Gastrointestinal (GI) bleeding, characterized by any hemorrhage within the digestive tract, is not a disease itself but rather a symptom indicating an underlying medical condition. The GI tract encompasses the esophagus, stomach, small intestine, large intestine (colon), rectum, and anus.
GI bleeding is broadly categorized into upper and lower GI bleeds, with the ligament of Treitz serving as the anatomical dividing line. Upper GI bleeding (UGIB) is more common than lower GI bleeding (LGIB). LGIB is slightly more prevalent in men, potentially due to higher rates of vascular disorders and diverticulosis in this population. The incidence of both UGIB and LGIB increases with age.
In this article, we will delve into the essential aspects of nursing care for patients experiencing GI bleeding, focusing on nursing diagnoses and comprehensive care plans.
Nursing Process for GI Bleeding
Prompt and effective management of hematochezia, hematemesis, or melena is crucial. Typically, this necessitates admission to an acute care hospital, along with consultations from both a gastroenterologist and a surgeon to accurately determine the source and cause of the bleeding for targeted intervention.
Expert nursing care is paramount in managing gastrointestinal bleeding. It plays a vital role in alleviating patient symptoms, minimizing the potential for complications, and promoting psychological well-being, ultimately contributing to improved patient outcomes and prognoses. Nursing interventions are implemented proactively to prevent and mitigate identified risk factors.
Nursing Assessment for GI Bleeding
The initial phase of nursing care involves a thorough nursing assessment. During this stage, nurses gather comprehensive data encompassing physical, psychosocial, emotional, and diagnostic aspects of the patient’s condition. Below, we explore both subjective and objective data pertinent to GI bleeding assessment.
Review of Health History
1. Inquire about Current and Past GI Bleeding Episodes: Gathering detailed information about the patient’s current and previous experiences with GI bleeding is essential. This history aids in analyzing symptom patterns and identifying potential underlying causes, which are critical for accurate diagnosis and timely treatment.
2. Examine the Patient’s Medical History: A comprehensive review of the patient’s medical records, past medical history, and existing comorbidities is vital. Certain conditions are strongly linked to an increased risk of GI bleeding. These relevant conditions include:
- Varices
- Portal hypertension
- History of alcohol abuse
- Smoking habits
- Peptic ulcers
- H. pylori infection
- Diverticulitis
- Hemorrhoids
- Inflammatory bowel disease (IBD)
- Cancers of the stomach, esophagus, or colon
3. Analyze the Patient’s Medication Regimen: Certain medications are known to increase the risk of GI bleeding. A careful review of the patient’s current medications is necessary to identify potential contributing factors. Medications of concern include:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Anticoagulants
- Antiplatelet drugs
- Bismuth-containing medications
- Iron supplements
4. Evaluate General Symptoms Related to GI Bleeding: GI bleeding can manifest through various systemic symptoms. Assessing for these general symptoms can provide further clues and help in understanding the impact of the bleeding. These symptoms include:
- Abdominal pain
- Difficulty swallowing (dysphagia)
- Unexplained weight loss
- Nausea
- Retching or vomiting
- Changes in bowel habits
- Abdominal bloating
- Fatigue and weakness
Physical Assessment for GI Bleeding
1. Assess for Specific Signs of GI Bleeding: A detailed physical examination is crucial to identify objective signs of GI bleeding. Key indicators to assess include:
- Central Nervous System (CNS): Changes in mental status, decreased level of consciousness, lightheadedness, fainting (syncope), dizziness. These can indicate reduced cerebral perfusion due to blood loss.
- Head, Eyes, Ears, Nose, and Throat (HEENT): Pallor of the eyes, mucosa, and lips. Pallor is a classic sign of anemia resulting from blood loss.
- Respiratory System: Decreased oxygen saturation, shortness of breath (dyspnea). Blood loss can lead to reduced oxygen-carrying capacity, causing respiratory distress.
- Cardiovascular System: Chest pain, tachycardia (rapid heart rate), hypotension (low blood pressure). These are compensatory mechanisms and direct effects of blood loss and hypovolemia.
- Gastrointestinal System: Abdominal pain, abdominal cramping, presence of anal fissures, hemorrhoids, masses, bright red blood or coffee-ground appearance in vomitus (hematemesis), black, tarry stools (melena). These are direct manifestations of bleeding within the GI tract, indicating the location and nature of the bleed.
