooming Un kept
Body Odor Smell of EtOH
Sign of Distress Mild confusion
Affect or Mood Alert
Speech Hoarse

VITAL SIGN
Temperature 37.8
Pulse Rate 115 bpm
Respiratory Rate 24 cpm
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Blood Pressure 105/60mmHg

Oxygen Saturation 96%

ANTHROPOMETRIC MEASUREMENT
Height N/A
Weight 80kg
Body Mass Index N/A

SKIN
ACTUAL FINDINGS ANALYSIS & INTERPRETATION
Color Jaundice Caused by high level of bilirubin that secreted by the liver.
HAIR Liver disfunction (medlineplus.gov)
Symmetry of Color Uniform
ACTUAL FINDINGS NoANALYSIS
remarkable &remarks
INTERPRETATION
Edema
Distribution NoEvenly
edemadistributed NoNoremarkable
remarkableremarks
remarks
Skin Lesions
Thickness NoThick
lesion NoNoremarkable
remarkableremarks
remarks
Moisture
Texture and Oiliness Dry N/A It may cause of dehydration
N/A
Temperature
Infestations Cool skin N/A It may cause of his current
N/Amedical condition
Skin
BodyTurgor
Hair Poor N/A It No
mayremarkable
cause of dehydration
remarks

NAILS
ACTUAL FINDINGS ANALYSIS &
INTERPRETATION
Curvature and angle N/A N/A
Texture N/A N/A
Nailbed Color N/A N/A
Surrounding Tissue N/A N/A
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Capillary refill N/A N/A

SKULL AAND FACE

ACTUAL FINDINGS ANALYSIS & INTERPRETATION
Size and Shape Normocephalic No remarkable remarks
Contour N/A No remarkable remarks
Facial Feathers Symmetrical No remarkable remarks
Edema/Hollowness No Edema No remarkable remarks
Facial Movement Symmetrical No remarkable remarks

EYE STRUCTURE AND VISUAL ACUITY

ACTUAL FINDINGS ANALYSIS & INTERPRETATION
Eyebrows Evenly distributed No remarkable remarks
Eyelashes Equally distributed No remarkable remarks
Eyelids N/A N/A
Conjunctiva Jaundice May cause of liver disfunction
Lacrimal Gland N/A N/A
Cornea Transparent No remarkable remarks
Pupils N/A N/A
Peripheral Vision Intact No remarkable remarks
Extraocular Movement N/A N/A

EARS AND HEARING

ACTUAL FINDINGS ANALYSIS & INTERPRETATION
Pinna N/A N/A
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Ear Canal Dry No remarkable remarks

Tympanic Membrane N/A N/A
Hearing Acuity Intact No remarkable remarks

NOSE AND SINUSES

External Nose symmetrical no remarkable finding

Nasal Cavity septum in midline / due to active hematemesis
presence of blood in nares
Sinuses Tenderness normal no remarkable finding

MOUTH AND OROPHARYNX

ACTUAL FINDINGS ANALYSIS & INTERPRETATION
Teeth Yellowish Due to nicotin
Gum Dark Due to high Bilirubin and nicotin
Tongue Dark Cause of nicotine
Palate N/A N/A
Uvula Presence of blood Due to medical condition
Oropharynx In Midline No remarkable remarks
Tonsil Presence of blood Due to his medical condition
Gag Reflex N/A N/A
Lips Pallor Due todehydration

NECK
ACTUAL FINDINGS ANALYSIS & INTERPRETATION
Muscles N/A N/A
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Movement N/A N/A

Rage of Motion N/A N/A
Muscle Strength N/A N/A
Lymph Nodes N/A N/A
Trachea N/A N/A
Thyroid Gland N/A N/A
Carotid Pulse N/A N/A
Jugular Veins N/A N/A

THORAX and LUNGS

ACTUAL FINDINGS ANALYSIS & INTERPRETATION
Breathing Pattern Dyspnea Due to his medical condition
Coastal Angle N/A N/A
Shape and Symmetrical N/A N/A
Spinal Alignment N/A NA
Skin N/A N/A
Respiratory Excursion N/A N/A
Percussion Sound N/A N/A
Breath Sound N/A N/A

HEART
ACTUAL FINDINGS ANALYSIS & INTERPRETATION
Precordium (-) pulsations, heaves, and no remarkable findings
thrills
Heart Sound 115bpm and sinus The heart muscle is weakened that forces it to
beat more often to pump enough blood to the rest
of the body
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BREAST AND AXILLA

ACTUAL FINDINGS ANALYSIS AND INTERPRETATION
Size and shape N/A N/A
Skin N/A N/A
Areola N/A NA
Nipples N/A N/A

ABDOMEN
Actual findings Analysis and interpretation
Skin Integrity + caput medusa, cirrhotic Cause by portal hypertension and liver problem.
habitus
Contour Distended Increase pressure in the portal vein can cause
abdomen ascites.
Symmetry + caput medusa Cause by portal hypertension
Bowel sounds Hyperactive increase in intestinal activity such as vomiting
Percussion Dull presence of a solid mass under the surface
Palpation Non-tender No remarkable findings

GENITALS
Actual findings Analysis and Interpretation
Pubic hair N/A N/A
Labial folds N/A N/A
Clitoris N/A NA
Vaginal orifice N/A N/A
Penile shaft and glands N/A N/A
Urethral Meatus N/A N/A
Scrotum N/A N/A
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Lymph nodes N/A N/A

ANUS AND RECTUM

Actual findings Analysis and Interpretation
Anus N/A N/A
Anal sphincter N/A N/A
Rectal wall N/A NA
Discharge N/A N/A

