Question

Nishad Singh- age 68- ED - sudden onset rectal bleeding w/ 2 bloody stools

•Tired & dragging…this AM worse than usual”

•Mildly anxious-tender LLQ

•BP 133/88, P 104 reg

•T 98

•RR 20, SaO2- 98% on room air

•In ED - 200mL BBB with small amount fecal material

•Now sweaty & light-headed -BP 120/76, P 120

•CT shows mass in sigmoid

•3 more bloody stools > BP 100/72, P 134

•Bolus 1000mL LR, 1unit RBCs ASAP

•To OR ASAP for colon resection

1.What factors will affect your pre-op assessment of Mr. Singh?

2.Describe how you might perform the assessment as well as provide physical care. What modifications, if any, would you make to his assessment?

1.What aspects of pre-op teaching should you stress when caring for Mr. Singh?

2.A bowel preparation is typically part of pre-op preparation for colon surgery. Do you think this will be done for Mr. Singh? Why or why not?

Answer 1

Rectal bleeding is characterized by passage of fresh blood which is bright red from anus or colon or rectum, the bleeding may be mixed with feces or blood clots.

Some causes of rectal bleeding are: cancer , hemorrhoids, anal fissure, rectal ulcer, trauma in rectum, Crohn 's disease, etc.

A written consent should be obtained from the patient or his family after explaining the surgical procedure.

1. The factors which may affect the pre-op assessment of Mr.Singh are:

• He is having pain in left lower quadrant of abdomen
• He is feeling dizzy(light headed)
• He is anxious, not psychologically prepared.
• He is having tachycardia(increased pulse rate)
• He is weak due to passage of bloody stools which makes him dehydrated and also tired.

2. A focused physical examination, and laboratory evaluation should be done to assess the severity of bleeding and its possible location and etiology. His fluid & electrolyte balance, his CBC,blood grouping&typing , Electrolytes, PT, INR, APTT should be assessed at emergency basis. He should be assessed for anemia and other blood disorders.

As he is hemo-dynamically unstable due to bleeding, intravenous fluid resuscitation is necessary to improve his hydration. Transfuse red blood cells to maintain his hemoglobin and blood level in body as he has rectal bleeding . Consider transfusing platelets to maintain hemostasis.

Inquire whether he is using any anticoagulant agents to decide whether to continue or hold medications or use reversal agents to balance the risk of ongoing bleeding with the risk of thrombo-embolic agents.

Digital examination is done for patients with rectal bleeding, as he is bleeding profusely and also having dizziness & tachycardia , MRI & CT can be performed.

He should be kept on NPO , with continuous NG tube aspiration to rule out cause for bleeding .

Carcinoembryonic antigen (CEA) should be checked .

His psychological status should be assessed. He should be provided with psychological support and his family should be engaged in his care.

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1. While caring for Mr. Singh , he should be said to quit smoking , alcohol ( if he is a smoker & drinker). He should be explained that he is very old , so he should be regularly monitored after & before surgery. Also explain him not to strain during defecation. He is high risk for surgery due to his age, so he is monitored closely for his hydration, elimination and cardiovascular along with respiratory status.

DVT(deep vein thrombosis) prophylaxis should be taught to patient and also measures should be taken.

2.Usually a bowel preparation is essential for colon surgery . But here patient is old age , dizzy and tachycardic. Oral administration of bowel preparation agent may lead to aspiration pneumonia, fluid overload, vomiting, and also increase rectal bleeding . So i think , bowel preparation shouldn't be done for Mr. Singh.