Question

N 30 Simulation Preparation Questions 1. What factors put a patient at risk for developing gastrointestinal bleeding? 2. What laboratory and diagnostic tests would you anticipate? 3. What diagnostic procedures might be used and what would be the nurse's responsibility before and after the procedures. 4. What type of management would you anticipate if the bleed had been acute rather than chronic? 5. What pharmacologic management would the nurse anticipate for a GI bleed? 6. Discuss the standard of care when transfusing any blood product. What will you do? 7. What assessment data do you need to identify an adverse blood transfusion reaction? 8. Describe different blood transfusion reactions. Include manifestations, treatment and potential complications. 9. Describe the pathophysiology and treatment for anaphylaxis.

Answer 1

1. Risk factors :-

• Medication use: ASA, NSAIDs, steroids, anticoagulants, chemotherapeutics

• Hx PUD

• Liver disease or cirrhosis

• Age > 60

• Alcoholism

• Current smoking

• Chronic medical co-morbidities: CHF, DM, CRF, malignancy, CAD

• Hx AAA graft

2. Laboratory and diagnostic tests :-

#. Serum Lab studies

CBC, complete metabolic panel, PT/PTT, triglycerides, liver function tests, amylase, lipase

-CEA/ CA 19-9 sensitivity for GI/colorectal CA (presence, stage, and extent of disease, prognosis, but NOT specific type); alpha-fetoprotein sensitivity for liver cancer

#. Stool Tests

test for: consistency, color, occult blood, urubilinogen, fecal fat, nitrogen, C-diff, fecal leukocytes, stool osmolar gap, parasites, pathogens, food residues, etc; random or quantitative

#. abdominal ultrasonography

-non-invasive; detects enlarged bladder/pancreas, gallstones, enlarged ovary, ectopic pregnancy, appendicitis; acute colonic diverticulitis

-FASTING 8-12 hrs b4 test (to decrease gas in bowel), for gallbladder study: fat free meal evening before test; schedule barium study AFTER US (barium interferes w/ US transmission)

-can't see behind bony tissue; gas/fluid in abdomen/ air in lungs prevent transmission of ultrasound

-Endoscopic ultrasonography (EUS): diagnoses GI disorders by direct imaging of target area; tumor staging; higher quality resolution than regular US; eval. submucosal lesions, barrette's, portal HTN, chronic pancreatitis, pancreatic neoplasm, biliary tract disease, changes in bowel wall d/t ulcerative colitis, biliary obstructive disease; gas, bone, thick layers of fat are no prob w/ EUS

#. DNA testing

test for risk factors: gastric cancer, lactose deficiency, IBS, colon cancer

#. Imaging Studies

x-ray and contrast studies, CT scan, 3-d CT scan, MRI, positron emission tomography (PET), scintigraphy (radionuclide imaging), virtual colonoscopy

#. Upper GI tract study

Barium Swallow: delineates entire GI tract after introduction of barium sulfate or other contrast; thin barium, hypaque, or water also options; double contrast; enteroclysis

-used to: detect or rule out anatomic fxn disorders of upper GI organs or sphincters; dx ulcers, tumors, regional enteritis, malabsorption syndromes; w/ or w/o SBFT; gastric motility, thickness of wall, mucosal pattern, pyloric valve, duodenum anatomy;

-multiple x-rays taken, additional images optional up to 24 hrs to eval gastric emptying; also ileitis/diverticula

Diet: CLEAR LIQUID, NPO from midnight night b4; no smoking, chewing gum, using mints (stimulate gastric motility); meds usually withheld on the morning of the study

Follow up: make sure client has eliminated the barium; increase fluids to facilitate BM's.

#. Lower GI tract study

rectal installation of barium; detects polyps, tumors, lesions of large intestine, anatomic abnormalities, malfxn; double or air contrast may cause cramping/ discomfort (better distinction btwn. lumen and walls);

-prep: evacuation/cleansing of entire colon; low-residue diet 1-2 days b4, clear liquid diet and laxative evening before; NPO after midnight, cleansing enemas until returns are clear morning of; no need for laxatives afterward (contrast expelled readily)

*barium enemas should be scheduled before any upper GI studies*

-enemas contraindicated in: IBD, perforation, obstruction (use water soluble contrast)

-post procedure: FLUIDS; eval BM's for barium passage, note inc. # of BM's b/c barium may cause greater output

#. CT

-provides cross-sectional images

-detects/localizes inflammatory conditions in colon: appendicitis, diverticulitis, regional enteritis, ulcerative colitis, and diseases of liver, spleen, kidney, pancrease, pelvic organs, structural abnorm. of walls