UPPER AND LOWER EXTREMITIES

Actual findings Analysis and Interpretation
Muscle size N/A N/A
Muscle tone N/A N/A
Muscle strength N/A NA
Bones N/A N/A

a. Review of System

ACTUAL FINDINGS ANAALYSIS AND

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INTERPRETATION
GENERAL Drowsy, smell of EtOH Due to his medical
condition
SKIN Jaundiced, cool skin May result of liver
problem
HEENT (head, eyes, ears, nose, throat) Presence of blood in Due to active
oropharynx and nares. hematemesis
NECK Thyroid gland non No Remarkable Findings
palpable
BREASTS N/A N/A
RESPIRATORY GAEB No Remarkable Findings
CARDIOVASCULAR Normal S1 and s, No No Remarkable Findings
EHS
GASTROINTESTINAL Hematemesisfor 2 days, May result of UGIB
coffee grounds (bright
red blood, ongoing)
URINARY N/A N/A
GENITAL N/A N/A
PERIPHERAL VASCULAR N/A N/A
MUSCULOSKELETAL Normal No Remarkable Findings
PSYCHIATRIC Mild confusion Sign of mild confusion
NEUROLOGIC due to his condition
HEMATOLOGIC N/A N/A
ENDOCRINE N/A N/A

III. Anatomy and Physiology

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COLLEGE OF NURSING

Mouth - the opening through which food is taken in and vocal sounds are made
Pharynx - the passageway leading from the mouth and nose to the esophagus and larynx. The pharynx permits the
passage of swallowed solids and liquids into the esophagus.
Esophagus - Its main job is to deliver food, liquids, and saliva to the rest of the digestive system. Along its course, it
runs down the neck, through the thorax (chest cavity), before entering the abdominal cavity, which contains the
stomach.
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Stomach -it receives food from the esophagus. As food reaches the end of the esophagus, it enters the stomach
through a muscular valve called the lower esophageal sphincter

LEGEND:

IV. Pathophysiology / Psychopathology

Non – modifiable TREATMENT AND

Modifiable factors: Alcohol abuse
factors:
Alcoholism 10-20 bottles per day LABORATORY
Age
Smoker
Lifestyle
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DISEASE PROCESS
Esophagitis
Gastro esophageal
lacerations Portal hypertension SIGNS & SYMPTOMS

Enlargement of vein Endoscopic therapy

Esophageal varices
in the tube hat
connects the throat
LIVER DAMGE
and stomach
INCREASE Blockage in the blood
Jaundice skin
BILIRUBIN LEVEL flow through the liver
756
rupture of the vein
Congestion and
enlargement of the
Administering
spleen
ReducedSengstaken
blood flow – Blakemore
to the liver Tube
Massive bleeding
Vomiting of Coffee
grounds andAdministering
progressed 2U of
Hemorrhagic
to brightBlood shock
red transfusion
Upper Gastrointestinal
Bleeding
Hypotension
Iron deficiency
V. 85/50 Laboratory
Laboratory and results
DECREASE HEMOGLOBIN BUN: 40
Diagnostic
AND HEMATOCRIT Study
CREATININE: 200
Chest X-Ray
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Sengstaken – Bblakemore Tube Insertion

The indication of X-Ray is to determine the placement of the tube.
It is located at the left midline since the esophagus is located there.
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LABORATORY RESULTS
Laboratory and date Result Normal Indication/Significance Analysis & Interpretation
(K) Potassium 4.5 mEq/L 3.5 – 5 mEq/L to prevent or treat low blood levels Potassium within the normal range
Chloride 104 mEq/L 96 – 109 mEq/L maintenaance of osmotic pressure, acid Chloride within the normal range
base balance and electrical neutrality
(Na)Sodium 129 135 – 145 mEq/L an electrolyte that the body needs to Sodium within normal range
function normally and help maintain
fluid and blood volume in the body
Bicarbonate 23 22 – 26 mEq/L it keeps the pH of blood from becoming Bicarbonate within the normal range
too acidic
BUN (blood urea 40 10 – 20 mg/dL test can reveal whether your urea Increase BUN means it has renal impairment
nitrogen ) nitrogen levels are higher than normal,
suggesting that your kidneys or liver
may not be working properly.
(Cr) Creatinine 200 60 – 110 one of the substances that your kidneys increase level of creatinine signifies impaired
micromoles/L normally eliminate from the body. kidney function
Doctors measure the level of creatinine
in the blood to check kidney function.
High levels of creatinine may indicate
that your kidney is damaged and not
working properly.
(GLU) Blood glucose 10 3.9 – 6.4 provides carbohydrate calories to a may be a sign of diabetes, a disorder that can
person who cannot eat because of cause heart disease, blindness, kidney failure and
illnesss, trauma, or other medical other complications
condition
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Venous Blood Gas

Laboratory and date Result Normal Indication/Significance Analysis & Interpretation

(Ph)power of hydrogen 7.21 7.35 – 7.45 measures hydrogen ion in blood A lower pH means that your
blood is more acidic
(PCO2) partial pressure 32 34 – 45 measures how much carbon The partial pressure carbon
carbon dioxide dioxide is dissolved in the blood dioxide is below the normal
and how well carbon dioxide is range
able to move out of the body

(PO2) partial pressure of 40mmhg 80 – 100 mmHg measures the presssure of oxygen PO2 below the normal range
oxygen dissolved in the blood and how
well oxygen is able to move from
the airspace of the lungs into the
blood

(HCO3) Bicarbonate 23 22 – 26 mEq/L chemicaal that keeps the pH of Bicarbonate within the normal
blood from becoming too acidic range

