A 60-year-old man is admitted to the emergency department (ED) with a report of vomiting bright red blood. He has had liver cirrhosis for the past 10 years and states that he has been drinking heavily since his wife died last year. His blood pressure is 106/68, and his pulse rate is 94. His abdomen is distended, and he is having some difficulty breathing; his respirations are 34 per minute. You are assigned to care for this patient.

 

  1.   For what complications is this patient at risk and why? What causes these complications?

  2.   In what position will you place the patient and why? What evidence supports your answer? Why do you think he has tachypnea?

  3.   The physician suspects that he has bleeding gastroesophageal varices. What laboratory tests will he likely request and why?

  4.   Vasopressin is prescribed for the patient, and several large-bore IV lines are inserted. What is the purpose of this drug for this patient?

  5.   How will you know if the drug was effective?

  6.   If the drug is not effective in treating the patient, what other options are available for his management?

 

  1.   For what complications is this patient at risk and why? What causes these complications?

Answer

Due to his heavy drinking, this patient is at risk for bleeding esophageal varices. Variceal bleeding can occur impulsively without triggering factors. Even so, any activity that rises abdominal pressure may escalate the possibility of a variceal bleed such as heavy lifting or strenuous physical exercises. Besides, chest damage or dry, hard food in the trachea can lead to bleeding.

  2.   In what position will you place the patient and why? What evidence supports your answer? Why do you think he has tachypnea?

Answer

The patient bed should be positioned with the elevated head of the bed high-Fowler's position at 30 °C or even higher to protect the patient's airway to improve breathing

He has tachypnea as a result of heavy blood loss due to hemorrhage and increases ascetic fluid volume. The elevated bed at an angle relives the patient from tachypnea to ease the breathing.

Step-by-step explanation

 1.   For what complications is this patient at risk and why? What causes these complications?

Answer

Due to his heavy drinking, this patient is at risk for bleeding esophageal varices. Variceal bleeding can occur impulsively without triggering factors. Even so, any activity that rises abdominal pressure may escalate the possibility of a variceal bleed such as heavy lifting or strenuous physical exercises. Besides, chest damage or dry, hard food in the trachea can lead to bleeding.

  2.   In what position will you place the patient and why? What evidence supports your answer? Why do you think he has tachypnea?

Answer

The patient bed should be positioned with the elevated head of the bed high-Fowler's position at 30 °C or even higher to protect the patient's airway to improve breathing

He has tachypnea as a result of heavy blood loss due to hemorrhage and increases ascetic fluid volume. The elevated bed at an angle relives the patient from tachypnea to ease the breathing.

  3.   The physician suspects that he has bleeding gastroesophageal varices. What laboratory tests will he likely request and why?

Answer

The physician will likely request red blood cell, hemoglobin, and hematocrit tests, and prothrombin time/international normalized ratio (PT/INR). Anemia may be indicated by reduced red blood cells, hemoglobin, and hematocrit values. PT/INR test is extended because the liver reduces the release of prothrombin. The platelet count is low, leading to characteristic thrombocytopenia of cirrhosis.

  4.   Vasopressin is prescribed for the patient, and several large-bore IV lines are inserted. What is the purpose of this drug for this patient?

Answer

Vasopressin is a vasoactive medicine that will decrease blood flow through vasoconstriction to minimize portal pressure.

  5.   How will you know if the drug was effective?

Answer

The patient's blood pressure should increase, while his respiratory rate should decline.

 6.   If the drug is not effective in treating the patient, what other options are available for his management?

Answer

Octreotide acetate (Sandostatin) drug may also be used as it inhibits production of gastrin, serotonin, and intestinal peptides which reduces GI blood flow to mitigate pressure within the varices.