Kingdom of Saudi Arabia

Ministry of Education
Taibah University
College of Applied
Medical sciences Yanbu

Case study

Prepared by: Hadeel Abdulrhman Alruhili

ID : 4051552
Section : YB
Supervised by: Dr. Eman sobhy
 profile

Name : Ms. Winnie

Gender : Female

Age : 33

Setting : Hospital

Ethnicity : White American

Coexisting Condition : Flulike symptoms for one week

Socioeconomic : Recently promoted to project manager

Spiritual/Religious : Jehovah’s Witness

Pharmacological : Norgestimate/ethinyl estradiol (Ortho Tri-

Cyclen); ibuprofen (Advil); pantoprazole (Protonix);
prochlorperazine (Compazine); omeprazole (Prilosec)

Delegation : Delegating within the scope of assistant nursing

personnel responsibilities
Client Profile
Ms. Winnie is a 33-year-old woman who presented to the emergency
department. She states, “I have been so sick. It must be the flu. Everyone at
work has it. I am achy and tired. I keep vomiting and have not been able to
keep anything down for the past three days. After a while, it is just these
violent dry heaves since there is nothing more in my stomach to throw up.
Tonight I vomited twice within three hours and it was red like blood. I got
scared and came in .

Case Study
Ms. Winnie’s vital signs are BP 110/60, HR 88, RR 20, temperature 100.5°F
(38°C). Her skin is clammy and pale. Lab results are WBC 11,800
cells/mm3, RBC 3.31 million/μL, Hgb 11 g/dL, Hct 34%, platelets 150,000
mm3, K 3.8 mEq/L, Na 140 mEq/L. An electrocardiogram (ECG, EKG)
shows normal sinus rhythm. A kidneys, ureters, and bladder (KUB)
abdominal X-ray is done, and she will have an
esophagogastroduodenoscopy (EGD) at 7:00 a.m. the next day. She is
admitted with the diagnosis of probable upper GI bleed. Ms. Winnie
expresses concern to the nurse, “Do you think I’ll be in the hospital long? I
have been managing an important project for the past few months at the
company I work for, and although my boss has been pretty understanding
about me being out sick for the past few days, there is an important
deadline coming up next week. Being in the hospital long may jeopardize
my job.” She is started on intravenous (IV) fluids of normal saline (NS) at
100 mL per hour. Pantoprazole continuous IV drip and prochlorperazine
as needed for nausea and vomiting are prescribed. Ms. Winnie is to have
strict monitoring of her intake and output and her vital signs assessed
every two hours. She will be on bed rest. Her stools are to be tested for
occult blood. She will have a complete blood count (CBC) assessed every
six hours. Results of the KUB are reported as a nonspecific gas pattern with
moderate amount of stool throughout the colon with no acute
abnormality noted. The EGD reveals a normal duodenum with no
vascular anomalies, ulceration, or inflammation. There is a normal
appearing gastric mucosa with no erosive changes, ulcer, or mass. A small
Mallory-Weiss tear is noted.
1. The nurse asks Ms. Winnie if she takes any medi- cations at home. Ms.
Winnie states, “I take Ortho Tri-Cyclen once a day and I was taking
Advil three to four times a day for the aches and pains of being sick.”
Should the nurse suggest to the health care provider that these two
medications be included in Ms. Winnie’s admission orders?
The nurse should suggest that these medications be included in Ms. Winnie's
admission orders. This history will be useful in informing the patient's medication

2. Identify four nursing diagnoses that are appro- priate for Ms. Winnie
upon admission.
1.Imbalanced Nutrition: Less than body requirements r/t unable to eat aeb NPO for
8 hrs before EGD.
2. Anxiety r / t lack of knowledge , and uncertainties about the outcomes of her
health and the fear of prolonged hospital stay.
3. Risk for deficient fluid volume r/t vomiting, gastrointestinal bleeding and
fevers of 38 ̊C.
4.Risk for bleeding r/t GI disorder alb low RBC, Hgb and HTC.
5.Discomfort r/t the disease process as evidenced by the patient feeling achy, tired
as well as the violent dry heaves.