Lactate 4.0 0.5 – 1 mmol/L used to monitor hypoxia and an increase in lactate can
response to treatment being indicate that organs are not
treated for acute condition functioning properly
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important part of the immune an increased production of white blood

system that help to fight cells to fight an infection
infections by attacking bacteria,
viruses and germs that invade
WBC 12.1 5 to 10 x 10.9/L the body. WBC originate in thhe
bone marrow but circulate
throughout the bloodstream.
Is the main component of  Low hemoglobin levels lead to anemia,
erythrocytes, which serves as the which causes symptoms like fatigue and
(Hg) hemoglobin 50 130-180g/L vehicle for the transport of trouble breathing
oxygen and carbon dioxide
In directly measures the RBC Low hematocrit may be due to Anemia
mass, and the result are
(Hct) Hematocrit 22% 40.7% to 50.3% expressed as percentage by
volume of packed red blood
cells.
has an important role in Platelet within the normal range
hemostatis by plugging and
(Plt) Platelet 220 150 – 350x10^9/L repairing damaaged blood
vessels, thus preventing blood
loss. They also participate in a
cascade of events that leads to
blood clotting by triggering the
release of a series of coagulation
factors.
(INR) international 1.8 0.8 - 1.2 ratio It is used to monitor blood means that your blood clots more slowly
normalized ratio thinning medicines, which are than desired
also known as anticoagulant.
(PTT) Partial 51 60- 70 seconds blood test that measures the time low level may be indicative of liver disease,
thromboplastin time it takes your blood to clot, can primary fibrinolysis (a breakdown of clots),
be used to check for bleeding or disseminated intravascular coagulation 
problems.
(AST) aspartate 175 100 to 200 IU/L one of the two enzymes Aspartate aminotransferase is within the
aminotransferase produced by the liver normal range
(ALT) Alanine 73 male: 29 – 33 u/L test measures the level of ALT High levels of ALT in the blood can
transaminase in your blood. ALT is an enzyme indicate a liver problem, even before you
made by cells in your liver. have signs of liver disease, such as
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jaundice, a condition that causes your skin

and eyes to turn yellow
(Bili) Bilirubin 756 3 - 20 an enzyme found in the blood Higher than normal levels of bilirubin in
micromoles/litre that helps break down proteins. your blood may indicate your liver isn't
ALP plays a role in numerous clearing bilirubin properly
processes in the human body,
and any abnormalities in blood
concentrations—either high or
low—may be indicative of
diseases ranging from gallstones
and thyroid disease to hepatitis
and cancer.
EtOH 40 0-50 mg/dL To determine if a person has Etoh result is within the normal range
consumed ethanol and to
measure the level of ethanol in
order to detect and evaluate
impairment, intoxication, or
overdose
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VI. Drug Study

Drug Name Dosage Action Indication Contraindicat Adverse Nursing Responsibilities
ion Effect
Generic name: Dosage:25mg Increase sodium Indicated alone Contraindicate CNS: dizziness, vertigo, headache, > monitor fluid intake and
Microzide, and water or combination d in patient paresthesia, weakness, restlessness output, weight, BP and
Oretic Frequency:QD excretion by for the with anuria CV: orthostatic, hypotension, electrolyte levels: correct
inhibiting management of and patients allergic, myocarditis, vasculitis. electrolyte disturbance
sodium and edema hypersensitive GI: pancreatitis, anorexia, nausea, before start of therapy.
Brand name:
Route: per orem chloride associated with to other epigastric distress, vomiting, > watch for sign and
hydrochlorothia reabsorption in congestive heart sulphonamide abdominal pain, diarrhea, symptoms of hypokalemia,
zide distal segment failure, hepatic derivatives constipation such as muscle weakness and
of the nephron. cirrhosis, GU: renal failure, polyuria, cramps.
Classification: nephritic frequent, urination, intestinal > drug may be used with
syndrome, acute nephritis, erectile dysfunction. potassium- sparing diuretic
glomerulonephri Hematologic: aplastic anemia to prevent potassium loss.
Pharmacologic tis and estrogen agranulocytosis, leukopenia, > consult prescribe and
class: therapy. thrombocytopenia, hemolytic dietitian about a high-
Thiazide Hydrochlorothia anemia. potassium supplement.
Diuretics zide is also Hepatic: Jaundice > monitor creatinine and
indicated alone Metabolic: asymptomatic BUN levels regularly.
or in hyperuricemia. Cumulative effects of drug
Therapeutic combination for Hypokalemia: hyperglycemia and may occur with impaired
class: the management impaired glucose tolerance: fluid renal function.
Diuretics of hypertension. and electrolyte imbalance including > monitor uric acid level,
dilutional hyponatremia and especially in patients with
hypochloremia; metabolic alkalosis, history of gout.
hypercalcemia; volume depletion > monitor glucose level,
and dehydration. especially in diabetic
Musculoskeletal: muscle cramps. patients.
Respiratory: respiratory distress,
pneumonitis.
Skin: dermatitis, photosensitivity
reactions, rash, purpura, alopecia,
erythema multiforme, exfoliative,
dermatitis.
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Drug Name Dosage Action Indication Contraindication Adverse Nursing Responsibilities

Effect
Generic name: Inhibits cell- lower respiratory Contraindicated in GI:pseudo  If large doses are given,
Ceftriaxone Dosage:1g, wall synthesis tract, gynecologic, patients membranecellulitis, therapy is prolonged, or
2g, and promoting bone or joint, intra- hypersensitive to diarrhea. patient is at high risk,
Brand name: 1g/50ml osmotic abdominal skin, or drug or other monitor patient for sign
Rocephin instability skin structure cephalosporins Hematologic: and symptoms of
usually infection; eosinophilia, superinfection
Classification: Route: bactericidal septicaemia. thrombocytosis,  Monitor PT and INR in
Intravenous leukopenia. patients with impaired
vitamin K therapy may
Pharmacologic class: Skin: pain induration, be needed.
Third –generation tenderness, at injection  Drug is commonly used
cephalosporin site, rash. in home antibiotic
programs for outpatient
Therapeutic class:
treatmentof serious
Antibiotic
infection, such as
osteomyelitis and
community-acquired
pneumonia.
 Monitor patients for
superinfection, diarrhea
and anemia and treat
appropriately
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Drug Name Dosage Action Indication Contraindication Adverse Nursing

