Gastrointestinal Bleeding: 72-Year-Old Male Patient

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Introduction

The provision of professional medical assistance to patients is closely linked to an in-depth study of the physiological and psychological components of patient health. It must be recognized that the times when a medical professional could diagnose and prescribe therapy based only on personal beliefs and experience are rapidly becoming a thing of the past. Medicine has been replaced by the science of evidence, which seeks to assess the patient’s condition objectively and comprehensively before making any decisions (What is evidence-based, 2016). On this basis, any diagnosis and prescribed treatment must be accompanied by a comprehensive collection of anamnesis and assessment of physiological data that includes not only explicit clinical parameters — be it pulse, pressure, and frequency of breathing exercises — but also information on the pathophysiology of internal systems.

Given the completeness of the information provided in Fabio’s description of the patient’s condition, it was necessary not only to make a potential diagnosis but also to identify possible causes for this condition. Once this had been done, the author of this paper began discussing the pathophysiology of the patient’s condition, including a theoretical description of the shock effect. Routine diagnostic tests and examinations required for checking were further discussed, after which treatment was proposed. As the services of a nurse are crucial for pre-and post-operative patient care, it was necessary to define the range of tasks to be performed. Scenarios were also briefly considered if Fabio would show an improvement or worsening of health after the proposed clinical measures.

Description of the Case Study

A 72-year-old man, Fabio, entered the hospital room complaining of acute epigastric pain and severe dizziness. The purely subjective picture of the patient on his part does not allow an accurate diagnosis to be made, but it is enough to localize the affected area: the anterior projection of the stomach onto the abdomen (Jaiswal, 2018). Dizziness does not appear to be the primary symptom, but rather reflects the effect of pain on sobriety and reasoning ability (Vertigo, 2020). Although traditionally, the patient’s psychological abilities have not been given due attention during acute pain, it is their assessment that makes it possible to choose the right treatment and postoperative recovery strategy. For example, Fabio looks pale, devastated, and sluggish, which can be caused by ongoing pain, as well as by morning vomiting episodes in his blood. The man was sent on an emergency medical examination, which showed the following physiological findings.

Parameter

Value

Respiratory Rate 26 bpm
Oxygen Saturations 90% (room air)
Pulse 124 bpm
Blood Pressure 90/60 mmHg
Capillary Refill Time 4 sec.
Temperature 35.8 °C

Making a Diagnosis

The establishment of a specific diagnosis must be preceded by a critical assessment of the psychosocial and physiological data available. Only based on an objective and comprehensive review of this information can a specific diagnosis be proposed, which must, however, be subject to additional expert evaluation (History taking, 2016). For example, if a potential diagnosis cannot be confirmed using instrumental medical analysis methods, there is, therefore, a risk of prescribing the wrong treatment and only aggravating Fabio’s already unfavorable health condition. In addition, the patient’s initial condition must be considered: vomiting blood cannot be a positive medical signal, which means that destructive processes must be stopped first, and only then must the condition be assessed.

Therefore, the sequence of actions for this patient should be as follows. First of all, he should be admitted to the ward, and professional medical consultation should be held as soon as possible. In the assessment, the doctor or nurse takes into account the general complaints of the patient, carefully examines the patient’s history, and makes a potential diagnosis. In the first few hours after the appointment, the patient must be referred to the operating theatre to stop the internal bleeding and eliminate the primary threats to life. Once the operation has been performed, it will be necessary to carry out a health assessment and determine the reasons for the stomach affection. The doctor will then prescribe treatment, and the nursing staff will ensure proper post-operative care for Fabio’s faster recovery. If the man shows a positive dynamic after a while, the therapy is therefore performed correctly. Otherwise, it will be necessary to reassess the physiological condition and prescribe an alternative treatment.

It is worth noting that at each stage, nursing care plays a decisive role for the patient. A professional practitioner nurse not only helps to keep track of the timing of treatment and medication intake, but also instructs the patient on the need to comply with medical regulations, and provides training on how to take the medication and how to proceed after recovery (Hill, 2017). Finally, the nurse is responsible for the mental state of the patient and supports him and his family members to speed up the recovery.

