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The following is a scenario of a patient who experienced ruptured esophageal varices. The patient, Nora Allen, a 55-year-old female presented to the emergency department (ER) on May 5, 2017 just after 10:00 a.m., with complaints of two episodes of melena that morning.
Upon further assessment, her husband expressed concern that his wife had been drinking again because her behavior had seemed “strange”. He had these concerns because his wife had a 20-year history of alcohol abuse and was “under a lot of stress” due to the recent loss of her job. Nora has a history of alcoholism, cirrhosis of the liver, coronary artery disease (CAD) and anemia.
Upon assessment in the ER, her vital signs were 110/76, 85bpm, 95% on room air, 98.2ºF, 22 breaths/min. Neurologically, she was oriented to person, time and situation, but was confused as to where she was. Her pupils were 2mm and sluggish to light. She appeared anxious, was slurring her speech and had visible hand tremors. She reported nausea and melena, and had obvious ascites with a distended firm abdomen. An occult stool was positive and her skin was cool and clammy with poor skin turgor and weak pedal pulses. The remainder of her body systems were within normal limits.
While in the ER, 1 L normal saline (NS) bolus was administered, labs were drawn, a foley catheter was inserted. A blood glucose (finger stick) was taken. She was kept NPO for a scheduled endoscopy later that day.
At 1300, the patient began vomiting and was given an emesis bag. At 1310, Nora’s husband quickly informed the nurse that his wife was violently vomiting bright red blood. On reassessment, the patient’s BP was 94/63 and the HR was 98bpm. The patient was started on octreotide 50mcg bolus. She was intubated for airway protection and to prevent aspiration. She was administered 1 unit of packed red blood cells (PRBCs) and was taken immediately to the gastrointestinal lab for a STAT endoscopy for possible esophageal banding therapy.
The patient was diagnosed with ruptured esophageal varices and sent to the ICU for close observation and monitoring after successful placement of 12 esophageal bands. Overnight, the patient was administered another (1) unit of PRBC, to maintain a hemoglobin greater than 8 g/dL. The following morning at 10:45 a.m. Mrs. Allen was extubated after a successful sedation vacation and spontaneous breathing trial.
When the patient was stable, she was transferred to the medical-surgical floor for observation and case management. On the floor, the patient was educated regarding the reason for the ruptured esophageal varices and taught about her new prescription, propranolol, which, if taken correctly, should decrease the chance of a re-bleed. Lastly, although the patient was resistant to the cessation of alcohol consumption, she met with case management and was educated on alcohol cessation programs and support groups, such as alcoholics anonymous.
Discussion Questions
- If you were the case manager who was educating this unwilling patient about the various rehabilitation facilities, how would you have approached the situation?
- In this scenario, the patient’s vomiting caused the varix to rupture. What type of interventions or nursing assessment tools could have been utilized to prevent vomiting and subsequent rupture of the varix?
- During this scenario, the patient began to vomit large amounts of blood. How would you deal with family members who are in the room who may be shocked about this sudden change in the patient’s condition while also taking care of your patient?