- Hematologic System: Signs of anemia, such as fatigue and weakness. Anemia is a direct consequence of blood loss.
- Integumentary System: Skin pallor. Reflects reduced blood flow and hemoglobin levels.
2. Monitor for Symptoms of Shock: In cases of severe GI bleeding, patients are at risk of developing hypovolemic shock. Recognizing the signs of shock is critical for prompt intervention. Shock symptoms include:
- Severely low blood pressure
- Orthostatic hypotension (drop in blood pressure upon standing)
- Supine hypotension (low blood pressure even when lying down)
- Resting tachycardia
- Palpitations
- Rapid, bounding pulses (initially, can become weak and thready later)
- Low urine output (oliguria) or absent urine output (anuria)
- Decreased level of consciousness
- Syncope
3. Perform Abdominal Examination: A thorough abdominal exam can reveal important clues about the source and severity of GI bleeding. Assess for:
- Abdominal distension
- Prominent veins
- Skin discoloration
- Auscultate for hyperactive bowel sounds. Increased bowel motility can be a response to irritation or blood in the GI tract.
- Palpate for abdominal tenderness or pain. Tenderness, especially with guarding, may suggest perforation or ischemia.
4. Monitor Vital Signs Regularly: Frequent monitoring of vital signs is essential. Vital signs can provide early indicators of complications related to GI bleeding, such as shock or hypovolemia. Pay close attention to trends in:
- Heart rate (tachycardia)
- Respiratory rate (tachypnea)
- Blood pressure (hypotension)
Diagnostic Procedures for GI Bleeding
1. Review Serum Lab Values: Blood tests play a crucial role in assessing the impact and severity of GI bleeding. Key lab values to review include:
- Complete Blood Count (CBC): Low hemoglobin and hematocrit levels are indicative of blood loss and anemia.
- Coagulation Profile: Abnormalities in blood clotting are common in GI bleeding. Expect to see:
- Increased International Normalized Ratio (INR)
- Prolonged Prothrombin Time (PT)
- Prolonged Activated Partial Thromboplastin Time (aPTT)
- Lactate Levels: Elevated lactate levels can indicate tissue hypoperfusion and shock due to blood loss.
- Liver Function Tests (LFTs): Abnormal liver enzymes may be present, especially if the underlying cause of bleeding is related to liver disease. Impaired liver function can reduce the production of clotting factors, exacerbating bleeding risk.
2. Obtain Stool Sample for Examination: Stool analysis can provide direct evidence of GI bleeding and help determine the location of the bleed. Assess stool for:
- Bright red blood: Suggests lower GI bleed (e.g., hemorrhoids, anal fissure).
- Dark, black, tarry stools (melena): Indicates upper GI bleed or slow lower GI bleed where blood has been digested.
- Fecal Occult Blood Test (FOBT): This bedside test can detect hidden blood in the stool, even if not visually apparent.
3. Assist with Endoscopy Procedures: Endoscopy is a cornerstone diagnostic and therapeutic procedure for GI bleeding. Different types of endoscopy are used depending on the suspected location of the bleed:
- Upper GI Endoscopy (Esophagogastroduodenoscopy or EGD): A thin, flexible tube with a camera is inserted through the mouth to visualize the esophagus, stomach, and duodenum. It allows for direct inspection of the upper GI tract for bleeding sources and provides opportunities for treatment such as injection therapy, thermal coagulation, or application of hemostatic clips or bands to stop bleeding.
- Lower GI Endoscopy (Colonoscopy or Sigmoidoscopy): A similar scope is inserted through the rectum to visualize the colon and rectum. This is used to identify and treat bleeding sources in the lower GI tract.
4. Consider Other Imaging Scans: When endoscopy is not sufficient or feasible, other imaging modalities may be employed to locate and assess GI bleeding:
- Capsule Endoscopy: A small, disposable capsule containing a camera is swallowed by the patient. As it passes through the small intestine, it captures images, which are recorded and later reviewed. This is particularly useful for visualizing the small intestine, which is often difficult to reach with traditional endoscopes.
- Flexible Sigmoidoscopy: A less invasive procedure than colonoscopy, using a shorter flexible scope to visualize the rectum and sigmoid colon.