In this scenario, special attention should be given to breathing frequency, pressure, and heart rate. For a 72-year-old man, this is clearly at odds with the norm: breathing and heart rate are faster, saturation and blood pressure are lower (McGrath, 2020; Kelly, 2018; Low blood pressure, 2020; Sharma and Ghadiyar, 2016). Such data can be a response to internal hemorrhage, and even signal the second stage of hemorrhagic shock (Overview, 2018). Moreover, special attention should be paid to capillary filling time, which is responsible for the specificity of the diet of biological tissues. Capillary filling time is checked by pressing the skin on the finger or in the central part of the sternum for five, followed by an estimate of the time it takes to restore the pale spot color (Gosselin et al., 2016). Since for adults, this rate is defined as two to three seconds, the deceleration characteristic of Fabio (4 seconds) may indicate reduced tissue perfusion (Jevon and Gallier, 2020). This phenomenon may be indicative of impaired capillary integrity and internal bleeding.

Summing up the preliminary assessment of Fabio’s patient, it can be assumed that he has gastrointestinal bleeding, which requires rapid intervention. Although serious dizziness and physiological parameters are likely to indicate such damage, it must be proven by clinical examination as soon as the life-threatening factors affecting Fabio’s life are eliminated. The search for specific reasons for such a diagnosis must be based on known history and from the patient’s perspective. For example, the health care worker knows for sure that Fabio regularly uses ibuprofen to reduce back pain.

An important retreat should be made to discuss how ibuprofen and similar non-steroidal anti-inflammatory drugs work to understand the nature of internal bleeding further. The central mission of taking such medications is to alleviate or reduce pain in combination with a general decrease in body temperature during fever (Rosenbloom et al., 2020). As a standard, NSAIDs are taken for less severe pain, which is due to the non-opioid structure of the active ingredient. The principle of action of such analgesic drugs is to block the enzyme cyclooxygenase, a COX that promotes biochemical reactions that produce prostaglandins. In addition, it has been observed that taking NPVs is associated with a violation of the blood-clotting mechanism (Clopidogrel, 2018) Although ibuprofen itself is an over-the-counter drug, the treating physician must prescribe its use, and the number of pills taken must be regulated.

Unreasonable taking ibuprofen every time Fabio had muscle pain could lead to the development of an NSAID-associated stomach ulcer. Pain relievers can have a specific negative effect on the metabolism of the digestive tract mucosa, significantly reducing its protective properties, potential, and resistance to the damaging effects of exogenous and endogenous factors of aggression (NSAIDs, 2020). In other words, taking these drugs naturally affects all parts of the gastrointestinal tract, causing a wide range of pathological changes. This primarily concerns induced gastropathy, which is detected endoscopically as damage to the mucous membrane of the upper parts of the gastrointestinal tract: gastrointestinal bleeding, ulcer perforation, and impaired digestive tract.

Pathophysiology of Shock

During periods of severe pain, the patient experiences a state of shock, which can, however, be classified according to specific emotional and pathophysiological manifestations and symptoms. For example, any type of shock occurs when the body is exposed to extreme stimuli and can develop in various diseases, injuries, and other pathological conditions (Procter, 2020). Depending on the cause, the classification of shock includes:

haemorrhagic,
traumatic,
burn,
cardiogenic,
septic,
anaphylactic,
neurogenic and other species.

However, it is worth noting that mixed forms of shock caused by a combination of several causes can also be identified: for example, physical trauma resulting in a heart attack.

Based on known facts, it can be said that Fabio is currently experiencing a hemorrhagic shock attack. In medical, scientific terms, it is worth clarifying that this type of shock is defined as a critical state of the body caused by large blood loss, which requires urgent professional assistance from medical professionals. As a result of this shock, the patient has a marked decrease in the blood supply to the organs, resulting in heart failure, expressed in tachycardia. Due to a pathological disturbance in the microcirculation of blood, there is a disturbance in the timely supply of oxygen, energy products, and nutrients to the tissues. Oxygen starvation occurs, which increases as rapidly as possible in the lung system, resulting in increased breathing, shortness of breath, and excitement. The compensatory redistribution of blood leads to a reduction in muscle count, which can be indicated by pale skin, cold and wet limbs. Almost all of these manifestations are characteristic of Fabio’s condition, so it is safe to say that he is in hemorrhagic shock. If he is not treated in time, there is a very high probability of death.

