Case Study 12 (Gastrointestinal Bleeding) - Prioritization, Delegation, and Assignment

The nurse is talking to Mr. S about his alcohol consumption. Which statement represents the *most* common defense mechanism that is used by people who have problems with alcoholism? •"You would drink, too, if you were married to my wife." •"My wife and I have a couple of beers after work. It's no big deal." •"If you think I drink a lot, you should see my wife put it away." •"I would rather talk to my wife about this situation when I get home."

•"My wife and I have a couple of beers after work. It's no big deal." •Denial is the most common defense mechanism seen among substance abusers. Option 1 represents rationalization, or giving reasons for behavior. Option 3 represents projection, which is a transfer of unacceptable behavior onto others. Option 4 represents suppression, which is a conscious awareness of and avoidance of dealing with the problem.

Mr. S needs to be admitted to the medical-surgical unit for observation and continued management of acute gastritis with bleeding. The ED nurse is calling the receiving nurse on the medical-surgical unit. Prioritize the following information according to the SBAR (situation, background, assessment, recommendation) format. •"Mr. S is 50 years old. He is a vague historian but admits to drinking alcohol for several days, and he takes medication for his stomach. He had intermittent dizziness and fatigue with worsening over the past 2 days. He drove himself to the ED after vomiting bright red blood twice within 6 hours." •"This is Nurse X from the ED. I am calling to give report about Mr. S. He is being admitted for acute gastritis with active bleeding." •"Mr. S should be monitored for removing the NG tube, drinking alcohol in his room, and possible alcohol withdrawal. The HCP is considering an esophagogastroduodenoscopy (EGD)" •"Mr. S is currently alert and oriented but is anxious. The last vital signs are blood pressure, 140/80 mm Hg; pulse, 90 beats/min; respirations, 24 breaths/min; and pulse oximetry reading, 98% on room air. Pain is 2 of 10 in the midepigastric area. He has a 16-gauge peripheral IV line in each forearm. Normal saline is currently infusing at 60 mL/hr in each IV line. He received one unit of packed red blood cells and one unit of fresh-frozen plasma. He has a NG tube in the right nares. Initially, there was small amount of bright red blood with a few small clots. Now the NG tube is on low wall suction."

•"This is Nurse X from the ED. I am calling to give report about Mr. S. He is being admitted for acute gastritis with active bleeding." •"Mr. S is 50 years old. He is a vague historian but admits to drinking alcohol for several days, and he takes medication for his stomach. He had intermittent dizziness and fatigue with worsening over the past 2 days. He drove himself to the ED after vomiting bright red blood twice within 6 hours." •"Mr. S is currently alert and oriented but is anxious. The last vital signs are blood pressure, 140/80 mm Hg; pulse, 90 beats/min; respirations, 24 breaths/min; and pulse oximetry reading, 98% on room air. Pain is 2 of 10 in the midepigastric area. He has a 16-gauge peripheral IV line in each forearm. Normal saline is currently infusing at 60 mL/hr in each IV line. He received one unit of packed red blood cells and one unit of fresh-frozen plasma. He has a NG tube in the right nares. Initially, there was small amount of bright red blood with a few small clots. Now the NG tube is on low wall suction." •"Mr. S should be monitored for removing the NG tube, drinking alcohol in his room, and possible alcohol withdrawal. The HCP is considering an esophagogastroduodenoscopy (EGD)" •Situation: Identify self, location, and purpose of communication. Background: Include relevant information that provides context for the problems or concerns. Assessment: Include current data that are directly related to care. Recommendations: Suggest actions that are needed for follow up and highlight issues that might evolve over time.

What are *priority* interventions to perform for this patient? *Select all that apply.* •Prepare for endotracheal intubation •Assist with central line placement •Check stool for occult blood •Administer supplemental oxygen •Monitor vital signs and oxygen saturation •Monitor hemoglobin and hematocrit

•Administer supplemental oxygen •Monitor vital signs and oxygen saturation •Monitor hemoglobin and hematocrit •Use the ABCs (airway, breathing, and circulation) to prioritize. The patient shows no overt signs of respiratory distress; however, there is a high risk for hypovolemic shock, and supplemental oxygen should be given based on the assumption that the patient has already sustained blood loss and therefore has decreased oxygen-carrying capacity. Vital signs and oxygen saturation should be monitored every 15 minutes for all unstable patients. Hemoglobin and hematocrit are obtained on arrival to establish a baseline for comparison. The patient does not need endotracheal intubation at this point. In an emergency situation, peripheral IVs are usually established first because central line placement is a sterile procedure that takes more time. Eventually the stool should be checked for occult blood, but the presence or absence will not affect the emergency treatment decisions.

