NUR 3480 Module 3 GI Bleeding Paper: Variceal Hemorrhage, Risk Scoring and Restrictive Transfusion Example

Seven, Not Nine: Restrictive Transfusion and Nursing Care for Variceal Bleeding in Camden

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-3480: Nursing Care of Clients with Acute and Chronic Conditions

Mentor Name

Month Day, Year

Seven, Not Nine: Restrictive Transfusion and Nursing Care for Variceal Bleeding in Camden

The Patient

Mr. Brennan and the Camden hospital exist only in this paper. Mr. Brennan, 58, has alcohol-related cirrhosis and known esophageal varices. He arrived at the emergency department of a Camden hospital after vomiting a large amount of bright red blood at home. His heart rate was 118, blood pressure 92/58, hemoglobin 8.1 g/dL and blood urea nitrogen elevated. He was confused and his abdomen was distended. He was admitted to the step-down unit after initial stabilization, and the BSN student cared for him with her nurse.

Judging Risk

Blatchford et al. (2000) built a score that sorts patients bleeding from the upper gut by their likely need for transfusion, endoscopy or surgery. It uses blood urea nitrogen, hemoglobin, systolic blood pressure, pulse, melena, syncope, hepatic disease and cardiac failure. A score of zero identifies patients at very low risk who may be managed as outpatients, and higher scores indicate greater need for intervention. Mr. Brennan's score was high, with low blood pressure, fast pulse, low hemoglobin, high urea and liver disease all adding points.

Managing Variceal Bleeding

Garcia-Tsao et al. (2017) set out guidance for portal hypertensive bleeding in cirrhosis. For acute variceal bleeding, they recommended beginning octreotide or a similar vasoactive drug the moment variceal bleeding is suspected, giving antibiotic prophylaxis, often ceftriaxone, because infection is common and worsens outcomes, using a restrictive transfusion strategy with a hemoglobin target of about 7 to 8 g/dL, performing endoscopy within twelve hours with band ligation of bleeding varices and protecting the airway in patients with confusion or massive bleeding. They warned that overtransfusion can raise portal pressure and worsen bleeding.

How Much Blood

Villanueva et al. (2013) randomly assigned adults with severe acute upper gastrointestinal bleeding to receive blood only when hemoglobin dropped under 7 g/dL or whenever it dropped under 9. Survival at six weeks was higher in the restrictive group, 95 percent compared with 91 percent, and further bleeding and adverse events were less common. Among patients with cirrhosis, the benefit was seen in those with less advanced liver disease, and the restrictive strategy prevented the rise in portal pressure seen with liberal transfusion.

Nursing Diagnoses

His diagnoses began with deficient fluid volume from blood loss, risk for aspiration related to vomiting blood and confusion, risk for infection and acute confusion related to hepatic encephalopathy.

Implementation

The nurse placed two large-bore intravenous lines and started fluids cautiously. Octreotide and ceftriaxone were given as ordered within the first hour. The student helped position Mr. Brennan on his side, bed raised at the head, suction ready at the bedside, because his confusion raised the risk of aspiration. When his hemoglobin fell to 6.8 g/dL, one unit of red cells was given, and his hemoglobin rose to 7.6, with no further unit ordered. The student monitored his vital signs every fifteen minutes during transfusion and watched for signs of transfusion reaction and of continued bleeding, such as rising heart rate or new melena. He went for endoscopy within eight hours, and bleeding varices were banded.

Watching for Rebleeding and Infection

After banding, the student watched for signs of rebleeding: a climbing pulse, a falling pressure, fresh blood in vomit, black stools or a lower hemoglobin. She checked vital signs every hour for the first twelve hours and reported a heart rate above 110. She also watched for infection, since patients with cirrhosis and bleeding are prone to bacterial infections, including spontaneous bacterial peritonitis; fever, abdominal pain or worsening confusion would be reported at once. Ceftriaxone continued as ordered for the full course.

Fluids and the Kidneys

Patients with cirrhosis can develop kidney injury after a bleed. The student tracked urine output hourly through the first night and reported two hours in a row of output under 30 mL. Fluids were adjusted, and his creatinine was followed daily; it rose slightly and then returned to his baseline.

Confusion and Lactulose

His confusion was attributed to hepatic encephalopathy triggered by the bleed. Lactulose was started as ordered once he could safely take it, and the student tracked his bowel movements, since the goal was two or three soft stools a day.

Communicating With the Team

During the first night, the student used SBAR when she reported a heart rate of 112 and a new episode of melena to her nurse, who called the gastroenterology fellow. The fellow asked for a repeat hemoglobin, which was stable, and the episode was judged to be old blood passing through. Clear reports helped the team respond in proportion: watchful but not alarmed.

Supporting His Wife

Mr. Brennan's wife was frightened by the amount of blood she had seen at home. The student explained what was being done and what to expect, and offered information about family support groups for alcohol use. She asked whether he could bleed again at home, and the student explained the warning signs and when to call 911.

Evaluation and Teaching

By day three, Mr. Brennan's vital signs were stable, his hemoglobin held at 7.8 g/dL and his confusion cleared. Before discharge, the student and nurse taught him about his new beta-blocker to lower portal pressure, the signs of bleeding to report and the importance of stopping alcohol, and connected him with an addiction counselor.

Limits

The trial excluded patients with massive bleeding and some with high cardiovascular risk. Guidance changes as new evidence appears. A student gives blood or medicines only with supervision, as the hospital's policy allows.

Conclusion

Mr. Brennan's variceal bleed was high risk by the Blatchford score. The AASLD guidance set priorities of vasoactive drugs, antibiotics, early endoscopy and restrictive transfusion, and the Villanueva trial showed that transfusing at 7 rather than 9 saves lives. Careful monitoring, aspiration precautions and attention to encephalopathy completed his nursing care.

References

Blatchford, O., Murray, W. R., & Blatchford, M. (2000). A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. The Lancet, 356(9238), 1318-1321. https://doi.org/10.1016/S0140-6736(00)02816-6

Garcia-Tsao, G., Abraldes, J. G., Berzigotti, A., & Bosch, J. (2017). Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the Study of Liver Diseases. Hepatology, 65(1), 310-335. https://doi.org/10.1002/hep.28906

Villanueva, C., Colomo, A., Bosch, A., Concepción, M., Hernandez-Gea, V., Aracil, C., Graupera, I., Poca, M., Alvarez-Urturi, C., Gordillo, J., Guarner-Argente, C., Santaló, M., Muñiz, E., & Guarner, C. (2013). Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine, 368(1), 11-21. https://doi.org/10.1056/NEJMoa1211801