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GI - 4 Page 1 of 11 Detail Clinical Significance/Impact It is Monday morning and you are working on the medical telemetry unit. History of present illness: You are caring for James Perez, a 37-year-old Hispanic male who arrived from the ED department an hour ago to your medical unit. He came into the ED complaining of bloody stools, abdominal pain, and abdominal cramps. He noticed having frequent, loose, bloody stools about 1 week ago, but reports having diarrhea for several weeks. He is admitted to the medical unit for further evaluation. He speaks English but prefers Spanish and comes to the hospital alone. His temperature is 37.6 °C. He is alert and oriented, ambulatory, and noticeably malnourished. Bloody stools are concerning, and the causes should be determined immediately to reduce the risk of further complications. Abdominal cramps and pain indicate an underlying process going on most likely in the gastrointestinal system. Prolonged diarrhea is a concern for dehydration and electrolyte abnormalities. Bloody diarrhea is a concern for anemia or hemorrhage. Fever may indicate an infection. Social History (from hospital Spanish interpreter) : James was born in Mexico and moved to the US 2 years ago. He is self-employed and works as an information technology consultant. He makes his own meals mostly but does eat fast food 3 or 4 times a week. He smokes cigarettes and reports 1 pack / week usage. He is a moderate alcohol drinker reporting 5, 12-ounce beers/week. His mother is diabetic, and he does not know his father’s medical history. He denies illicit drug use. He is unable to perform his job due to recent Cigarette and alcohol usage are valuable information for gastrointestinal workup. Not being able to perform activities of daily living such as going to work due to the acute illness is cause for concern and should warrant further investigation. Note the last known alcoholic drink so that withdrawal symptoms can be anticipated.
GI - 4 Page 2 of 11 abdominal cramps and diarrhea episodes. Detail Clinical Significance/Impact Medical History: His past medical history includes GERD and Anemia. Subjective History (from Hospital Spanish interpreter) : James believes that his condition has gotten worse over the last month. He used to walk his dog 5 or 6 times a week but has not been able to walk the dog for 2 weeks due to fatigue. James has lost weight recently. James has tried to quit smoking but thinks that cigarettes help his diarrhea slow down. He is concerned that his gastrointestinal issues will affect his career because he has not felt well enough to continue working with clients. James has finished a course of antibiotics recently for an abscess tooth. A reported change in overall wellbeing is something to look into. Often times, patients will know when something is “wrong” within their own body. The correlation between smoking cigarettes and the slowing of diarrhea should be explored. Concern that his condition will affect his livelihood is understandable and should be addressed. Although this could be attributed to generalized anxiety, there could be an underlying issue that needs to be diagnosed. Recent antibiotic use may predispose James to an infection with Clostridioides (formerly Clostridium) difficile. Nursing Assessment: What assessment data is important and why? Vital signs can be impacted by pain, septic shock, hemorrhagic shock, decompensation, and deterioration of a patient’s condition. Gastrointestinal assessment: Bloody stool is significant and profoundly serious if confirmed. The abdomen should be palpated for tenderness, upon which quadrant is tender, appearance, stool characteristics, stool amount, stool color, stool size, stool frequency. Last BM date and time. Auscultation of bowel sounds in all four quadrants. Are they hypoactive, hyperactive, normoactive? Is the patient belching, passing flatus, nauseous? Has the patient vomited? If so, what was the color, frequency, amount, and characteristics of the emesis? Pain: James’ pain is located in his abdomen and is severe. The severe pain correlated with a fever is concerning. The pain is secondary to an underlying gastrointestinal disease process.