After the EGD procedure, Mr. S returns to the medical-surgical unit. He is drowsy but readily arouses to light stimuli. His vital signs are blood pressure, 110/74 beats/min; pulse, 82 beats/min; respirations, 20 breaths/min; and temperature, 99°F (37.2°C). What is the *priority* intervention? •Offer cool oral fluids for sore throat •Raise the side rails of the bed •Apply a small ice pack to the periorbital area •Assess the presence of the gag reflex

•Assess the presence of the gag reflex •During the EGD procedure, a local anesthetic is sprayed into the throat. This makes the passage of the tube less uncomfortable for the patient; however, it also depresses the gag reflex. Food and fluids should be held until the gag reflex returns to reduce the risk of aspiration. A sore throat is expected for a few days and is treated with throat lozenges and cool fluids. The side rails are up during the recovery period but are generally considered as a form of restraints. HCP must prescribe restraints for use on the medical-surgical unit. Periorbital bruising may occur in a few patients but should resolve spontaneously after several days.

The health care provider (HCP) has ordered several immediate (STAT) interventions for Mr. S. Which task would the nurse perform *first*? •Draw blood for complete blood count, and type and crossmatch •Establish two peripheral IV lines with 16-gauge catheters •Insert an NG tube and observe gastric contents •Repeat the vital signs and apply pulse oximeter

•Establish two peripheral IV lines with 16-gauge catheters •The priority for this patient is fluid loss and potential for hypovolemic shock, so the nurse would insert two large-bore peripheral IVs. (Note to student: In clinical, you may see experienced nurses drawing blood from newly inserted peripheral IVs catheters before IV fluid is started; however, drawing blood is not the priority concern.) NG tube is an important part of the therapy for this patient, but it is not considered a life-preserving measure. Repeat vital signs and application of the pulse oximeter are needed. This can be delegated, but the UAP must be instructed to report all values so that the nurse can monitor trends.

A labor and delivery (L&D) nurse calls the ED charge nurse and says, "I heard that Mr. S is in the ED throwing up blood. He's my ex-husband, so I looked up his medical record. How's he doing?" What should the ED charge nurse do *first*? •Invite the L&D nurse down to the ED to see Mr. S in person •Ask Mr. S if he wants information released to his ex-wife •Report the L&D nurse for violation of patient privacy •Explain to the L&D nurse that no information can be given out

•Explain to the L&D nurse that no information can be given out •Even if the L&D nurse is employed by the hospital, only staff members who provide direct care should have access to medical records and patient information. It is inappropriate to invite the L&D nurse to visit the patient. There should be some investigation as to how the L&D nurse found out that the patient was in the ED. If an ED staff member is giving out information about patients, that employee needs to be reminded of the consequences. There should also be some report on the behavior of the L&D nurse. Possibly, more safeguards are needed for computer access to records. The L&D nurse also needs to be reminded of the consequences of obtaining these medical records. Possibly, her or his license could be revoked or suspended or have sanctions placed on it.

The nurse is selecting personal protective equipment (PPE) to don before inserting the NG tube. Which factors will the nurse consider before making the selection? *Select all that apply.* •Facility policies for procedures •Likelihood of exposure to blood and body fluids •Patient's ability and willingness to cooperate •Own skill level and proficiency at procedure •Patient's health history and medical conditions •Availability of PPE at the bedside or on the unit

•Facility policies for procedures •Likelihood of exposure to blood and body fluids •Patient's ability and willingness to cooperate •Own skill level and proficiency at procedure •Patient's health history and medical conditions •The facility should have policies for procedures. For example, gloves, a gown, and an eye shield might be part of the protocol. (Note to student: You may see nurses only wearing gloves for NG tube insertion; this may or may not be a violation of their facility policy.) The likelihood of exposure to blood or body fluids is increased by patient behaviors, such as pulling the tube out or thrashing movements and by nurse's skill level (e.g., unskilled attempts increase gagging, vomiting, coughing, and sneezing; repeated attempts increase saliva, tears, and mucus production). The patient's health history (e.g., tuberculosis or other respiratory disorders) may prompt the nurse to don a filter mask. For Mr. S, the nurse may opt to wear shoe covers because he reports vomiting blood. The availability of PPE should not be a deciding factor. In the case of NG tube insertion, the urgency does not outweigh the time it would take to obtain the proper equipment to maintain personal safety.