Detailed Discussion Status And Consequences

Gastrointestinal bleeding observed in this patient is defined as the flow of blood from eroded or pathologically damaged blood vessels into the lumen of the digestive organs. Depending on the degree of blood loss and the location of the source of bleeding, the patient may experience vomiting, dark stools, general weakness, tachycardia, dizziness, pallor, cold sweat, and fainting (Oakland et al., 2018). The consequences of continued bleeding affect the whole body.

Thus, when significant amounts of blood are lost, the total amount of blood in the body is reduced, although the effective diameter of the blood vessels remains the same: this leads to a decrease in the velocity of fluid circulation, which is equivalent to a disturbance in the harmony of oxygen delivery to organs and tissues. Slower movement can also lead to stagnation and the formation of glued red blood cells or blood clots (Oakland, 2017). Subsequently, a microcirculation disorder in the liver leads to the organ ceasing to neutralize toxins from the blood and poor production of clotting factors. As a result, the blood becomes liquid or does not coagulate at all. If Fabio had left this situation without medical supervision, the man could soon have died of either pain syndrome or extensive blood loss. In any case, only a professional clinical intervention would significantly increase the man’s chances of recovery and full recovery.

Necessary Diagnostic Examinations

Although the likelihood of a proposed diagnosis matching is high enough, a professional medical specialist should not rule out the possibility of alternative diagnoses. In other words, to establish a specific, confirmed diagnosis, it is necessary to use some instrumental, science-based analysis methods that will help shed light on the problem. An abdominal surgeon examines Fabio: it must begin with a thorough history, an assessment of the nature of vomiting masses and excrement, and a finger rectal examination (Oakland et al., 2019). Attention must also be paid to the color of the skin, as the presence of hematomas and bruises on the skin can be evidence of hemorrhagic diathesis. Assuming that no additional evidence of heredity was found in Fabio’s condition, then we need to move on to the next stage, namely abdominal palpation in various areas. In doing so, special care must be taken to avoid increased gastrointestinal bleeding.

At the time of the examination, blood should be taken from the patient for further biochemical analysis. As this procedure requires a significant amount of time while the lab technicians take measurements, the attending physician must make a direct observation of the state of the gastrointestinal tract. For example, specific practical ideas for this case could be x-rays of the esophagus and stomach, combined with angiography of blood vessels. However, the fastest and most appropriate method is fibro gastro duodenoscopy, which makes it possible to detect even surface defects in the mucosa and the direct source of gastrointestinal bleeding.

If a lesion source is detected, Fabio must be taken immediately to the operating theatre to stop the internal bleeding and to perform surgical treatment of the ulcer. The correct, albeit very radical, strategy to directly treat bleeding from a stomach ulcer is resection (Kawachi et al., 2018). This surgery provides a reliable guarantee of hemostasis and reduces the frequency of repeated bleeding and relapses of ulcers. However, the patient’s age characteristics must be taken into account, and potential risks taken into account. Perhaps a more correct treatment option would be to perform local bonding of blood vessels by ligation or sclerosing (Park et al., 2016). Depending on the specific case, physician’s recommendations, anamnesis, and the patient’s wishes, the medical specialist may use endoscopic bleeding stop methods, electrocoagulation, or blood vessel splintering.

Previously collected blood from a patient’s vein is subject to thorough laboratory examination in several areas at once. In combination with general blood condition indicators such as the concentration of form elements and their physiological dynamics, it is advisable to measure hemoglobin levels and calculate the hematocrit number. Furthermore, the potential for damage to other organs and organ systems should be checked, which can be done by measuring creatinine, urea, and liver samples. Based on the data obtained, the attending physician can confirm his guesses and prescribe postoperative treatment.

Treatment Recommendations

The nursing staff at the clinic takes care of the patient after the surgery, which not only regulates Fabio’s activity after the surgery but also monitors the correctness of the pills. First of all, the patient needs to reduce his motor activity, transfer him to bed rest and, if necessary, transport him on a stretcher (Siau et al., 2017). Simultaneously with these measures, it would be correct to perform the treatment to catalyze thrombosis in damaged vessels. Moreover, it would be appropriate to suggest that Fabio use medication to heal wounds, inhibit the formation of new ulcers and restore homeostasis.