GI - 4 Page 5 of 11 The provider orders the following tests Clinical Significance/Impact Fecal occult blood sample FOB will confirm the presence of blood not seen by the eye. Cdiff stool sample To exclude Cdiff infection given diarrhea symptom. Stool cultures To exclude infection due to Salmonella, Shigella, Campylobacter, Yersinia, and Escherichia coli. Stool ova and parasites sample To exclude infection due to parasites and Giardia. CBC Blood test Elevated WBC may indicate infection. Low Hemoglobin/Hematocrit may indicate anemia or blood loss. Chemistry Blood test (^) To evaluate fluid and electrolyte balances due to diarrhea and dehydration. Erythrocyte sedimentation rate An inflammatory marker-Elevated sed rate may indicate ulcerative colitis Albumin level Low albumin may indicate ulcerative colitis and malnutrition Blood cultures Blood cultures will determine if the infection has progressed to the bloodstream. What orders do you expect and why? Vital signs Q4 hours Hemodynamic stability should be frequently assessed (BP and HR). Nursing physical assessment Q6 hours Performing physical examination such as abdominal distention/tenderness), tracking stool output (frequency, consistency, and presence of visible blood). NPO Patients should be made NPO in order to prep for surgical procedures or endoscopic procedures. Intravenous fluid therapy Fluid and electrolyte replacement are necessary to correct and prevent dehydration or electrolyte imbalances. Blood product transfusions Red blood cells are typically needed if the hemoglobin is <7 g/dL Broad Spectrum Antibiotics (ciprofloxacin and metronidazole) Antibiotic therapy is initiated for patients with fever and peritoneal signs. Glucocorticoid therapy (methylprednisolone) (hydrocortisone) systemic (IV) and topical (suppository, foam, or enema) Clinical improvement from glucocorticoid therapy includes fewer stools and less bleeding. Possible Surgical intervention Total abdominal colectomy with end ileostomy may be needed for life-threatening complications such as colonic perforation, toxic megacolon, severe hematochezia with hemodynamic instability requires emergent surgery.
GI - 4 Page 7 of 11 Family Education What education is essential to communicate to James right now about his condition and possible need for blood transfusion? What is important to tell James about fall precautions? •James lives alone, but you can update family as per his request. The provider call phone a family member to update care. James needs to know that he may require a blood transfusion and has a severe, acute illness but is in stable condition. •James is a fall risk due to generalized weakness, secondary diagnosis, continuous IV fluids, and overestimating abilities while ill. •Educate about fall precautions: •Explain the WHY: For your safety, fall precautions reduce the risk of falls while in the hospital thus reducing potential unnecessary injury and complications. a. Bed alarm is on an audible b. Bed is locked and side rails are up x c. Non-slip socks are applied to feet prior to ambulation. d. Call light is in reach. Detail: Case Study Continued Clinical Significance/Impact James is being transferred to the Surgical ICU. You prepare to call report to the ICU nurse Sarah, RN. You review James’s most recent labs and presenting symptoms. James’s has just had a large BM with frank red blood noted. The amount is estimated 400 mL of blood. James reports feeling weak and dizzy. His last meal was 6 hours ago, and he had a sip of water with medications an hour ago. He has Normal Saline 0.9% infusing into a peripheral IV at 100 mL/hr. He is arousable to voice and gentle touch/shaking, while before he had spontaneous eye opening. A large bloody bowel movement is cause for concern. Hemodynamic stability needs to be assessed and maintained. The nurse should give Sarah and updated set of vital signs. Feelings of dizziness could indicate lower blood pressures. No family at bedside, but you can inform which family member was updated earlier via phone. James has been NPO for 6 hours which is important in case he must go for emergency procedures. A sip of water with pills is still considered NPO status. It is important to disclose what IV access is available in case blood transfusion and vasopressor therapy is necessary. Change in LOC is a sign of deterioration in this case possible hemorrhagic shock.
GI - 4 Page 8 of 11 Considering James’s history, what information is important to include handover? Practice using the SBAR format. Situation: James is a 37-year old being admitted for bloody diarrhea for several weeks, with worsening symptoms over the past week. He is a full code, does not have any drug allergies, and is being followed by an Internal Medicine team, GI specialty team, and general surgery. Background: James has a PMH of GERD and anemia. He is a current smoker and social drinker of alcohol. His last drink was 7 days ago. He arrived at the emergency department 1 day ago and has been on the medical telemetry unit for 1 day. His conditioning is worsening, and a higher level of care is needed at this time for hemodynamic monitoring and persistent hypotension. Assessment: James is lethargic, oriented x4, arousable to voice and gentle touch. He reports feeling “tired” and has generalized weakness. His PERRLA is intact. He is on room air with RR between 20- 25 bpm/ is dyspneic with activity and on continuous Sp02 reading 92% currently on RA. Current CXR shows no cardiopulmonary diseases or infiltrates. He is on telemetry with sinus tachycardia reading 125 BPM and denies chest pain. Troponin lab is negative. Current BP is 90/55 mmHg. Peripheral pulses are weak and thready x4. He is NPO with last intake 6 hours ago. He complains of severe abdominal pain 10/10. No opiates have been given. Abdomen is distended, tender to touch in all four quadrants. STAT CT abdomen/pelvis is completed. Last BM was 30 minutes ago hour ago. It was large, liquid, bloody stool with frank blood noted. Estimated 400 mL of blood loss. Stool samples were collected and sent to lab. Recent blood glucose check is 75 mg/dL. Strict intake and output. Voids in a urinal. Output 500 mL so far this shift. Intake is 400 mL of IV fluid. Urine samples collected and sent to lab. Moves all extremities with no overt deficits, generalized weakness noted. Stand by assistance with ambulation. Fall risk precautions placed. Speaks English but prefers Spanish. Lives alone in a house without stairs. Is on SCDs for DVT prevention. Has a 20-gauge peripheral IV catheter in the left AC with NS at 100 mL/hr infusing. Tmax is 101 °F, blood cultures have been collected and sent to lab. Metronidazole has been ordered but first dose not given. CBC, sed rate, and Chemistry labs have been collected and resulted. Recommendation: CT scan results are pending. GI and surgery consultation are pending. IV antibiotic administration is due in 1 hour. Stool sample results pending. Fall precautions. Frequent BP monitoring. Continuous cardiac monitoring. Possible PRBC transfusion. Continue IV fluid for hemodynamics and electrolyte imbalance.