Which medications does the nurse anticipate including in the discharge teaching for Mr. S's self-management of gastritis? •H2-receptor antagonists, proton pump inhibitors, and antacids •Diuretics, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors •Mucolytics, expectorants, and nonopioid antitussives •HMG-CoA reductase inhibitors (statins) and bile-acid sequestrants

•H2-receptor antagonists, proton pump inhibitors, and antacids •H2-receptor antagonists, proton pump inhibitors, and antacids are typical medications used to manage gastritis and other gastrointestinal disorders that are aggravated by excessive gastric acid. Diuretics, beta-blockers, and ACE inhibitors would be used for hypertension. Mucolytics, expectorants, and nonopioid antitussives are used for symptom relief of allergic rhinitis, cough, or colds. HMG-CoA reductase inhibitors (commonly referred to as statins) and bile-acid sequestrants are used for cholesterol management.

The nurse sees that Mr. S's international normalized ratio (INR) value is 2.5. Which action should the nurse take *next*? •No action should be taken because this is an expected finding related to gastrointestinal bleeding •HCP should be notified for possible prescription of fresh-frozen plasma (FFP) •Laboratory findings should be reevaluated at completion of treatments •The blood bank should be contacted for additional units of packed red blood cells

•HCP should be notified for possible prescription of fresh-frozen plasma (FFP) •FFP can be used to replace the coagulation factors. This patient has a history of alcohol abuse and may have liver disease, and the liver produces prothrombin and other blood clotting factors. The INR should be 1.1 or below. A higher than normal INR indicates that blood clotting will be slower than expected. For anticoagulation therapy, the therapeutic range is 2.0 to 3.5 (depending on the purpose of therapy, such as deep vein thrombosis prophylaxis or prosthetic valve prophylaxis).

The nurse is preparing to administer a blood transfusion to Mr. S. First, the nurse inspects the bag for leaks, clots, or unusual color and compares the bag label with the chart and the blood bag forms. Place the steps of transfusion in the correct order. •Prime the correct tubing and filter with normal saline •Take vital signs before starting the transfusion •Transfuse the first 10 mL slowly; monitor the patient closely •Have two nurses (or HCPs) compare the blood band identification with the tag on the blood bag •Document the outcomes, names of personnel, and starting and ending times •Repeat vital sign measurement after 15 minutes and then every hour until the transfusion is complete

•Have two nurses (or HCPs) compare the blood band identification with the tag on the blood bag •Prime the correct tubing and filter with normal saline •Take vital signs before starting the transfusion •Transfuse the first 10 mL slowly; monitor the patient closely •Repeat vital sign measurement after 15 minutes and then every hour until the transfusion is complete •Document the outcomes, names of personnel, and starting and ending times •Inspect the bag. If the product appears unusable or if the bag is damaged, contact the blood bank for another unit. Checking labels against the original prescription and blood bank forms is essential. At the bedside, two licensed professionals should compare the bag and identification band. (Note: Priming of the tubing and filter could be done any time before starting the transfusion. In an emergency situation, equipment preparation can be done while waiting for the unit to come from the blood bank.) Measuring vital signs immediately before starting the transfusion provides a baseline in case of transfusion reaction. An acute reaction is most likely to result with transfusion of a small amount blood (or within 15 minutes). A delayed reaction may occur several days after the transfusion. Frequent measurement of vital signs (according to hospital policy) and complete documentation are standard requirements.

The HCP prescribes NG tube insertion. The nurse places the patient in a high Fowler position, provides an emesis basin, and inspects the nostrils for patency. List the correct order of actions for this procedure. •Measure tube from the tip of nose, to the earlobe, to the xiphoid process •Insert the lubricated tube into the most patent nostril •Ask the patient to sip water as the tube is passed •When tube is just above the oropharynx, instruct the patient to bend the chin forward •Check pH to verify tube placement; obtain an order for a radiograph

•Measure tube from the tip of nose, to the earlobe, to the xiphoid process •Insert the lubricated tube into the most patent nostril •When tube is just above the oropharynx, instruct the patient to bend the chin forward •Ask the patient to sip water as the tube is passed •Check pH to verify tube placement; obtain an order for a radiograph •The patient is placed in high Fowler position to prevent aspiration. The length is measured for tip placement into the stomach. Gently insert the tube into the most patent nostril. When the tube is just above the oropharynx, have the patient tip the chin down and then gently advance the tube. When the tip reaches the posterior pharynx, have the patient sip water. Swallowing closes the epiglottis and helps to prevent tracheal intubation. Checking placement is essential before instilling any fluids or medications.