Effect Responsibilities
Generic name:EpHineprine intramuscula Relaxes Bronchospasm Contraindicated CNS: drowsiness,  In patient with
r injection bronchial hypersensitivity with in patients headache, Parkinson disease,
Brand name: 1mg/mL smooth muscle reactions anaphylaxis with angle closure nervousness, tremor, drug increase rigidity
Epinephrine hydrochloride by stimulating glaucoma shock, cerebral hemorrhage, and tremor.
beta 2 receptors To restore cardia organic brain stroke, vertigo, pain,  Drug interferes with
Classification and alpa and rhythm in cardiac damage, cardiac disorientation, test for urinary
beta receptors in arrest dilation, agitation, fear, catecholamines.
Pharmacologic class: the sympathetic arrhythmias, restlessness, dizziness,  Epinephrine is drug
Adrenergics nervous system coronary weakness, of choice in
insufficiency or subarachnoid emergency treatment
Therapeutic class: cerebral hemorrhage of acute anaphylactic
Vasopressors arteriosclerosis CV: palpitation, reactions.
ventricular fibrillation
shock, widened pulse
pressure,
hypertension,
tachycardia, angina
pain, cardiac
arrhythmias, altered
ECG
GI: nausea, vomiting
Respiratory:
Dyspnea
Skin: urticaria,
hemorrhage at
injection site, pallor
sweating.
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VII. Treatment Modalities

Description Indication Contraindication Nursing Responsibility
IV NS Fluid Bolus This route is normally used in the acute care Contraindicated in any Monitor vital signs, assess for edema, lung
setting when a rapid infusion of fluids is situation where salt retention sounds, and heart sounds, and continue
necessary (e.g., hypovolemia). Delivery of is undesirable such as edema, monitoring during and after the infusion. Monitor
fluid should be administered through large- heart disease, cardiac for continued signs of hypovolemia, including
bore peripheral lines or via central-line decompensation and primary urine output < 0.5 mL/kg/hour, poor skin turgor,
access. or secondary aldosteronism. tachycardia, weak pulse, and hypotension.
Blood Transfusion 2U Indications for transfusion include Megaloblastic anemia Verify doctor’s order. Inform the client and
symptomatic anemia (causing shortness of (vitamin B12 or folate explain the purpose of the procedure. Check for
breath, dizziness, congestive heart failure, deficiency - transfusion may cross matching and typing. To ensure
and decreased exercise tolerance), acute cause heart failure and death), compatibility. Obtain and record baseline vital
sickle cell crisis, and acute blood loss of iron deficiency anemia, signs. Practice strict asepsis. At least 2 licensed
more than 30 percent of blood volume. transfusion in healthy adults nurses check the label of the blood transfusion.
and children where use of Check the following: Serial number, Blood
oral iron could rectify a low component, Blood type, Rh factor, Expiration
hemoglobin. date, Screening test (VDRL, HBsAg, malarial
smear) – this is to ensure that the blood is free
from blood-carried diseases and therefore, safe
from transfusion. Warm blood at room
temperature before transfusion to prevent chills.
Identify client properly. Two Nurses check the
client’s identification. Use needle gauge 18 to 19
to allow easy flow of blood. Use BT set with
special micron mesh filter to prevent
administration of blood clots and particles. Start
infusion slowly at 10 gtts/min. Remain at bedside
for 15 to 30 minutes. Adverse reaction usually
occurs during the first 15 to 20 minutes.
Monitorvital signs. Altered vital signs indicate
adverse reaction (increase in temp, increase in
respiratory rate) Do not mix medications with
blood transfusion to prevent adverse effects. Do
not incorporate medication into the blood
transfusion. Do not use blood transfusion lines for
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IV push of medication. Administer 0.9% NaCl

before; during or after BT. Never administer IV
fluids with dextrose. Dextrose based IV fluids
cause hemolysis. Administer BT for 4 hours
(whole blood, packed RBC). For plasma,
platelets, cryoprecipitate, transfuse quickly (20
minutes) clotting factor can easily be destroyed.
Observe for potential complications. Notify
physician.
Massive Transfusion Massive transfusion protocols are activated There are no absolute Ensure right patient gets right blood product.
Protocol Activation by a clinician in response to massive contraindications for massive Blood administration sets should be as follows,
bleeding. Generally, this is activated after transfusion. according to whichever criterion is met first:
transfusion of 4-10 units. MTPs have a between every 4 units of blood, between
predefined ratio of RBCs, administration of different blood products,
FFP/cryoprecipitate and platelets units between similar blood products but different
(random donor platelets) in each pack (e.g., blood groups, every 12 hours, before infusion of
1:1:1 or 2:1:1 ratio) for transfusion. fluids other that 0.9% saline. Blood Warming,
only use agent compatible with blood products
and lastly document all products administered for
the follow up of any possible complications
related to Infusion therapy.
IV PPI (Bolus and Infusion) IV PPI is indicated in the treatment of high- Contraindicated in patients 5 R’s in medicine administration. Proper
risk peptic ulcers and decreases the size of with PPI hypersensitivity, administration, safety and comfort measures,
esophageal varices and whenever it is vitamin B12 deficiency, institute a bowel program, monitor nutritional
impossible or impractical to give oral hepatic disease, diarrhea, status, ensure follow up, provide support, educate
therapy. pseudomembranous colitis, patient and family.
gastric cancer, bone fractures,
osteopenia, osteoporosis,
hypomagnesemia, long qt
syndrome, rebound acid
hypersecretion, pregnancy,
breast feeding,
phenylketonuria, infants and
neonates, SLE, Lab test
interference, geriatric.
Intubation Indications for intubation to secure the Contraindicated in severe 1. Never leave the patient alone.
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airway include respiratory failure (hypoxic or airway trauma or obstruction

hypercapnic), apnea, a reduced level of that does not permit the safe
consciousness (sometimes stated as GCS less placement of an endotracheal 2. Watch and maintain an open airway.
than or equal to 8), rapid change of mental tube. If an endotracheal tube
status, airway injury or impending airway cannot be placed, but an 3. Remove secretions by effective suctioning.
compromise, high risk for aspiration, or airway needs to be secured, a
'trauma to the box (larynx),' which includes surgical airway is indicated. 4. Prevent displacement of the tube.
all penetrating injuries to the neck, abdomen,
or chest.
5. Watch for complications such as laryngeal
oedema, tracheal stenosis, hemorrhage etc.

