Kyle Butler, RN, is about to start his shift. Although a recently graduated nurse, Kyle feels comfortable providing care even to the sickest patients because he knows the rapid response team (RRT) is available if needed.
As Kyle reviews his assignment, he notes a new admission from the emergency department (ED). Jon LeBlanc, age 32, was admitted for dehydration secondary to intractable vomiting caused by a GI virus.
History and assessment hints
On assessment, Kyle notes the patient’s pulse is 124 beats/minute (bpm); respiratory rate, 28 breaths/minute; blood pressure, 100/60 mm Hg; and temperature, 99° F (37.2° C). He is alert and oriented, with clear breath sounds and 94% arterial oxygen saturation. Abdominal assessment reveals hyperactive bowel sounds and vague tenderness accompanying persistent nausea. Kyle notes that Mr. LeBlanc has not urinated, vomited, or moved his bowels since his ED admission.
He checks the I.V. line in the patient’s right forearm to verify that the fluids and infusion rate match the physician’s orders. After ensuring that the patient is comfortable and oriented to his environment, he leaves for the nurses’ station to check laboratory results.
Suddenly, the nursing assistant (NA) calls down the hall to him—Mr. LeBlanc is vomiting large amounts of bright red blood. Kyle quickly reassesses the patient’s vital signs (pulse 140 bpm, blood pressure 88/40 mm Hg, respiratory rate 32. He knows bright red blood could mean a Mallory-Weiss tear—which precludes blind placement of a nasogastric tube because this could enlarge the tear. He asks the NA to call the RRT at once.
On the scene
When the RRT arrives, the doctor orders insertion of a second I.V. line to infuse normal saline solution at a wide-open rate, oxygen by nasal cannula, and additional laboratory tests, including a STAT blood type and crossmatch, complete blood count, prothrombin time, and activated partial thromboplastin time to check for coagulopathy.
Meanwhile, the RRT has stabilized the situation, though Mr. LeBlanc continues to bleed from the GI tract. His narrow pulse pressure, tachycardia, and rapid respiratory rate suggest he’s in hypovolemic shock. He’s transferred to the intensive care unit (ICU).
In the ICU, Mr. LeBlanc receives four units of packed cells and undergoes an emergency endoscopy, which finds a Mallory–Weiss tear. This mucosal tear near the gastroesophageal junction may result from forceful vomiting or coughing; the amount of bleeding varies with size of the tear. In most cases, bleeding stops spontaneously, but sometimes blood loss is significant and leads to shock. Mallory-Weiss tears account for about 5% of acute GI bleeding cases.
Treatment depends on the amount of blood lost. The goal is to stop the bleeding and support the patient. Therapy may include fluid replacement, maintaining a patent airway, supporting respiratory and cardiovascular functions, maintaining strict fluid intake and output, monitoring laboratory values (especially hemoglobin and hematocrit), and providing support and education to the patient and family. Complications may include severe thrombocytopenia and coagulopathy.
If GI bleeding doesn’t stop spontaneously, the patient may require endoscopic therapy for both diagnosis and corrective therapy. If all other treatment options fail, surgery may be needed.
Fortunately, Mr. LeBlanc’s endoscopic therapy is successful. After endoscopy and fluid and blood replacement, his hypovolemic status normalizes and he is transferred back to the med-surg unit. When providing discharge teaching, Kyle stresses the importance of getting early treatment for symptoms of a GI illness to help prevent serious complicationns.
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Mary Beth Rauzi is manager of Learning Services at University Hospitals Richmond Medical Center in Richmond Heights, Ohio.