Clinical scenarios Victor Newton is a 51-year-old known alcoholic who was admitted to ICU via A&E with a three week history of malaena, recent large volume haematemesis that morning and severe epigastric pain. He had previous episodes of malaena and haematemesis over the Christmas holiday season and was awaiting an out patient endoscopy appointment. Q.1 List the nursing priorities when preparing for and admitting a patient with an emergency GI bleed. Include resources needed such as equipment, drugs, investigations, specialists. An emergency endoscopy is performed which confirms three bleeding oesophageal varices that were banded. Victor then re-bled. A balloon tamponade tube was inserted to exert direct pressure on the ruptured and bleeding vessels. His current medications include intravenous infusion of omeprazole at 8 mg/hour and oral sucralfate (antepsin®) suspension of 2 grams every 6 hours. Q.2 Analyse nursing interventions following balloon tamponade tube insertion which monitor effect and minimise potential complications (e.g. checking tube placement, type of traction methods, free drainage or not, sputum clearance, saliva removal, aspiration pneumonia, tissue pressure necrosis, malaena, metabolic effects of blood in lower GI tract). Q.3 It is decided to remove the balloon tamponade tube at 24 hours. Consider how this process should be managed to minimise the risk of re-bleeding. Victor’s experience of haematemesis and emergency intervention have made him very anxious. Review possible causes of his ruptured varices and the risk of reoccurrence. Specify the liver function investigations he may undergo. Design a plan of care for Victor that focuses on reducing his anxiety and the risk of re-bleeding in ICU, following transfer to ward and after discharge from hospital care.
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Advice should include the reason for and practical strategies regarding: ■ ■ ■ ■ ■ ■ ■ avoiding vigorous coughing and sneezing recognition of early signs and symptoms of re-bleeding relaxation techniques drug action affected by his condition and hepatic impairment (e.g. benzodiazepines, aspirin) paracetamol, some antibiotics, alcohol, cigarettes/nicotine lifestyle changes use of specialist nurses, referral groups.