-not useful for thin/cachectic patients (fat helps study)

-considerable radiation doses

-w or w/o IV contrast (eval allergies/serum creat.; urine human chorionic gonadotropin); renal protection: administer IV sodium bicarb 1 hr b4, and 6 hrs after contrast, and oral acetylcysteine (Mucomyst) before or after the study

#. MRI

supplements US and CT; eval's soft tissues, blood vessels, abscesses, fistulas, neoplasms, sources of bleeding

*ferromagnetic objects (containing iron) can be attracted to magnet: jewelry, pacemakers, dental implants, paperclips, pens, keys, IV poles, clips on gowns, O2 tanks; artificial heart valves, implanted insulin pumps/transcutaneous electrical nerve stimulation devices, cochlear implants

-Diet: NPO 6-8hrs prior to study, remove all jewelry/ metals, study takes 60-90 mins; may cause claustrophobia

3. #. Imaging Studies

x-ray and contrast studies, CT scan, 3-d CT scan, MRI, positron emission tomography (PET), scintigraphy (radionuclide imaging), virtual colonoscopy

#. Upper GI tract study

Barium Swallow: delineates entire GI tract after introduction of barium sulfate or other contrast; thin barium, hypaque, or water also options; double contrast; enteroclysis

-used to: detect or rule out anatomic fxn disorders of upper GI organs or sphincters; dx ulcers, tumors, regional enteritis, malabsorption syndromes; w/ or w/o SBFT; gastric motility, thickness of wall, mucosal pattern, pyloric valve, duodenum anatomy;

-multiple x-rays taken, additional images optional up to 24 hrs to eval gastric emptying; also ileitis/diverticula

Diet: CLEAR LIQUID, NPO from midnight night b4; no smoking, chewing gum, using mints (stimulate gastric motility); meds usually withheld on the morning of the study

Follow up: make sure client has eliminated the barium; increase fluids to facilitate BM's.

Lower GI tract study

rectal installation of barium; detects polyps, tumors, lesions of large intestine, anatomic abnormalities, malfxn; double or air contrast may cause cramping/ discomfort (better distinction btwn. lumen and walls);

-prep: evacuation/cleansing of entire colon; low-residue diet 1-2 days b4, clear liquid diet and laxative evening before; NPO after midnight, cleansing enemas until returns are clear morning of; no need for laxatives afterward (contrast expelled readily)

*barium enemas should be scheduled before any upper GI studies*

-enemas contraindicated in: IBD, perforation, obstruction (use water soluble contrast)

-post procedure: FLUIDS; eval BM's for barium passage, note inc. # of BM's b/c barium may cause greater output

CT

-provides cross-sectional images

-detects/localizes inflammatory conditions in colon: appendicitis, diverticulitis, regional enteritis, ulcerative colitis, and diseases of liver, spleen, kidney, pancrease, pelvic organs, structural abnorm. of walls

-not useful for thin/cachectic patients (fat helps study)

-considerable radiation doses

-w or w/o IV contrast (eval allergies/serum creat.; urine human chorionic gonadotropin); renal protection: administer IV sodium bicarb 1 hr b4, and 6 hrs after contrast, and oral acetylcysteine (Mucomyst) before or after the study

MRI

supplements US and CT; eval's soft tissues, blood vessels, abscesses, fistulas, neoplasms, sources of bleeding

*ferromagnetic objects (containing iron) can be attracted to magnet: jewelry, pacemakers, dental implants, paperclips, pens, keys, IV poles, clips on gowns, O2 tanks; artificial heart valves, implanted insulin pumps/transcutaneous electrical nerve stimulation devices, cochlear implants

-Diet: NPO 6-8hrs prior to study, remove all jewelry/ metals, study takes 60-90 mins; may cause claustrophobia

4.

Blatchford score low-risk for all parameters Possible discharge with early investigation as an outpatient YES Upper gastrointestinal endoscopy Non-variceal Variceal Rockall score Endoscopic haemostasis plus medical therapy loctreotide tertipressin Early discharge. If ulcer, treat with usual dose PPI for 6 weeks Stop NSAID & eradicate H. pylori Stop smoking If high-risk ulcer stigmata then PPI infusion 72 hrs usual dose PPI for 6 weeks Stop NSAID & eradicate H. pylori Stop smoking Reduce portal pressure with medical therapy (beta blocker +/ISMN) with or without endoscopic techniques (band ligationsclerotherapy PPI ISMN NSAID proton pump inhibitor isosorbide mononitrate non-steroidal anti-inflammatory drug (including aspirin) Re-bleeding may require repeat endoscopy Surgical or radiological intervention