6. Provide for the humidification of the air by

boiling a kettle of water in the patient’s unit.

7. Prevent infection introduced into the lungs.

8. Prevent contamination of the inhaled air.

9. Maintain adequate nutrition of the patient by

nasogastric feeding or by giving intravenous
fluids. They should never be fed on oral feeds as
long as the tube is in the mouth.

10. Maintain the oral hygiene of the vital signs.

11. Carefully watch and record the vital signs.

12. Apply suction if there is much secretions.

13. Give oxygen if the patient is cyanosed.

14. Keep an emergency tracheostomy tray with

tracheostomy tubes of correct size at the bed side
of the patient for emergency care.
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Vasopressin Infusion Indicated to increase blood pressure in adults Hypersensitivity; multiple Monitor vital signs, especially blood pressure,
with vasodilatory shock (e.g., post dose vial (10 mL) is hourly during intravenous infusion. Monitor urine
cardiotomy or sepsis) who remain contraindicated in patients output and specific gravity. Assess patient closely
hypotensive despite fluids and with known allergy or for signs of chest discomfort or TIA. Look for
catecholamines. hypersensitivity to 8-L- signs of life-threatening conditions.
arginine vasopressin or
chlorobutanol; the 1 mL
single dose vial does not
contain chlorobutanol;
contraindicated only in
patients with a known allergy
or hypersensitivity to 8-L-
arginine vasopressin
With gastrointestinal (GI)
bleeding, infusion should be
continued for 12-24 hours
after bleeding has stopped,
and dosage should then be
tapered over 24-48 hours
Continuous infusion should
be administered via
controlled infusion device
Use caution in chronic
nephritis with nitrogen
retention
Patients may experience
reversible diabetes insipidus,
manifested by development
of polyuria, a dilute urine,
and hypernatremia, after
cessation of treatment with
vasopressin; monitor serum
electrolytes, fluid status and
urine output after vasopressin
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discontinuation; some
patients may require re-
administration of vasopressin
or administration of
desmopressin to correct fluid
and electrolyte shifts.
Pre- and postoperative
patients with polyuria may
occur.
Use caution in patients with
seizure, migraine, asthma,
heart failure, vascular
disease, angina pectoris,
coronary thrombosis, renal
disease.
Use in pregnant women only
when clearly needed
Sengstaken-Blakemore tube The Sengstaken-Blakemore (SB)tube is a red Contraindications include: Assess for aspiration and airway occlusion, have
tube used to stop or slow bleeding from the Variceal bleeding stops or surgical scissors at bedside, monitor for
esophagus and stomach. The bleeding is slows. Recent surgery that respiratory distress, suction saliva from upper
typically caused by gastric or esophageal involved the esophagogastric esophagus and nasopharynx, check nostrils
varices, which are veins that have swollen junction. Known esophageal frequently and cleanse and lubricate to avoid
from obstructed blood flow. stricture. ulceration, remove after bleeding is controlled.

PCC Vitamin K Indeed, PCC are indicated for the treatment The significant Assess bleeding, monitor for signa and symptoms
or prophylaxis of bleeding in congenital contraindications to PCC for hypersensitivity and thromboembolism,
deficiency of any of the vitamin K-dependent include the following: monitor for infections, For IV administration
coagulation factors when purified specific History of DIC (disseminated observe intermittent infusion, correct rate and y-
coagulation factor products are not available intravascular coagulation) site incompatibility. Inform patient of the purpose
Angina, myocardial and risks of PCC and for female patients to notify
infarction, peripheral vascular nurse of pregnant.
disease, or stroke in the last
three months.
Thromboembolic disease
event history in the previous
three months.
Cardiopulmonary Cardiopulmonary resuscitation (CPR) is an The only absolute Usually, the nurses are the first ones to arrive on
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resuscitation (CPR) emergency procedure that can help save a contraindication to CPR is a the scene so they must initiate cardiopulmonary
person's life if their breathing or heart stops. do-not-resuscitate (DNR) resuscitation (CPR) as well as summon assistance
When a person's heart stops beating, they are order or other advanced from the ‘advanced life support/arrest’ team.
in cardiac arrest. During cardiac arrest, the directive indicating a person's
heart cannot pump blood to the rest of the desire to not be resuscitated
body, including the brain and lungs. in the event of cardiac arrest.
A relative contraindication to
performing CPR is if a
clinician justifiably feels that
the intervention would be
medically futile.

