Mrs. Baker is a 54 year old female who presented to the ED complaining of nausea and severe epigastric pain x 3 days. She reports a history of osteoarthritis and reports taking ibuprofen 400 mg 3-4 times a day regularly for the last few months since her “arthritis has gotten really bad”.
Critical Thinking Check
Bloom's Taxonomy: Application
What initial nursing assessments should be performed?
Put the patient on a monitor to assess EKG. A 12-lead EKG should be done to rule out cardiac involvement, request order for cardiac enzymes from provider
Auscultate heart and lung sounds
Full abdominal assessment – inspect, auscultate, palpate and percuss. Assess for tenderness over specific areas, feel for masses, and look for guarding.
Get more detailed history questions – vomiting? Bloody stools? Has this happened before?
Patient demonstrates guarding when palpating epigastric region, no tenderness to palpation over RLQ, LLQ, or LUQ. Some tenderness over RUQ. Bowel sounds are hyperactive, lungs are clear to auscultation, S1 and S2 heard clearly with no murmurs. As you finish your assessment, Mrs. Baker reports she is going to be sick and vomits approximately 300 mL of coffee-ground emesis.
Patient may need an EGD (esophagogastroduodenoscopy) to check for bleeding ulcers
Mrs. Baker is now weak and drowsy. Her fecal occult test is positive and her CBC shows a Hemoglobin of 10 g/dL and a Hematocrit of 31%. Per provider orders, you insert an NG tube to evaluate stomach contents and decompress the stomach. You connect the NG tube to intermittent low wall suction.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What is likely going on with Mrs. Baker physiologically?
Decompressing the stomach removes the majority of stomach acid, thereby decreasing the irritation on the stomach lining
The hope is to prevent further irritation to any bleeding ulcers
The UAP notifies you that Mrs. Baker’s blood pressure has dropped to 96/60. You enter the room and see that the suction canister is over halfway full of bright red blood.
She may have an ulcer that is bleeding more actively than before. With that amount of blood, it could possibly be an arterial bleed.
Mrs. Baker is pale, diaphoretic, and drowsy. Her heart rate is up to 122. You notify the provider who orders to transfuse 2 units of PRBC’s and calls the Gastroenterology team for a STAT EGD. Within 30 minutes the patient is taken to the GI lab for an EGD, where they find two slow-bleeding gastric ulcers, which they cauterize, and 1 arterial bleed which they repair as well. Mrs. Baker returns to the unit post-procedure for observation.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What are nursing priorities for Mrs. Baker after this procedure?
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 