- Balloon-Assisted Enteroscopy: A specialized endoscope with balloons is used to navigate and visualize deeper portions of the small intestine, allowing for diagnosis and treatment in areas beyond the reach of standard endoscopes.
- Angiography: This invasive procedure is used to detect and treat actively bleeding vessels. A contrast dye is injected into an artery, and X-rays are taken to visualize blood vessels. If bleeding is identified, it can often be treated during the procedure through embolization (blocking the bleeding vessel) or intra-arterial vasopressin administration (to constrict blood vessels).
- CT Angiography (CTA): A less invasive imaging technique that uses CT scanning with contrast dye to visualize blood vessels and detect active bleeding.
- Enteroscopy: A general term for procedures that visualize the small bowel for bleeding, including capsule endoscopy and balloon-assisted enteroscopy.
- Nuclear Scintigraphy (Tagged Red Blood Cell Scan): This highly sensitive test is particularly useful for detecting active lower GI bleeding when the bleeding site is elusive. Radioactive tracers are attached to red blood cells, and a gamma camera detects the accumulation of these cells at the bleeding site.
Nursing Interventions for GI Bleeding
Nursing interventions and comprehensive care are crucial for patient recovery and management of GI bleeding. The following section outlines key nursing interventions for patients with GI bleeding.
Detect and Address the Underlying Cause
1. Manage the Active Bleeding: The primary immediate goal is to control and stop the GI bleeding. While GI bleeding often resolves spontaneously, interventions are necessary when bleeding is persistent or severe. The specific treatment approach depends on the bleeding location and severity.
2. Correct the Underlying Cause: Identifying and treating the root cause of the GI bleeding is essential for long-term management and prevention of recurrence. This may range from simple measures like discontinuing certain medications (e.g., anticoagulants) to more complex interventions like surgery to address conditions such as ulcers, tumors, or varices.
3. Bowel Rest (NPO Status): Placing the patient on NPO (nothing by mouth) status is often necessary initially. This allows the GI tract to rest and reduces further irritation, promoting healing and recovery during treatment.
Administer Supportive Care
1. Oxygen Administration: If the patient exhibits hypoxia (low oxygen saturation), administer supplemental oxygen as prescribed, typically via nasal cannula. In cases of ongoing hematemesis or altered mental status, intubation and mechanical ventilation may be required to secure the airway and ensure adequate oxygenation.
2. Maintain Hydration with Intravenous Fluids: Adequate intravenous access is crucial for fluid resuscitation. Insert at least two large-bore peripheral IV catheters. Normal saline or lactated Ringer’s solution are the preferred isotonic crystalloid solutions for volume replacement, helping to restore intravascular volume and blood pressure.
3. Transfuse Blood Products as Necessary: Blood transfusions are a critical intervention to replace lost blood components and maintain adequate oxygen-carrying capacity.
- Packed Red Blood Cell (PRBC) Transfusions: Typically indicated when hemoglobin levels fall below 7 g/dL to improve oxygen delivery to tissues.
- Platelet Transfusion: Initiated if the platelet count drops below 50,000/microL, especially in patients with ongoing bleeding or at high risk of bleeding.
4. Reverse Anticoagulation if Indicated: For patients taking anticoagulants like warfarin or heparin, reversal agents may be necessary to counteract the effects of these medications and stop the bleeding.
- Vitamin K: Used to reverse warfarin’s effects.
- Protamine Sulfate: Used to reverse heparin’s effects.
5. Administer Medications as Prescribed: Various medications may be used to manage or halt GI bleeding, depending on the cause and location. Common medications include:
- Proton Pump Inhibitors (PPIs): Used primarily for upper GI bleeding to reduce gastric acid production, which can exacerbate bleeding from ulcers or erosions. PPIs may be continued or discontinued once the bleeding source is identified and managed.
- Prokinetics (e.g., Erythromycin, Metoclopramide): These medications promote gastric emptying, helping to clear the stomach of blood, clots, and food, which improves visualization during endoscopy.
- Somatostatin and its Analog Octreotide: Vasoactive medications used to treat variceal bleeding. They reduce portal blood flow and pressure by inhibiting the release of vasodilatory hormones, thus decreasing bleeding from esophageal or gastric varices.
