Gastrointestinal Bleeding: Assessing Patient Comfort & Changes in Stool

Introduction

The first step is to make sure the patient is comfortable by helping him get on the bed and lie down, increase the air circulation in the room, by opening the window and adjusting the temperature for the patient breathe better. Given that the patient has been diagnosed with bleeding into the gastrointestinal tract, I would inquire from the patient if he has noticed any changes in the appearance of the stool, balk tarry stool would be an indication of active bleeding into the gastrointestinal tract. Next step is to conduct a general examination of the patient to determine if the symptoms experienced are due to active bleeding or by general body weakness caused by intake of a liquid diet (Runciman, Edmonds & Pradhan, 2012).

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After ensuring that the patient is comfortable and breathing better, the next step is to carry out a physical examination of the patient to determine if there are any visible changes in the patient's body. At this point, I would start with the less invasive examinations which include; evaluating the respiratory rate of the patient given that the patient was previously experiencing shortness of breath, examining the eyes and extremities to determine the efficiency of blood circulation. This is especially necessary because of the prior diagnosis.

A further examination of the abdomen is necessary to determine if there are any abdominal distention and tenderness, which is a sign of active bleeding into the gastrointestinal tract (McClennan, 2004).

The patient is on a liquid diet, and this is an indication that he has had an intervention to stop the bleeding and so there is a risk of rapture of the bleeding site inside the tract. Upon determination from the physical examination and information from the patient that there is a possibility of active bleeding, I would then proceed to order for a CT abdomen with the use of intravenous contrast to determine the site of bleeding as well as any other bleeding sites that might not have been detected in the prior examination (Arnold & Pulich, 2004). The choice to go for a CT scan instead of endoscopy is in the best interest of the patient as it is less invasive and would give more conclusive results (Biggs, Hugh & Dodds, 2006).

The results of the endoscopy would then dictate the actions to be taken to restore the patient's health (Costello, 2013). If there is active bleeding in the gastrointestinal tract, I would recommend that the patient be put on tranexamic acid to prevent any further on the fibrinolysis. If the bleeding does not subside, there is then a need for surgical intervention to stop the bleeding. One surgical procedure is the utilization of shunts to treat the bleeds. The energy levels of the patient also need to be boosted by the use of intravenous fluids and increasing the portions of the diet though it might still be a liquid diet (ECRI Institute, 2014). The above measures would ensure the rapid improvement of the patient while still focusing on the safety of the patient.

Prioritization

The question arising from the situation is that of having time versus adequate time to perform the different tasks.

First, it is necessary to evaluate the situation. There are ten minutes between the time the requests are made and the time the patients need to take their breakfast. Of the four patient s who have made a request, One patient needs to be assisted to the bathroom; One patient needs to be prepared for surgery within twenty minutes, One patient needs assistance with his intravenous infusion and the fourth needs nebulization for acute asthma (Ballard, 2003).

The first step is to communicate with the associate nurse letting her know where the list for the preoperative checklist for Mrs. Walters is. The associate nurse is also of help and as she gets the checklist.

Delegation of duties is part of time management. Between the times the requests are made and the time Mrs. Walters has to go in for surgery there is thirty minutes, the presence of the associate nurse serves as extra help in handling the patients. The nurse can first be of assistance in the patient's room by helping the first patient Mrs. Peterson to the bathroom and back into the ward in time for breakfast at 0740 HRS.

Two more patients in the room who need immediate attention, Mr. Young who needs his intravenous line changed as well as addressing his pain, and Mr. Stavropoulous who requires nebulization for acute asthma. Once the associate nurse is through assisting Mrs. Peterson, I would delegate the care of Mr. Young, to change his intravenous line, administer pain medication and give a report on the progress of the patient. Once Mr Yung pain is addressed he just needs to be made comfortable for the rest of the day as he is Nil by mouth and will not require the breakfast.

The third patient is Mr. Stavropoulous, when his blood sugar level was last checked; it was at 4.6mmol/L which is still within the normal range. Patient consideration comes into play. For Mr. Stavropoulous, I would first administer the medication and get the nebulization going. Ventolin nebulization can take up to 15 minutes, and by the time he will be done with the medication, breakfast will have already been served to the patients. I would make arrangements for the hospital caterer to bring Mr. Stavropoulous' breakfast a bit later when he is done with the nebulization.

The fourth patient in the room is Mrs. Walters; she does not need to be served breakfast with the other two patients as she is on her way to the operating room and by this time is NIL by mouth. With the other three patients catered for and the pre-operation checklist located by the associate nurse, the two of us would now have ample time to focus on the preparation of Mrs. Walters for surgery. This is a critical time for both the patient and the doctors, there is a transition of care from one department to another, and the patient has to comprehensively assessed and handed over to the surgical team. I would assist the associate nurse in going through the checklist and handover Mrs. Walters.

