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1. INTRODUCTION
• DEFINE DISEASE OR DISORDER
• PATHOPHYSIOLOGY OF DISEASE 1-5
• ETIOLOGY

2. PRESENTATION OF CASE
• DEMOGRAPHIC DATA
• GENERAL HEALTH HISTORY 6
• PAST HEALTH HISTORY
• FAMILY HEALTH HISTORY
• PRESENT HEALTH HISTORY

ASSESSMENT FINDINGS
• PHYSICAL EXAMINATION
• ADL 7-10
• INVESTIGATION

MANAGEMENT OF THE PATIENT FROM ACUTE PASTE UNTILL

DISCHARGE
• SUMMARY OF REPORT OF PATIENT
11-16
• MANAGEMENT AND RATIONALE OF PATIENT
• PHARMACOLOGY MANAGEMENT
• NURSING CARE AND MANAGMENT

3 CONCLUSION
17

4. REFERENCES (APA)
18
 INTRODUCTION

Upper gastrointestinal bleeding (UGIB) is a common problem with an annual

incidence of approximately 80 to 150 per 100,000 population, with estimated
mortality rates between 2% to 15%. UGIB is classified as any blood loss from a
gastrointestinal source above the ligament of Treitz. It can manifest as
hematemesis (bright red emesis or coffee-ground emesis), hematochezia, or
melena. Patients can also present with symptoms secondary to blood loss,
such as syncopal episodes, fatigue, and weakness. UGIB can be acute, occult,
or obscure. About 75% of people presenting to the emergency department with
gastrointestinal bleeding have an upper source. The diagnosis is easier when
the people have hematemesis. In the absence of hematemesis, 40% to 50% of
people in the emergency department with gastrointestinal bleeding have an
upper source.
 PTHOPHYSIOLOGY OF DISEASE

Acute upper GI bleeding may originate in the esophagus, stomach, and

duodenum. Upper GI bleeding can be categorized based upon anatomic and
pathophysiologic factors: ulcerative, vascular, traumatic, iatrogenic, tumors,
portal hypertension. The commonest causes of acute upper GI bleeding are
peptic ulcer disease including from the use of aspirin and other non-steroidal
anti-inflammatory drugs (NSAIDs), variceal hemorrhage, Mallory-Weiss tear
and neoplasms including gastric cancers. Other relatively common causes
include esophagitis, erosive gastritis/duodenitis, vascular ectasias and
Dieulafoy’s lesions. Significant geographical variations in pathophysiology exist
for esophageal varices and peptic ulceration between the East and the West,
with East Asians having a stronger association with non-alcoholic cirrhosis and
helicobacter pylori as their respective etiologies which generally have a more
favorable prognosis. However, esophageal varices and peptic ulcer disease are
nevertheless major causes of upper GI bleeding in both Eastern and Western
societies

Acute lower GI bleeding may originate in the small bowel, colon or rectum.The
causes of acute lower GI bleeding may also be grouped into categories based
on the pathophysiology: vascular, inflammatory, neoplastic, traumatic and
iatrogenic. Common causes of lower GI bleeding are diverticular disease,
angiodysplasia or angiectasia, neoplasms including colorectal cancer, colitis
including Crohn’s disease and ulcerative colitis, and benign anorectal lesions
such as hemorrhoids, anal fissures and rectal ulcers.In the special setting
where the patient is known to have an abdominal aortic aneurysm or an aortic
graft, acute GI bleeding should be considered secondary to aortoenteric fistula
until proven otherwise
 DEFINE DISEASE OR DISORDER
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper
gastrointestinal tract, commonly defined as bleeding arising from
the esophagus, stomach, or duodenum. Blood may be observed in vomit or in
altered form as black stool. Depending on the amount of the blood loss,
symptoms may include shock.
Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric
erosions, esophageal varices, and rarer causes such as gastric cancer. The
initial assessment includes measurement of the blood pressure and heart rate,
as well as blood tests to determine the hemoglobin.
Significant upper gastrointestinal bleeding is considered a medical
emergency. Fluid replacement, as well as blood transfusion, may be
required. Endoscopy is recommended within 24 hours and bleeding can be
stopped by various techniques.[1] Proton pump inhibitors are often
used.[2] Tranexamic acid may also be useful.[2] Procedures (such as TIPS for
variceal bleeding) may be used. Recurrent or refractory bleeding may lead to
need for surgery, although this has become uncommon as a result of improved
endoscopic and medical treatment.
Upper gastrointestinal bleeding affects around 50 to 150 people per 100,000 a
year. It represents over 50% of cases of gastrointestinal bleeding.[2] A 1995 UK
study found an estimated mortality risk of 11% in those admitted to hospital
for gastrointestinal bleeding.[3]
DEMOGRPHIC DATA
NAME: NG CHANG CHAI
NEW IC: 481106085365
AGE:74 YEARS OLD
GENDER: MALE
CITIZEN: CHINESE
OCCUPATION: NOT WORKING
MRN NUMBER: HRPB 220314
DIAGNOSIS: UPPER GASTROINTESTINAL BLEEDING (UGIB)