For example, medications are used to take into account the severity and intensity of gastrointestinal bleeding. In the case of relatively mild blood loss, when the volume deficit does not exceed a few percent, it is sufficient to use drugs that block fibrokinase to initiate blood clot conservation. As an analog, tranexamic acid is widely used, which is injected as an intravenous agent in a low-concentration solution at the rate of 15 mg/kg of body weight (Ghadimi et al., 2016; Tranexamic acid, 2017). The more serious drugs for Fabio are Omeprazole (20 mg 2 times a day) and Clarithromycin (500 mg 2 times a day) (Omeprazole 40 mg, 2017). The action of Omeprazole aims to inhibit the enzyme hydrogen potassium ATPase in the parietal cells of the stomach and thus block the final stage of hydrochloric acid synthesis. In this case, this measure is necessary to preserve the integrity of the irritated stomach cavity. Clarithromycin can be prescribed as a preventive measure to erode the development of Helicobacter pylori in the walls of the stomach and intestines (Clarithromycin, 2018).

This drug has a pronounced bactericidal effect.

Nursing Care

The functions of a qualified nurse in an inpatient department include communicating with patients, monitoring their health, performing doctor-appointed procedures, sterilizing instruments, collecting tests as well as bureaucratic paperwork, and collecting statistics (Hill, 2017). Special attention should also be paid to the tasks of communication with family members. If Fabio has relatives who are concerned about his or her health, the nurse should discuss with them the strategy for his or her postoperative treatment, set deadlines, and predict the patient’s stay in the hospital. It would be a good idea to have family contacts in case the medical staff need their help and to ask about possible food and drug allergies of the retired person.

Although Fabio’s case is not an example of palliative care, as the man is expected to survive and recover soon psychosocial help and nurse support are still needed. The psychological problems of the patient significantly reduce the quality of life of the patient and his relatives, so effective support, which is based in colleges and universities, is important. It is important to recognize that a lack of knowledge and communication most often causes anxiety, so the nurse must build a conversation aimed at making up for the lack of knowledge and the need to communicate.

Interprofessional Activities

As the complexity and integrity of Fabio’s therapy system are recognized, it is important to indicate which medical specialists have a direct or indirect impact on the patient’s treatment. Of course, the central figures should include the attending physician, the abdominal surgeon, and the nurse who provides the care. During the time that Fabio spends in the clinic’s ward, he will interact with service staff, administrators, and doctors from other fields who investigate the dynamics of Fabio’s organ pathologies. The male treatment process thus includes several specialists who are responsible for specific tasks: however, the joint and harmonious work of all employees encourages the patient’s quick recovery.

Effects and Consequences

Although it is expected that Fabio will be able to postpone the proposed procedure and show a positive recovery trend in the first weeks, it is necessary to consider a scenario where the disease will continue to progress. This is typical, for example, of a situation where the affected bowel area has been removed, but the blood stagnation has caused path morphology of other organs. In this case, if Fabio is as sluggish, pale, and weak as he was before the resection a few days after the operation, then the current treatment policy needs to be reviewed and new tests collected. Interdisciplinary specialists will help assess the condition of non-intestinal organs, and if organic changes are detected, urgent action will be required. Otherwise, if Fabio’s treatment is smooth and uncompromising, it can be expected that once a man is better, he will be discharged from the hospital. At the same time, some post-clinical examinations must be carried out to ensure that the initial results are reliable in the long term.

Conclusion

An in-depth analysis of medical data obtained from a patient is a priority for the professional’s clinical work. Only based on the principles of evidence-based medicine can assumptions about the diagnosis and causes of pathology be made. This essay examined the case of Fabio’s patient suffering from gastrointestinal bleeding. Based on the history and physiological parameters of the body, some assumptions were made about the diagnosis of this patient – an NPAA-associated stomach ulcer caused by excessive use of ibuprofen. Options for surgical treatment and postoperative care were thus proposed after the diagnosis. It was also shown that Fabio’s treatment is a comprehensive system of clinical interventions requiring the work of multidisciplinary professionals.

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