# A nurse is caring for a 70-year-old female client with a history of non-alcoholic fatty liver disease (NAFLD) who presents with hematemesis. Which assessment finding would be the highest priority for the nurse to monitor?

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## 문제

A nurse is caring for a 70-year-old female client with a history of non-alcoholic fatty liver disease (NAFLD) who presents with hematemesis. Which assessment finding would be the highest priority for the nurse to monitor?

The client appears anxious and reports feeling dizzy when standing.

## 보기

1. Abdominal pain intensity using a 0-10 pain scale
2. Blood pressure and heart rate **✔ 정답**
3. Bowel sounds in all four quadrants
4. Level of consciousness using the Glasgow Coma Scale

**정답: 2**

## 해설

Monitoring blood pressure and heart rate is the highest priority to assess for hypovolemic shock from potential bleeding, which can rapidly lead to hemodynamic instability. Other options are important but less urgent for immediate monitoring.

## 심화 해설

Clinical Reasoning – Prioritization in Suspected Acute Upper Gastrointestinal Bleeding

The client’s history of non-alcoholic fatty liver disease (NAFLD) and presentation with hematemesis should immediately raise suspicion for an acute upper gastrointestinal bleed (AUGIB), potentially from ruptured esophageal varices secondary to advanced liver disease. In this context, the highest priority is to assess for hemodynamic instability caused by acute blood loss.

Why Blood Pressure and Heart Rate Are the Priority

The client’s report of dizziness upon standing is a classic symptom of orthostatic hypotension, a key indicator of significant intravascular volume depletion. In the setting of active hemorrhage, the body’s initial compensatory mechanism is to increase heart rate and constrict peripheral vessels to maintain cardiac output. A drop in blood pressure, particularly orthostatic hypotension, and a compensatory tachycardia are the most immediate and objective indicators of the severity of blood loss and the onset of hypovolemic shock. Monitoring these vital signs allows the nurse to detect early decompensation and guide urgent fluid resuscitation and transfusion decisions. The foundational principle in managing AUGIB, as highlighted in the graded nursing approach based on the Glasgow-Blatchford score, is to first stabilize the patient by assessing and managing their hemodynamic status [1]. The Glasgow-Blatchford score itself relies on blood pressure, heart rate, and hemoglobin levels to stratify risk and determine the need for urgent intervention [1].

Analysis of Other Options

- Option 1: Abdominal pain intensity using a 0-10 pain scale

While pain assessment is a core nursing function, it is not the highest priority in a potentially life-threatening hemorrhage. AUGIB from varices is often painless, and focusing on pain first delays the critical assessment of the client’s circulatory status. Hemodynamic stability takes precedence over comfort measures in the acute phase.

- Option 3: Bowel sounds in all four quadrants

Auscultating bowel sounds can provide supportive information, as blood in the GI tract can stimulate peristalsis. However, this assessment does not provide immediate data on the client’s hemodynamic stability. It is a secondary assessment that follows the primary survey of airway, breathing, and circulation.

- Option 4: Level of consciousness using the Glasgow Coma Scale

A change in level of consciousness is a late sign of hypovolemic shock, indicating critically reduced cerebral perfusion. By the time this occurs, the client is already in a state of severe decompensation. The nurse’s priority is to identify the shock state in its earliest, compensated stage, which is best achieved by monitoring blood pressure and heart rate. The client’s current anxiety may be an early manifestation of hypoxia and decreased cerebral blood flow, making close hemodynamic monitoring even more critical to prevent a decline in mental status.

The graded nursing model for AUGIB emphasizes that the initial step is risk stratification and stabilization based on hemodynamic parameters [1]. Therefore, trending blood pressure and heart rate is the most direct and effective way to monitor for ongoing hemorrhage and the body’s response to volume loss.References (research sources)

- [1]Effect of graded nursing based on the Glasgow-Blatchford score in liver cirrhosis patients complicated with acute upper gastrointestinal bleeding.Research articleLiu M, Wang H, Shao F, Xu Y, Huang J, Zhang H, Han Y. (2025) · DOI: 10.3389/fmed.2025.1679939

## 임상 시나리오

Hemodynamic Priority in Acute Upper GI BleedImmediate Nursing Action for Suspected Variceal Hemorrhage
In a patient with hematemesis and liver disease, assume an acute upper GI bleed until proven otherwise. The first priority is assessing hemodynamic stability.

Monitor blood pressure and heart rate immediately. A report of dizziness upon standing is a red flag for orthostatic hypotension, defined as a drop in systolic BP of at least 20 mmHg or diastolic BP of 10 mmHg.

CautionCompensatory tachycardia and narrowed pulse pressure are early signs of hypovolemic shock. Do not rely solely on a single normal BP reading; serial orthostatic vitals are crucial to detect occult volume loss before decompensation occurs.

## 핵심 개념

- **Hematemesis** — Vomiting of blood, indicating active upper gastrointestinal bleeding, often from esophageal varices or peptic ulcers.
- **Orthostatic Hypotension** — A drop in systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg upon standing, indicating significant volume depletion.
- **Esophageal Varices** — Dilated submucosal veins in the esophagus, a common complication of portal hypertension from liver cirrhosis.
- **Glasgow-Blatchford Score** — A pre-endoscopic risk assessment tool for upper GI bleeding that uses hemodynamic markers like blood pressure and heart rate.
- **Hemodynamic Instability** — A state of inadequate blood flow and oxygen delivery to tissues, often presenting with tachycardia and hypotension in hemorrhage.

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