Which serious complications may result from alcohol withdrawal delirium? *Select all that apply.* •Myocardial infarction •Electrolyte imbalance •Aspiration pneumonia •Anaphylaxis •Sepsis •Suicide

•Myocardial infarction •Electrolyte imbalance •Aspiration pneumonia •Sepsis •Suicide •Death can occur from myocardial infarction, fat embolism, peripheral vascular disease, aspiration pneumonia, electrolyte imbalance, sepsis, or suicide. Anaphylaxis would not ordinarily occur unless the patient was allergic to one of the treatments (e.g., drug allergy).

The HCP orders a STAT blood transfusion. In the event of an emergency, a type-specific non-cross-matched blood product could be used. Which blood product could be used in this case? •O negative •AB negative •AB positive •A negative

•O negative •In a medical emergency, the patient can receive O-negative blood. An antibody reaction could result if type A or B blood is administered without typing and cross matching.

After the NG tube is inserted, which assessment finding is cause for *greatest* concern? •The patient reports that the tube is irritating nose and throat feels sore •Gastric contents have a coffee-ground appearance •The patient demonstrates coughing and cannot speak clearly •Gastric fluid is bright red and has small clots

•The patient demonstrates coughing and cannot speak clearly •Coughing and an inability to speak or difficulty in speaking clearly suggests that the tube has been inserted into the trachea. The tube should be removed immediately. Bright red blood with clots indicates active bleeding; this finding verifies the patient's initial history and should be immediately reported to the HCP so that therapy can begin. Coffee-ground appearance of gastric contents indicates old blood; this finding should also be reported but is less urgent. Irritation of the throat and around the nares is commonly reported. Perform hygiene around the nares as needed; irritation of the throat usually subsides, but an anesthetic throat spray may offer some temporary relief.

Mr. S and his wife ask for privacy so that they can talk. Later, when the nurse returns to check on him, the NG tube is on the floor, there is a strong odor of alcohol on Mr. S's breath, and he appears very drowsy. What should the nurse do *first*? •Politely ask the wife to leave and call security to check the room for illicit substances •Assess the patient's mental status and ask what happened to the NG tube •Explain that his behavior is unacceptable and counterproductive to his therapy •Reinsert an NG tube and call the HCP for an order for a STAT blood alcohol test

•Assess the patient's mental status and ask what happened to the NG tube •First assess the patient and try to determine exactly what occurred. Based on the assessment findings, the other options may be used.

What is the *priority* nursing concept to consider in planning emergency interventions for Mr. S? •Pain •Anxiety •Fluid and electrolyte balance •Adherence

•Fluid and electrolyte balance •Vomiting of bright red blood is a sign of active bleeding. The patient's physical assessment findings and vital sign values are indicative of physiologic compensation for blood loss. Pain, anxiety, and adherence can be addressed after the patient is stabilized.

The nurse is *most* likely to seek out which laboratory results to determine if there are untoward effects associated with vomiting, NG suction, or lavage? •White blood cell (WBC) counts •Hematocrit and hemoglobin •Serum electrolytes •Blood urea nitrogen (BUN) and serum creatinine

•Serum electrolytes •The nurse always monitors all laboratory results, but vomiting, NG suction, and lavage (if it is ordered) are most likely to cause fluid and electrolyte imbalances. Fluid loss can cause hemoconcentration and cause artificially elevated levels for hematocrit, hemoglobin, and BUN. BUN is generally more affected by fluid loss than serum creatinine. The WBC count could be elevated because of stress, inflammation, or infection.

The nurse is talking to Mr. S about self-care measures that he should take to prevent recurrence of acute gastritis. For Mr. S, what is the *most* important point to emphasize? •Eat a well-balanced diet that includes protein and carbohydrates •Avoid drinking excessive amounts of alcoholic beverages •Use caution in taking aspirin, other nonsteroidal anti-inflammatory drugs, and corticosteroids •Drink at least eight glasses of noncaffeinated fluid each day

•Avoid drinking excessive amounts of alcoholic beverages •All the teaching points are relevant for self-management of gastritis, but based on the patient's history and the possible use of alcohol even in the hospital, it would appear that Mr. S may have the greatest difficulty in avoiding alcohol consumption.