- Antibiotics: Considered as a prophylactic measure in patients with cirrhosis to prevent bacterial translocation (the movement of bacteria from the gut into the bloodstream), which can complicate GI bleeding in this population. Antibiotics are often administered prior to endoscopy.
Prepare for Diagnostic or Surgical Procedures
1. Nasogastric Tube (NGT) Lavage: Prior to upper endoscopy, NGT lavage may be performed to remove fresh blood and blood clots from the stomach. This improves visualization during the endoscopic procedure, allowing for better identification and treatment of the bleeding source.
2. Sengstaken-Blakemore Tube Placement: In patients with massive GI bleeding due to varices that is unresponsive to other treatments, a Sengstaken-Blakemore tube may be considered as a temporary measure to tamponade esophageal varices and control bleeding. This is typically a last resort due to its potential complications.
3. Anticipate Possible Surgical Intervention: Surgery may be necessary for patients with significant, ongoing bleeding or hemodynamic instability that does not respond to endoscopic or medical treatments. Surgical options may include bowel resection or colectomy, depending on the bleeding source and underlying pathology.
4. Manage Diverticular Bleeding: For bleeding originating from diverticulitis, colonoscopy with targeted therapy is often used. Techniques include bipolar probe coagulation, epinephrine injection, or application of metal clips to achieve hemostasis.
5. Apply Thermal Therapy for Angiodysplasia: Lower GI bleeds caused by angiodysplasia (abnormal, fragile blood vessels in the GI mucosa) can be effectively treated with thermal therapy during endoscopy. Common methods include electrocoagulation and argon plasma coagulation to cauterize and stop bleeding from these lesions.
6. Prevent Complications of GI Bleeding: Untreated or poorly managed GI bleeding can lead to severe complications. Anticipate and monitor for the following potential issues:
- Respiratory Distress
- Myocardial Infarction
- Infection or Sepsis
- Shock (Hypovolemic Shock)
- Death
Educate Patients on Preventing Recurrent GI Bleeds
1. Limit NSAID Use: Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin can cause mucosal injury in the GI tract, increasing the risk of bleeding. Educate patients about the risks and advise them to avoid or limit NSAID use as directed by their healthcare provider.
2. Smoking Cessation: Smoking increases the risk of peptic ulcers and impairs healing, making smokers more susceptible to GI bleeds. Counsel patients on the importance of quitting smoking and provide resources to support smoking cessation efforts.
3. Reduce Alcohol Intake: Excessive alcohol consumption irritates and erodes the GI tract. It also damages the liver, which can impair clotting function and increase the risk of GI bleeding, especially in patients with liver disease. Advise patients to reduce or eliminate alcohol intake.
4. Manage Inflammatory and Infectious Conditions: Conditions like H. pylori infection, diverticulitis, Crohn’s disease, and ulcerative colitis can cause GI bleeding if not properly managed. Emphasize the importance of adherence to prescribed medication regimens and follow-up care to control these conditions and minimize bleeding risk.
Nursing Care Plans for GI Bleeding
Once nursing diagnoses are identified for a patient with gastrointestinal bleeding, nursing care plans become essential tools for prioritizing assessments and interventions. These plans guide both short-term and long-term goals of care. Below are examples of nursing care plans for common nursing diagnoses associated with gastrointestinal bleeding.
Acute Pain
Acute pain associated with gastrointestinal bleeding can arise from gastrointestinal perforation or ischemia. These conditions lead to decreased blood flow and oxygen supply to the gastrointestinal system, triggering pain.
Nursing Diagnosis: Acute Pain
Related to:
- Gastrointestinal perforation
- Gastrointestinal ischemia
As evidenced by:
- Changes in blood pressure, pulse rate, and respiratory rate
- Guarding position of the affected area
- Restlessness and agitation
- Patient report of abdominal pain
- Patient report of heartburn
Expected Outcomes:
- Patient will verbalize a reduction or control of pain to a tolerable level.
- Patient will appear relaxed and report improved comfort, able to sleep or rest adequately.
Assessments:
1. Comprehensive Pain Assessment: Evaluate the patient’s pain characteristics in detail, including:
- Location of pain
- Quality of pain (e.g., sharp, dull, cramping, burning)
- Severity of pain using a pain scale appropriate for the patient
- Palliative factors (what makes the pain better)
- Provocative factors (what makes the pain worse)
- Pattern of pain (constant or intermittent)
- Determine if the pain is constant, aching, stabbing, or burning.