VIII. Problem List

a. All Identified Problems
 Alcoholism (history of present illness)
 Hypotension (course in the ward)
 Smoker (history of present illness)
 Hyperglycemia (Laboratory Result)
 General Chest discomfort (chief complaint)
 Jaundiced (P.A. Skin)
 Nausea and vomiting
 Sinus tachycardia (ECG Result)
 Caput medusa
 Drowsy and mild confusion
 Cirrhotic habitus
 Hypoventilation (PA-VS)
 Hematemesis
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 Abdominal pain (history of present illness)

b. List of Priority Problem

Nursing Diagnosis Rank Justification

Deficient fluid volume related to 1st first priority because when there is too
hypovolemia as evidence by bright much volume is lost it will lead to
red hematemesis hypovolemic shock. It is a condition in
which severe blood and fluid loss impedes
the heart to pump sufficient blood to the
body and as a result tissues are not able to
get enough oxygen that will lead to tissue
or organ damage.
Decrease cardiac output related to 2nd this is second priority because decreased
altered heart rate and rhythm as cardiac output is an often-serious medical
evidence by sinus tachycardia and condition that occurs when the heart does
abnormal heart rate not pump enough blood to meet the needs
of the body.
Ineffective renal tissue perfusion 3rd this is third priority problem because
related to hypovolemia as evidence decrease in oxygen resulting to failure in
by blood pressure of 85/50 and nourishing the tissue at the capillary level
elevated BUN and Creatinine and elevated BUN and creatinine will
result to renal impairment
Deficient knowledge related to lack 4th least priority problem because the
of interest in learning as evidence by condition of the client is already severe and
continues unhealthy habits the student nurse is unable to provide
health education since he passed away.
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IX. Nursing Care Plan

Assessment
Nursing Diagnosis
Scientific Explanation
Goal&Expected Outcome
Nursing Interventions
Rationale
Evaluation
Subjective cues: “dalawangarawnaakongnagsusuka ng dugo” as verbalized by the client

Objective cues:
 BP: 85/50
 massive vomiting of coffee ground to bright red
 drowsy and mild confusion
 jaundice
 elevated hemoglobin (50) and hematocrit (22)

Deficient fluid volume related to hypovolemia as evidence by bright red hematemesis

massive gastrointestinal bleeding

elevated result of hemoglobin and hematocrit

hemorrhagic shock
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reduced cardiac output

deficient fluid volume

Goal: after 8hrs of nursing interventions the client will be able to maintain fluid volume at a functional level

Expected Outcome:
 the clients blood pressure level within normal range
 the client will be able to minimize vomiting of blood
 the client’s hemoglobin and hematocrit level will increase to functional level

Independent:
assess vital signs particularly blood pressure level

monitor serum electrolytes and urine osmolality and report abnormal values

insert an IV catheter to have IV access

provide frequent oral care

assess the skin color of the client monitor signs and symptoms of hypovolemia
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Dependent:
administer blood transfusion as prescribed

Collaborative:
collaborate to a medical technologist

collaborate to the gastroenterology

Independent:

hypovolemia due to GI bleeding may lower blood pressure levels and put the patient at risk for hypotensive episodes that lead to shock

elevated blood urea nitrogen suggests fluid deficit. Urine specific gravity is likewise increased
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parenteral fluid replacement is indicated to prevent or treat hypovolemic complications

to prevent from dryness and to wash out the blood stain inside the mouth

to identify the signs and symptoms of hypovolemia

Dependent:

to increase the hemoglobin level and treat anemia and hypovolemia related to GI bleeding

Collaborative:
to monitor the level of hemoglobin and hematocrit

to examine the gastrointestinal of the client.

after 8hrs of nursing interventions the goal and expected outcome not met because the client wasn’t able to cope up with the
nursing interventions being provided and suddenly passed away.

Assessment
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Nursing Diagnosis
Scientific Explanation
Planning
Nursing Interventions
Rationale
Evaluation

Subjective Cue:
Nahihirapanakonghuminga” as verbalized by the patient.

Objective Cues:
*VS:
BP: 105/60
PR: 115 bpm
RR: 24 cpm
Temp:37.8
*Sinus tachycardia
* massive hematemesis

Decrease Cardiac output related to altered heart rate and rhythm as evidenced by sinus tachycardia and abnormal heart rate
Partial blockage in the artery

Decreased blood supply

Decreased venous return

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Decreased amount of blood expelled by the ventricles

Decrease cardiac output

Goal:
After 8 hours of nursing intervention the patient will be able to display hemodynamic stability(blood pressure and cardiac output) by 105/60 to 120/80

Expected Outcomes:

 After nursing intervention, the pt. will be

able to exhibit warm, dry skin

 After nursing intervention, the pt. will be able to display hemodynamic stability(blood pressure and cardiac output) by 105/60 to 120/80

 After nursing intervention, the client will be able to increase in activity intolerance

Independent:
 Assess and monitor vital Signs
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 Record intake and output.

Note chest pain. Identify location, radiation, severity, quality, duration, associated manifestations such as nausea, and precipitating and relieving factor.

Provide calm, restful surroundings, minimize environmental activity and noise.

Advise to have relaxation techniques, guided imagery such as tv

Dependent:
Administer
Medication (epinephrine)

Blood tranfusion

Collaborative:

Collaborate to cardiologist

Collaborate with medical technologist

independent:
To provide baseline for comparison to follow trends and evaluates response to intervention
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Reduced cardiac output result in reduced perfusion of the kidneys, with a resulting decrease in urine output.

Chest pain/discomfort is generally suggestive of an inadequateblood supply to the heart, which can compromise cardiac output

Helps lessen sympathetic stimulation, and promote relaxation

Can reduce stressful stimuli

dependent:
To increase the output of blood and raising blood pressure.

To replace blood loss

collaborative:
To perform ECG

To examine and monitor laboratory data.

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after 8hrs of nursing interventions the goal not met because the client wasn’t able to cope up with the nursing interventions that being provided

ASSESSMENT
NURSING DIAGNOSIS
SCIENTIFIC
EXPLANATION
GOAL AND EXPECTED OUTCOME/S
INTERVENTIONS

Rationale
EVALUATION
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Objective Cues:
“ ihiako ng ihi, at may time nahinihingalako” as verbalized by the patient.