GENERAL HEALTH HISTORY

-warded 3 years ago because covid-19
-do USG HBS on 20/10/2021
-OGDS on 8/12/22

PAST HEALTH HISTORY

-gallbladder polyp
-liver cyst

FAMILY HEALTH HISTORY

-no family history of malignancy

PRESENT HEALTH HISTORY

-he comes to the hospital with the chief complaint of persistent epigastric pain
and altered bowel habit for 3 months
 PHARMACOLOGY MANAGMENT

NO MEDICATIONS TREAT SIDE EFFECT INDDICATIONS CONTRAINDICATIONS

1. Tablet -to help -nausea -treat -hypersensitivity
bisacodyl 10 empty -diarrhoea constipation. -obstruction
mg STAT bowels if -weakness -vomiting
have stomach -rectal bleeding
constipation. pain or
cramping
2. Tablet -is to treat -headaches -treatment of -severe liver disease
perindopril high blood -flushing hypertension, to -high level potassium
10mg om pressure -swollen lower blood in the blood
ankles pressure -decreased function
-feeling of bone marrow
dizzy

3. Tablet -to treat -blurred -to treat demage -patient with

pantoprazole heartburn, vision from hypersensitivity to
80mg STAT acid reflux -dry skin gastroesophageal the drug itself,
and gastro- -stomach Reflux disease
oesophageal pain
reflux -trouble
disease breathing
 SUMMARY REPORT OF PATIENT

14/3/2023 – patient go to SOPD and complaint of persistent epigastric

pain 6/10
- doctor take blood to do blood test and the result show that
patient have low hemoglobin
- doctor give treatment and refer letter that patient need to be
ward.

15/3/2023 - patient came to the ward and patient general condition alert
and stable.
- admitted from clinic for upper gastrointestinal bleeding with
Alter bowel habit
- doctor plan to do colonoscopy and continue infusion
Pantoprazole.

16/3/2023 -done for colonoscopy and patient result show is contact

bleeding and hemorrhoids
 PHYSICAL EXAMINATION

1. skin -dryness skin

-warm temperature
-darking in upper arm
2. hair -no dandruff
-dry hair
3. eye -pupil black
-conjunctiva is red in right eyes
4. nose -symmetry nose
-have fluid
5. mouth -tonsil not swollen
-dry lips
-pale lips
6. ear -symmetry ear
7. face -symmetry face
8. neck -dry skin
-redness around the tenckhoff wound
9. Chest/thorax -no scars
10. breast -no lumps
-symmetry
11. hands -symmetry
-clean nails
12. legs -symmetry
-clean nails
13. back -normal curvature
14. genitalia -petient refused to answer
MANAGEMENT AND RATIONALE OF PATIENT

✓ Patient need to do procedure COLONSCOPY to detect any upper

gastrointestinal bleeding

✓ Patient need to take medication as prescribe to treat patient

complain for persistent epigastric pain and treat constipation.

✓ Typically treated with a proton pump inhibitor (PPI). The optimal

approach to PPI administration prior to endoscopy is unclear.
Options include giving an IV PPI every 12 hours or starting a
continuous infusion.

✓ Advice patient to rest in bed to reduce patient abdominal pain

 NURSING CARE AND MANAGEMENT

1.Inffective tissue perfusion related to upper gastrointestinal bleeding as

evidenced by patient complain of persistent epigastric pain.

2.Acute pain related to persistent epigastric pain as evidenced by patient pain

score 6/10

3.Deficient knowledge related to patient first time of upper gastrointestinal

bleeding as evidence by patient doesn’t have knowledge to continue health
care plan

4.Deficient fluid volume related to hematemesis as evidenced by abdominal

pain

5.Risk for bleeding related to patient has history of upper gastrointestinal

bleeding.
 ETIOLOGY

Esophageal inflammation and erosive esophagitis and erosive gastritis

represent the second most common causes of upper GI bleeding. Acid reflux is
the most common cause of inflammation of the esophagus. Esophageal varices
(abnormally dilated vessels) are typically seen in patients with portal
hypertension and chronic liver disease and these patients are at an increased
risk for hemorrhage.