- Pinpoint the exact location of abdominal pain.
2. Observe for Verbal and Nonverbal Pain Cues: Assess both verbal reports of pain and nonverbal indicators. Discrepancies between verbal and nonverbal cues can provide insights into the actual severity of pain, the need for further pain management, and the effectiveness of current interventions.
3. Assess Coping Mechanisms: Evaluate the patient’s current coping mechanisms for dealing with pain and discomfort. Understanding how the patient typically manages stress and pain can help tailor interventions and support. Observe and inquire about coping mechanisms the patient is using.
Interventions:
1. Administer Pharmacologic Pain Management as Ordered: Provide pain relief using prescribed medications. Acetaminophen is often favored over NSAIDs due to its lower risk of GI irritation and bleeding. Antacids without aspirin and proton pump inhibitors may be used to alleviate heartburn.
2. Evaluate Effectiveness of Pain Management: Regularly assess the effectiveness of pain medications and other pain relief measures. Because pain perception is subjective, evaluate pain management within one hour after medication administration. If the patient cannot communicate verbally, rely on physiological and nonverbal pain cues to assess pain levels and relief.
3. Implement Comfort Measures and Non-Pharmacologic Pain Management: Enhance pain relief through non-pharmacologic approaches. Provide comfort measures such as:
- Frequent repositioning
- Back rubs
- Pillow support for comfort
- Relaxation techniques
- Guided imagery
- Appropriate diversional activities to promote distraction and reduce pain perception.
4. Promote Rest and a Conducive Environment: Ensure adequate rest to enhance coping abilities and reduce fatigue. Create a restful environment by:
- Planning rest periods
- Reducing interruptions
- Grouping nursing tasks to minimize disturbances
- Ensuring a quiet, restful atmosphere conducive to sleep.
Deficient Fluid Volume
Deficient fluid volume in gastrointestinal bleeding is primarily caused by blood loss from the GI tract. This blood loss leads to a decrease in circulating blood volume, potentially resulting in reduced blood flow and ineffective tissue perfusion throughout the body, including the gastrointestinal system.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- GI hemorrhage
- Hematochezia
- Hematemesis
- Abdominal cancer
- Bleeding ulcers
- Abdominal or rectal fistulas
As evidenced by:
- Hematochezia
- Hematemesis
- Melena
- Abdominal pain
- Resting tachycardia
- Orthostatic hypotension
- Weakness and fatigue
- Nausea and/or vomiting
- Decreased skin turgor
Expected Outcomes:
- Patient will maintain adequate fluid volume, evidenced by stable vital signs, balanced fluid intake and output, and normal capillary refill.
- Patient will demonstrate improved fluid volume status, evidenced by stable hemoglobin and hematocrit levels within acceptable limits.
Assessments:
1. Assess Nutritional Status: Evaluate the patient’s overall nutritional status, considering factors that impact fluid balance and intake. Assess:
- Current dietary intake
- Recent weight changes
- Oral intake issues (e.g., dysphagia, anorexia)
- Use of nutritional supplements
- Tube feedings if applicable
- Presence of nausea and vomiting, which can affect fluid intake.
2. Monitor Intake and Output (I&O): Maintain meticulous records of fluid intake and output to track fluid balance trends accurately. Record all:
- Oral intake
- Intravenous fluid intake
- Fluid losses through vomiting
- Urine output
- Bloody stools
- Output from drains or tubes.
3. Evaluate Laboratory Results: Closely monitor key laboratory values that reflect fluid volume status and blood loss. Pay particular attention to:
- Hemoglobin (Hgb) and Hematocrit (Hct): Low levels indicate blood loss and reduced blood volume.
Interventions:
1. Collaborate with Healthcare Provider to Treat Underlying Cause: Work closely with the healthcare provider to identify and address the underlying cause of fluid volume deficit and GI bleeding. Stopping the source of bleeding is crucial to resolving the fluid volume deficit.
2. Ensure Adequate Fluid Intake: Provide sufficient free water with meals and ensure a nutritionally balanced diet or enteral feedings, as appropriate. Avoid formulas that are excessively hyperosmolar or high in protein, which can exacerbate fluid imbalances. Proper nutrition supports overall health and reduces the risk of anemia.