BP: 105/60
Hr: 115bpm
RR: 24cpm
Temp: 37.8
O2sat: 96%

(+) increased creatinin

(+) increase BUN

(+) jaundice

(+) decreased PH

Ineffective renal tissue perfusion related to hypovolemia as evidence by blood pressure and elevated BUN and Creatinine.
Kidney dysfunction

The kidney doesn’t excrete nitrogenous waste product

Increase lab result of BUN and creatinine

Renal tissue perfussion

Goal.
After 8 hours of nursing intervention the client will demonstrate increased perfusion as individually appropriate as evidence by:

- normal vital sign 105/60 to 105/80

-

Expected outcome:
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After 8 hours of nursing intervention the client will verbalize understanding of condition, therapy regimen, side effects of medication and when to contact health
care provider

- demonstrate behaviors/lifestyle changes to improve circulation

Independent:
- monitor vital sign

- note the characteristic of urine

- review the results of diagnostic studies

- note Mentation

Dependent

Medication given as prescribe by the physician.

- Administer IV fluids as ordered.

Collaborative:

- Laboratory

- Dietician

- Provide baseline data/comparison with the current findings

- to measures specific gravity

- to determine the location/ severity of condition

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- may be altered by increased of BUN and Cr

- sufficient fluid intake maintains adequate filling pressures and optimizes cardiac output needed for tissue perfusion.

- Eating less red meat and fewer fish products may reduce high creatinine levels
After 8 hours of nursing intervention the goal and expected outcome not met because the client wasn’t able to cope up with the nursing interventions being
provided and suddenly passed away.

Assessment Diagnosis Scientific Planning Nursing Rationale Evaluation

Explanation Interventions
Subjective: Deficient Deficient Goal: 1.Establish To ensure compliance of the All of the goals and
“Bakit po knowledge Knowledge After the rapport. patient. Expected outcome were not
akonandito(hospital)? related to nurse’s duty, met due to the patient
Mawawalanarinnama lack of the patient will a.Introduce unfortunately passing away
n po ito(hematemesis) interest in Habitual be able well- self. due to hypovolemic shock
maya maya. Iiinom ko learning as Drinking informed about b.Explain secondary to massive upper
lang po ito ng red evidence by (Alcoholism) his condition purpose. Use of different means of gastrointestinal bleeding
horse hihintona.” as continous and the ways he accessing information
verbalized by the unhealthy can do to 2.Select a promotes learner retention.
patient. habits Abdominal prevent it from variety of
(Alcoholism pain worsening. teaching
Objective: ) strategies (e.g., Individual may not be
(+) Appears confused pamphlets, physically, emotionally, or
(+) Drowsy Esophageal Expected visual aids, mental capable at this time.
Varices Outcomes: hand-outs)
After 3-4 hours
of nursing Assessment
interventions, 1.Assess
Hematemesis the family of readiness to
the patient will learn and
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be able to: individual

learning needs:
Massive
UGIB Participate in a.Ascertain
the learning level of
process. knowledge, Patient may need to suffer
including consequences of lack of
Hypovolemic State the factors anticipatory knowledge before he is ready
Shock that caused needs. to accept information.
Massive Upper b.Determine
Gastrointestinal family’s ability Motivation may be positive or
bleeding and or readiness negative.
Death Esophageal and barriers to
Varices. learning.
(Specify c.Be alert to
modifiable signs of
(Lifestyle, Diet) avoidance.
and non- To prevent overload.
modifiable
(Age) risks)

Verbalize in
his/her own
understanding Can enforce continuation of
the disease efforts.
process.

Verbalize in 2.Assess the

his/her own SO’s
understanding motivation:
of therapeutic a.Identify
needs and motivating Provides knowledge base
possible ways factors for the from which client can make
to prevent the individuals. informed choice.
patient’s
condition on b. provides
becoming information
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worse. relevant only

to the
Demonstrate, situation.
properly check
and monitor the
patient's blood c.Provide
pressure. positive
reinforcement.
Enumerate at
least 3 ways on
how to prevent Health
the recurrence Teaching
of the disease.
Specifically, 1.Review
stop habitual disease
drinking of process/
alcohol and prognosis at
maintain a family’s level
healthy lifestyle of
by eating understanding.
healthy and
drinking a.Etiology
supplementary b.Risk Factors
vitamins and c.Disease
other Process
medications as
necessary.

Initiate
necessary
lifestyle
changes and
participate in
treatment
regimen.
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X. Evidence – Based Nursing

Present Practice Evidence-Based Nursing Practice Recommendation to Present Nursing
Practice
(Hypovolemic Shock) Nasogastric lavage — The use of nasogastric Rapid assessment and resuscitation should
Maintain fluid volume at a tube (NGT) placement in patients with precede the diagnostic evaluation in unstable
functional level suspected acute upper GI bleeding is not patients with severe bleeding. Some patients
Nursing care focuses on assisting recommended, as studies have failed to may require to decrease the risk of aspiration.
with treatment targeted at the demonstrate a benefit with regard to clinical Patients with active bleeding resulting in
cause of the shock and restoring outcomes. As an example, a retrospective hemodynamic instability should be admitted
intravascular volume. study looked at whether there were clinical to an intensive care unit for resuscitation and
Safe administration of blood. It is benefits from NGT lavage in 632 patients close observation. The physician should
important to acquire blood admitted with gastrointestinal bleeding. consider transferring a patient with
specimens quickly, to obtain Patients who underwent NGT lavage were significant upper gastrointestinal bleeding to
baseline complete blood count, matched with patients with similar a tertiary medical center based on local
and to type and crossmatch the characteristics who did not undergo NGT expertise and the availability of facilities.
blood in anticipation of blood lavage. NGT lavage was associated with a Patients admitted primarily for upper
transfusions. shorter time to endoscopy. However, there gastrointestinal bleeding have lower
Safe administration of fluids. The were no differences between those who mortality rates compared with patients
nurse should monitor the patient underwent NGT lavage and those who did admitted for other reasons who have
closely for cardiovascular not with regard to mortality, length of subsequent upper gastrointestinal bleeding
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overload, signs of difficulty of hospital stay, surgery, or transfusion during their hospitalization.
breathing, pulmonary edema, requirement. Similarly, in a randomized trial
jugular vein distention, and with 280 patients with upper GI bleeding,
laboratory results. there were no differences in rebleeding rates
Ref: https://nurseslabs.com or mortality between patients who underwent
/hypovolemic-shock/ NGT lavage and those who did not.
NGT lavage may be used when it is unclear
if a patient has ongoing bleeding and thus
might benefit from an early endoscopy. In
addition, NGT lavage can be used to remove
particulate matter, fresh blood, and clots from
the stomach to facilitate endoscopy.