Once all the patients have been attended to, I would go back to reassess the other patients making sure they are all comfortable.

Patient Review at Handover

In this case evaluation of the situation is required. The patient in question has a history of heart disease and has undergone surgery to replace and repair the heart valves. The patient is therefore at risk of developing blood clots and hence the prescription of warfarin as an anticoagulant. The patient also requires arthroscopy which is an elective minimally invasive surgery which is essential in countering arthritis (Cvetanovich, 2016). For this purpose, the patient needs to be put off warfarin at least five days before the operation takes place to reduce the risk of excessive bleeding during the surgery. There is still however need to reduce the formation of thrombi during and after the surgery. For this reason, then the patient needs to be put on prophylactic enoxaparin perioperative as well as after the surgery, and that is what is indicated in the medication together.

The patient has however been given additional medication during the stay at the hospital to counter the pain the patient experienced. Though the administration of the pain medication is in the best interest of the patient, the drug interactions between the medication is detrimental to the patient.

According to my knowledge, NSAIDs and Aspirin should not be administered concurrently with Warfarin. Aspirin on its part acts as an anticoagulant and would only increase the thrombolytic effect in the body, the impact of Aspirin on the platelets is also permanent and would take the lifespan of the platelets in the body for the drug to be cleared. The anticoagulative effect of the NSAID on the platelets is not permanent but still would increase the risk of the patient bleeding excessively during the surgery (Schippinger et al. 2015).

The doctor handing over the patient in the morning might not have evaluated the whole situation taking into account the current medication the patient was on, the reason the patient was in the hospital and the pending surgery to be performed later in the week before administering the pain medication.

My action therefore as the doctor who would be handling the patient for the day, my first action would be to consult with the doctor handing over the patient to ascertain the reason for administering the pain medication to the patient, and if he was aware of the patient's prior diagnosis and treatment as well as the upcoming operation that the patient is supposed to undergo.

Standard and quality medical care require that patient safety be placed as a top priority; this involves ensuring that no harm comes to the patient during their stay at the hospital (Gavronski, Hartikainen & Zharkovsky, 2012). This responsibility falls on all the health practitioners concerned with particular medical cases, and so it would be necessary for me bring it to the attention of the previous doctor and the nurses involved, the errors that had occurred and the potential danger this would pose to the patient (Wright, Williams & Wilkinson, 2008). It is my responsibility as a doctor take actions preventing any further errors that would endanger the life of the patient, offer the best possible quality of medical care to the patient.

With the above aspects considered, I would then move to propose that the scheduled surgery be moved to a later date when the hemostatic nature of the patient's blood has been normalized to a considerably safe for operation in consultation with the orthopedic surgical team (Lussier & Richard, 2004).

The patient also needs to be informed of the pending decisions concerning their health and the measures to be taken moving forward (Falterman, Hill, Markey, Fox & Cohn 2004). It is my opinion that the prescribed ibuprofen and Aspirin be withdrawn immediately. The comfort of the patient is also essential, and I would recommend the use of acetaminophen for pain relief until the patient can get the arthroscopy done.

Since the surgery would likely be postponed, I would further recommend that the patient be put back on the initially prescribed warfarin up to five days before the surgery is to be done (Kasper DL et al. 2013). At this point, the warfarin would be withdrawn and replaced with enoxaparin as prophylaxis for thromboembolism and continued for five days postoperative. This would ensure that, the patient is stable enough to undergo surgery and that there is reduced risk of excessive blood loss which might otherwise prove fatal for the patient if not adequately controlled. With the above measures taken, the patient would be assured of quality healthcare, and further errors that might occur in future similar cases would be prevented.

References

Arnold, E., & Pulich, M. (2004). Improving Productivity through More Effective Time Management. The health care Manager, 23(1), 65-70.Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/15035350

Ballard, K. A. (2003). Patient Safety: A Shared Responsibility. Online Journal Of Issues In Nursing, 8(3), 4. Retrieved from: https://www.researchgate.net/profile/Karen_Ballard/publication/8976114_Patient_safety_A_shared_responsibility/links/5a67ea4caca2720266b5e300/Patient-safety-A-shared-responsibility.pdf

Barer, D., Ogilvie, A., Henry, D., Dronfield, M., Coggon, D., French, S., ... & Langman, M. (2013). Cimetidine and Tranexamic Acid in the Treatment of Acute Upper-Gastrointestinal-Tract Bleeding. New England Journal of Medicine, 308(26), 1571-1575. Retrieved from: https://www.nejm.org/doi/full/10.1056/NEJM198306303082606

Biggs, J. C., Hugh, T. B., & Dodds, A. J. (2006). Tranexamic Acid and Upper Gastrointestinal Haemorrhage--A Double-Blind Trial. Gut, 17(9),...