In addition to these, vomiting, due to force, can cause ruptures in the

esophagus. (Boerhaave syndrome) and resultant upper GI bleeding. Patients in
shock due to trauma, sepsis, or organ failure can also have upper GI bleeds as a
result of erosions occurring in the presence of decreased blood flow and
altered acidity of the gastric lumen.
 NURSING CARE PLAN
DATE NURSING GOALS NURSING EVALUATION
DIAGNOSIS INTERVENTIONS
Acute pain
15/2/2022 related to Patient’s pain 1.Assess patient pain After 4 hours
@ persistent score will score as a baseline patient’s pain
8:30 am epigastric pain reduce from data and ask the score reduce to
as evidenced 6/10 to 2/10 patient to rate the 2/10
by patient pain pain score from 0 to
score 6/10 10

2.Advice patient to
do not do something
that can get
abdominal pain to
reduce pain from
getting worse.

3.Teach patient to do
deep breathing
exercise to reduce
pain.

4.Promote rest and

sleep by provide
comfortable
environment to
make patient relax
from pain.

5.Administer
medication for
example
paracetamol
according pain
management scale or
base on Dotor’s
order to reduce
patient pain
 CONCLUSION
In the conclusion what I learn, Upper gastrointestinal bleeding was more
common in men of middle age in this study. Proton pump inhibitors were
used in most patients. The overall mortality of 5.7% is similar to other
series. Early EGD and use of endoscopic therapy may lead to a decrease in
mortality in high risk patients. Based on patient case he got symptom such
as complaint of persistent epigastric pain and altered bowel habit for 3
months. After done colonoscopy we can see the abnormalities such as
haemorrhoid,contact bleeding and ascending colon tumor.
 REFERENCES

1.Information given by patient

2.https://www.google.com/search?q=pathophysiology+of+ugib&tbm=isch&ve
d=2ahUKEwjpsrzE_N_9AhWN-nMBHfREB0wQ2-
cCegQIABAA&oq=P&gs_lcp=CgNpbWcQARgAMgQIIxAnMgQIIxAnMgQIABBDM
gQIABBDMgUIABCABDIFCAAQgAQyBQgAEIAEMggIABCxAxCDATIICAAQgAQQs
QMyBQgAELEDOgcIIxDqAhAnULkGWKERYNgpaAFwAHgBgAH6AogBhgiSAQcxLj
EuMi4xmAEAoAEBqgELZ3dzLXdpei1pbWewAQrAAQE&sclient=img&ei=bcsSZK
nIHI31z7sP9Imd4AQ&bih=657&biw=1366#imgrc=gxnjS9agCW2-
nM&imgdii=dTnYcuZSQwkJEM

3.Information get from patient BHT

4. https://empendium.com/mcmtextbook/chapter/B31.II.4.25.4.
 NURSING CARE PLAN

DATE NURSING GOALS NURSING EVALUATION

DIAGNOSIS INTERVENTIONS
15/3/2023 Inffective tissue Patient’s no 1.Assess for the After 4 days in
8:00 am perfusion related complain of patient pain and ask hospitalization
to upper persistent the patient to rate patient no
gastrointestinal epigastric the pain scale from 0 complain of
bleeding as pain to 10 persistent
evidenced by epigastric pain
patient complain 2.Assess for patient
of persistent history of
epigastric pain. gastrointestinal
bleeding to avoid
from getting worse

3.Provide patient to
do not do activity or
take thing that can
causes
gastrointestinal
bleeding.

4.Provide patient to
do endoscopy or
surgery to determine
the location and
cause of upper
gastrointestinal
bleeding.

5.Administer
medication such as
bisocodyl to prevent
further irritation of
the GI mucosa
 ACTIVITY DAILY LIVING
• Patient independent to do daily activity

INVESTIGATION

• FULL BLOOD COUNT

TEST RESULT RANGE

WBC 8.5 4.0 – 11.0
RBC 4.7 4.5 – 6.5
HAEMAGLOBIN 8.7 13.0 – 18.0
PLATELETS 379 150- 400

For blood test show that patient hemoglobin is low because patient
have anemia.
COLONOSCOPY RESULT

IMAGE

FINDINGS
BOWEL PREPARATION pool of fluid at flexures,easily
Aspirated

EXTENT OF COLONOSCOPY complete to caecum

GENERAL APPEARANCE Abnormal

[+] malignancy

Ascending colon

APPEARANCE Fungating

SIZE 2-5 cm

EXTENT OF STENOSIS Able to pass scope through

Ascending colon tumor
COMMENTS Malignant appearance with
Necrotic and slough

[+] Polyp(s)
SITE Transverse colon

TYPE Sessile

MUCOSA Pale

SIZE < 0.5 cm

 NUMBER OF POLYPS 1

COMMENTS Excised completely

[+] Other Findings

ABNORMALITIES Haemorrhoids, contact bleeding
[+] Biopsy for HPE
LESION BIOPSIED Tumour
Polyp

SITE Transverse colon

Ascending colon

NUMBER OF BIOPSIES 4

COMMENTS Biopsy x 16 over Tumour

Biopsy x1 of polyp- complete
excision

ENDOSCOPIC IMPRESSION Bleeding ascending colon tumour