GI - 4 Page 10 of 11 Detail Clinical Significance/Impact Strict I&O High fever places patient at risk for fluid volume deficit. Also, decreased UOP indicates worsening of hemorrhagic or septic shock (decreased blood flow to the kidneys). Follow antibiotic schedule To maintain therapeutic levels and decrease risk of complications. Assist patient with ADL’s (nutrition, elimination, hydration, personal hygiene). Patient may not be aware of needs during acute phase of illness. Test your knowledge!
- How is ulcerative colitis different than Crohn diseases?
- Why does smoking cigarettes affect ulcerative colitis?
- How likely is a colectomy with ulcerative colitis?
- What are the three acute complications of ulcerative colitis? 1. Crohn disease that involves the colon may have a similar clinical presentation to ulcerative colitis, but Crohn’s Disease includes the absence of gross bleeding, anal fissures, anorectal abscesses, or fistulas. 2. Cigarette smoking may decrease or even resolve symptoms of UC which makes smoking cessation for these patients difficult. 3. About 20 - 30 percent of patients with UC will require a colectomy. 4. Severe bleeding- massive hemorrhage may necessitate the need for emergent colectomy. Toxic megacolon- severe inflammatory process with systemic toxicity. Bowel perforation- ulcerative colitis weakens the intestinal wall. Discharge Instructions: What instructions will be included in his discharge home? You are preparing James for discharge. He was in ICU for 14 days and underwent an emergent total abdominal colectomy with end ileostomy. He continuous to have mild abdominal pain and rates his pain 3/10. He is able to ambulate with minimal assistance and will be going home with a home health nurse visiting 3 times a week. He can tolerate his meals with no vomiting or nausea. He is on a low fat, mechanical soft diet. He has a RUQ ileostomy 2-piece pouch that he empties independently. He has a decreased appetite and reports feeling depressed. What instructions will be included in his discharge home? ● Increase activity as tolerated. James will require several weeks of rest but can return to remote computer work when he feels ready. He may have to take more frequent breaks. ● Control pain with acetaminophen and do not take ibuprofen or naproxen. ● Follow low fat, soft textured diet. Drink plenty of fluids. ● Review ileostomy care: - when and how to empty bag - when and how to place new bag - how to check your stoma for problems - showering with your bag ● Follow up with GI provider in 1 week. Follow up with psychiatrist may be warranted due to new onset depression for body image changes. Outpatient ostomy/wound clinic ● follow up in 1 week. PCP follow up in 2
GI - 4 Page 11 of 11 weeks. References Hinkle, J.L., & Cheever, K.H. (2018). Brunner & Suddarth's textbook of medical-surgical nursing (870). Philadelphia: Wolters Kluwer. Lippincott Williams & Wilkins. (2012). The acute abdomen. The Washington Manual of Critical Care. (566). Philadelphia: Wolters Kluwer. Peppercorn, M., Farrell, R., Rutgeerts, P., & Robson, K. (2020). Management of the hospitalized adult patient with severe ulcerative colitis. Uptodate. Philadelphia: Wolters Kluwer. Peppercorn, M., Kane, S., Rutgeerts, P., & Robson, K. (2020). Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults. Uptodate. Philadelphia: Wolters Kluwer.