3. Which lab results are abnormal and what is the significance of the
abnormal results in Ms. Winnie’s case?

WBC 11,800 cells/mm3 – ( 4,5-11) infection

RBC 3.31 million/μL (4,3-5,7)
Hct 34% –(39% -49%) decreased could be sing of bleeding
Hgb 11 g/dL –( 13,5-17,5) decreased could be of bleeding
Temp 100.5°F (38°C) - Normal body temperature may range between 97 F
(36.1 C) and 99 F (37.2 C)

4. Distinguish between the characteristics of upper and lower GI

bleeding.
Upper GI bleeding
The upper GI tract includes the esophagus
(the tube from the mouth to the stomach),
stomach, and first part of the small intestine.
Symptoms include hematemesis or melena.
Hematemesis – blood in vomitus or gastric
aspirate – may be bright red (indicating fresh
bleeding) or the color of coffee grounds
(indicating older blood decomposed by gastric
hydrochloric acid). Hematemesis almost always
reflects upper GI bleeding.
lower GI bleeding
The lower GI tract includes much of
the small intestine, large intestine or
bowels, rectum, and anus.
Symptoms include hematochezia or maroon
or black stools. Hematochezia – bright red
blood passed rectally – usually indicates
lower GI (primarily colonic) bleeding.
Maroon stools, formed from gross blood
combined with melena, usually indicate
bleeding distal to the duodenum.
5. It is 1:00 a.m. and Ms. Winnie is settled into her room on the
nursing unit. She asks the nurse “Do you have some saltine
crackers and ginger ale to try and help settle my stomach?”
Should the nurse give Ms. Winnie something to eat?
No, the nurse should not give food or drink because before the
Esophagogastroduodenoscopy (EGD) it is necessary to fast for 6-8 hours before
the operation begins.

6. The nurse recognizes the scenario in Question 5 as a teaching

opportunity. How might the nurse explain why an EGD has been
prescribed for Ms. Winnie and what she can expect during the
procedure?
The nurse should explain that the procedure has been prescribed to diagnose
GI bleeding and to note the location of this bleeding so as to determine the most
appropriate intervention to address this problem.The nurse also needs to
instruct the patient on the requirements before the procedure which includes
the avoidance of solid food from the midnight of the night before the
procedure. The nurse should also prepare the patient by informing them that
they will be required not to eat or drink anything 8 hours prior to the procedure
to ensure a clear visualization of the GI tract.The technique is fairly awkward
yet requires simply 20 to 30 minutes to finish. A local sedative will be utilized
in throat. The nurse should also provide other information such as how the
procedure will be conducted to allay the anxiety of the patient. After the
system, the patient will be permitted to eat and drink when your gag reflex
returns and can swallow. the patient may encounter gentle bulging, beiching, or
tooting . Contact your doctor quickly on the off chance that you build up any of
the accompanying: trouble gulping epigastric, substernal or shoulder torment;
vamiting blood or dark delay stools; or fever.

7. What are the nursing responsibilities after Ms. Winnie has the
EGD and returns to her room?

1.Respond to any questions and concerns raised by the patient.

2.Monitor vital sign and recovery after procedure .
3.NPO and NG tube to low intermittent suction
4. IV fluid replacement
5. Bed rest
6. Monitor vital sings
7. Administer antacids, H2-receptor antagonist, proton pump
inhibitors, anticholinergics, and sedatives as prescribed.
8.documentation .
8. Discuss the Mallory-Weiss tear found during Ms. Winnie’s EGD.
What is a Mallory-Weiss tear? What are the common symptoms
of a Mallory-Weiss tear and what causes it?
1. What is a Mallory-Weiss tear ?

Esophagus It plays a vital role in digestion. Sometimes, violent coughing or

vomiting can tear the tissue of your lower esophagus and it can start to bleed.
The condition is called a Mallory-Weiss tear. and can be diagnosed and treated
through an endoscopic procedure

2. What causes a Mallory-Weiss tear?

A Mallory-Weiss tear is most often caused from violent coughing or vomiting.
Less common causes are a hiatal hernia, or childbirth, which can increase pressure
in your abdomen.

3. What are the symptoms of a Mallory-Weiss tear?

1) Vomit that is bright red or that looks like coffee grounds

2) Stools with blood in them
3) Black or tar-like stools
4) Abdominal or chest pain that sometimes goes to your back
5) Weakness, dizziness, faintness
6) Shortness of breath
7) Diarrhea
8) Paleness

9. Which factors determine if blood products will be administered to

a client with GI tract bleeding secondary to a Mallory-Weiss tear ?
On the off chance that Ms. Winnie turns out to be hemodynamically
temperamental (keeps on dying). Ms. Winnie's hemoglobin is exorbitantly low
under 25% and have clinical manifestations that may should be revived with blood
or blood items.

10. If a transfusion is needed and Ms. Winnie’s blood type is A

positive, what are compatible blood types? Explain why a person
can only receive compatible blood types.
A+ can receive A+, A-, O+, O-. If she given that contradictory blood B,AB, her
antibodies will attack and destroy the foreign red blood cells with antigen B and
thereby causing a transfusion reaction. the benefactor cells are treated as though
they were unfamiliar intruders, because having blood group A means the person
will make antibodies against antigen B. The patient's insusceptible framework
assaults them in like manner. Not exclusively is the blood bonding delivered futile,
yet a possibly enormous actuation of the invulnerable framework and thickening
framework can cause stun, kidney disappointment, circulatory breakdown, and
passing.