XI. Course in the Ward

Day Assessment data Doctor’sOrder Nursing Intervention Client response
Day 1 Rhythm: Sinus For progression to next Monitors/ full vital signs Alert, drowsy, intoxicated
tachycardia state Physical examination GCS: 13
HR: 115/min 2 large bore IV access active intermittent bright red
BASELINE BP: 105/60 2 minutes IN NS fluid bolus blood hematemesis
STATE RR: 24/min Hemorrhagic Shock CXR/AXR
O2Sat: 96% EKG
Temp: 37.8 ⁰c Blood work ordered including
type&screen +Coags

Hemorrhagic shock - Blood - IV ns Fluid bolus #2 1 episodes of copious

HR 140 over transfusion/MTP - blood transfusion 2U hematemesis
30seconds initiation HR 120. - Massive Transfusion protocol GCS: 7 (E1V3M4)
BP: 85/50 BP 95/60 activation
- IV PPI (Bolus + Infusion)
- IV NS bolus w/o - Central lines access
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Blood HR 125, BP - Octreotide Bolus + infusion

90/55 transiently - Intubation
- +Vasopressin infusion
Intubation - sengstaken- - 2 suction tips prepared Patients require significant
blakemore tube - Difficult Airway Kit suction, able to intubate via direct
Display - 5 minutes without - Appropriate induction med laryngoscopy
Vt: 500ml Blakemore tube - Appropriate paralytic med
RR 12 placement after - Sengstaken –Blakemore tube
Fi02: 1.0 intubation - GI/ICU/surgery consult
EtC02 = 50 normal -PEA Arrest
waveform
- Preparation (HOB at 45ºc test balloons,
Sengstaken – Blakemore tube check tube markings
Blakemore Tube confirmed with CXR - placement of tube
- CXR
- IV antibiotics
(Ceftriaxone)

Resolution END SCENARIO + PCC/ Vit K Patient Transferred for emergent

HR: 110 endoscopy
BP: 105/80 + TXA

PEA Arrest GI/ICU arrive and - CPR Patient has no Pulse

declare patient - epinephrine
HR: 130 unsalvageable
BP: 0/0
02sat: 0

XII. Discharge Plan

Medications All the remaining tubes, IV lines, and other equipment will be
removed.
Exercise and Activity Restriction N/A
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Diet N/A
Spiritual A spiritual counselor may do a religious ritual depending on the
person's or his family's wishes.
Nursing Coordination  If the person or family agreed on organ donation, certain
body organs or tissue may be taken for donation.
 Family members may want clothing that was removed or
cut away during resuscitation (reviving) efforts.
 The body may be bathed or dressed. The funeral home
may be called when the family is ready to have the body
moved.

XIII. Evaluation
a. Summary of the Study
This case scenario is all about the Hypovolemic Shock secondary to Massive Upper Gastrointestinal Bleeding to a
58 years old male residing at Mandaluyong City and brought to Emergency Department. The client’s complaint of
“general chest pain and nausea” as verbalized by the client. Due to massive upper gastrointestinal bleeding patient
FJ passed away because he couldn’t cope up anymore.

b. Conclusion

The objectives being obtained because the case presenters assessed the health condition of the client and gain a lot
of knowledge that they may be use in the long run of practicing their profession. It is a privilege to have this kind
of case scenario but difficult as well because the case presenters didn’t, we the patient in actual.
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XIV. References

Nurses Pocket Guide 14th Edition by Marilynn E. Doenges, Mary Frances Moorhouse and Alice C. Murr

Nursing Drug Handbook 2018 by Wolters Kluwer

Brunner &Suddarth’s Textbook of Medical – Surgical Nursing Volume 1&2 11th Edition by Suzanne C. Smeltzer, Brenda G.
Bare, Janice L. Hinkle and Kerry H. Cheever

Kozier &Erb’s Fundamentals of Nursing Volume 1&2 11th Edition

Retrieved from https://www.bmj.com/content/364/bmj.l536#:~:text=Upper%20gastrointestinal%20bleeding%20is%20a

%20common%20medical%20emergency,bleed%20and%20is%20typically%20associated%20with%20hemodynamic
%20instability.

Retrieved from https://pubs.niaaa.nih.gov/publications/aa41.htm

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www.ncbi.nlm.nih.gov%2F%3Ffbclid%3DIwAR1Y2IH8n9X1ElxCv_CqhpIL6oShgxhEBqfTrMf-8e9i7DjB2-
tDtL0sizE&h=AT0syr1dMc5k9NhBo9TuyKp2h2iDF7ko2MRKi5QNm37c-zs9v2tsfGN7N7DmowNVrN-K9flhsEqGXK-
BoIG8qgFUxrhO2gkQYb1MdxVu0gBi_pscT6yTs3Q-moRodVh0Rs0ZWLDMUDR035M

net www.researchgate

Kozier and Erbs, Fundamental of Nursing 8th edition. p.1106

https://pubs.niaaa.nih.gov/publications/aa41.htm
medlineplus.gov

https://www.ncbi.nlm.nih.gov/books/NBK422/