The HCP recommends that Mr. S have an EGD to stop the bleeding. The nurse sees that the HCP has written on the order sheet: "Have patient sign consent form for EGD." What should the nurse do *first*? •Assess the patient's understanding of the procedure, explain the risks, and obtain the patient's signature if he appears to understand •Call the HCP and politely state that obtaining the patient's consent for a procedure is outside the scope of nursing practice •Ask the charge nurse to clarify if HCPs would typically write this type of order and, if so, how it should be handled •Decline to follow the order, write an incident report, and call the unit manager to report the HCP for writing an inappropriate order

•Call the HCP and politely state that obtaining the patient's consent for a procedure is outside the scope of nursing practice •The best response is to politely and firmly state that the action is outside the scope of nursing practice. Support from the charge nurse would be nice, but if the HCPs typically expect the nurses to have the consent form signed, then the nurse still has to decide whether to go along with the unit norms or to act according to own ethical beliefs and personal understanding of scope of practice. Assessing the patient's understanding is always useful, and if the patient does not understand, then the HCP would have to return to speak with the patient. Declining to follow the order, writing an incident report, and calling the unit manager are viable options, but trying to directly resolve the issue with the HCP would expedite the patient's care.

The laboratory informs the nurse that the phlebotomist may have mislabeled or drawn the sample for STAT blood tests from another patient, not Mr. S. What should the nurse do *first*? •Call the phlebotomist to come back •Draw a new blood sample and label it •Report the phlebotomist to her or his supervisor •Ask the phlebotomist to explain what happened

•Draw a new blood sample and label it •To expedite the STAT order, the nurse would draw the specimen. The other options will only delay the STAT order. After Mr. S's condition is stabilized, tracking down the cause of the error will help prevent recurrences.

During the EGD procedure, Mr. S is given midazolam hydrochloride. What is the *priority* assessment related to this medication? •Monitor for cardiac dysrhythmias •Assess for adequate relief of pain •Monitor depth and rate of respirations •Assess for relief of nausea and vomiting

•Monitor depth and rate of respirations •Midazolam hydrochloride is commonly used for procedures requiring moderate sedation. Depression of depth and rate of respirations is a possible side effect.

Despite the nurse's best efforts at therapeutic communication, Mr. S refuses to cooperate with the NG tube insertion. He threatens to leave "if you stick that tube down my nose." What should the nurse do *first*? •Physically restrain him and insert the tube •Explain the "against medical advice" (AMA) form •Notify the nursing supervisor and patient advocate •Page the HCP and document the attempt

•Page the HCP and document the attempt •Page the HCP and document actions. The HCP may opt to order restraints if the patient cannot make safe decisions. The HCP may try to convince the patient to agree to the therapy or have the patient sign an AMA form if he continues to refuse treatment. The nursing supervisor and the patient advocate can be notified if the situation escalates.

Which task is *most* appropriate to delegate to the unlicensed assistive personnel (UAP)? •Repeating measurement of vital signs •Gathering equipment for nasogastric (NG) tube insertion •Obtaining the blood glucose level every 2 hours •Offering ice chips or small sips of water

•Repeating measurement of vital signs •Repeating vital sign measurements falls within the scope of the UAP's abilities. The UAP (with training) can obtain blood glucose levels and report them; however, there is no indication that blood glucose level should be checked every 2 hours. Gathering certain types of equipment can be delegated; however, for NG tube insertion, the UAP would need an itemized list. The UAP should not be instructed to give ice chips or sips of water. It is likely that the HCP will order oral food/fluid restrictions because of vomiting and to facilitate decompression of the stomach and for possible diagnostic testing.

The nurse suspects that Mr. S may be at risk for alcohol withdrawal effects. What is an *early* manifestation? •Startles easily •Paranoid delusions •Slurred speech •Grand mal seizure

•Startles easily •Watch for signs of neurologic irritability (e.g., psychological [anxiety, jumpiness, or nervousness] and physical [fine tremors, tachycardia, diaphoresis]). Delusions and seizure are later signs. Slurred speech is more frequently associated with alcohol intoxication.

The nurse is performing additional assessment and history taking for Mr. S. Which finding should be *immediately* reported to the HCP? •Melena stools •History of nonsteroidal anti-inflammatory drug use •Tense and rigid abdomen •Risk factors for human immunodeficiency virus

•Tense and rigid abdomen •A tense, rigid abdomen could signal perforation, peritonitis, or a worsening hemorrhage. The other findings are relevant but are less immediately urgent.