3. Review and Administer Prescribed Medications: Review the patient’s medication list, including prescription drugs, over-the-counter (OTC) medications, herbal supplements, and nutritional supplements. Identify any substances that could affect fluid and electrolyte balance or contribute to GI bleeding. Administer proton-pump inhibitors as prescribed to reduce gastric acid production and protect the GI mucosa.
4. Administer Blood Products as Ordered: Prepare for and administer blood product transfusions as ordered, typically packed red blood cells (PRBCs), to replace lost blood volume and improve oxygen-carrying capacity. Ensure the patient is properly typed and cross-matched before blood administration.
Imbalanced Nutrition: Less Than Body Requirements
Gastrointestinal bleeding is often associated with various gastrointestinal disorders that can impair nutritional status, including peptic ulcer disease, gastric cancer, and inflammatory bowel disease. GI bleeding can lead to nutrient malabsorption, fluid volume deficit, anemia, and other GI symptoms, all of which contribute to imbalanced nutrition.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Disease process associated with GI bleeding
- Nausea and vomiting
- Food aversion
- Loss of appetite (anorexia)
- NPO status
- Nutrient malabsorption
As evidenced by:
- Abdominal pain and discomfort
- Abdominal cramping
- Abdominal distension
- Body weight less than ideal for age and gender
- Hyperactive bowel sounds
- Lethargy and fatigue
- Pale mucous membranes
- Vomiting
Expected Outcomes:
- Patient will maintain stable albumin, iron levels, and electrolytes within normal limits, indicating improved nutritional status.
- Patient will maintain body weight within acceptable parameters for their age and health condition.
Assessments:
1. Assess Eating Patterns and Diet History: Thoroughly assess the patient’s eating habits and dietary intake. GI bleeding is often linked to GI disorders that significantly affect appetite and eating patterns. Identify:
- Typical daily food intake
- Food preferences and aversions
- Any recent changes in appetite
- Cultural or religious dietary considerations.
2. Review Medication History: Assess past and current medication use, as certain medications can contribute to nutritional imbalances or GI bleeding. Pay attention to medications such as:
- Corticosteroids
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Antibiotics (which can alter gut flora).
3. Monitor Laboratory Studies: Regularly assess laboratory values that reflect nutritional status and electrolyte balance. GI bleeding can lead to significant losses of nutrients, fluids, and electrolytes. Monitor:
- Electrolyte levels (sodium, potassium, chloride, bicarbonate)
- Serum albumin and prealbumin levels (indicators of protein status)
- Iron studies (ferritin, serum iron, total iron-binding capacity) to assess for iron-deficiency anemia.
Interventions:
1. Administer Fluid and Electrolyte Replacement: Provide initial supportive therapy by replacing fluids and electrolytes as prescribed. This is crucial to correct hypovolemia and electrolyte imbalances caused by GI bleeding and associated symptoms like vomiting and diarrhea.
2. Minimize NPO Status and Advance Diet as Tolerated: Prolonged NPO status can exacerbate nutritional deficits. Minimize the duration of NPO orders and advance the patient’s diet as soon as clinically appropriate and tolerated. Early enteral nutrition may be considered for patients at low risk of re-bleeding to support nutritional needs.
3. Provide Small, Frequent Feedings: Offer small, frequent meals rather than large meals, especially if nausea and vomiting are present. Small, frequent feedings:
- Reduce early satiety
- Decrease the incidence of vomiting
- Allow the gastrointestinal tract to heal gradually.
4. Encourage Avoidance of Gastric Irritants: Advise the patient to avoid foods and beverages that can irritate the gastrointestinal mucosa and potentially worsen bleeding or discomfort. These include:
- Caffeine-containing beverages (coffee, tea, soda)
- Alcohol
- Carbonated beverages (soda)
- Spicy foods.
5. Refer to a Registered Dietitian: Consult with a registered dietitian for comprehensive nutritional assessment and individualized dietary planning. A dietitian can:
- Develop appropriate, well-balanced meal plans
- Address specific nutritional deficits
- Provide dietary education and counseling
- Recommend foods rich in iron (e.g., meat, seafood, nuts)
- Advise on including whole grains, fruits, and vegetables in the diet
- Suggest limiting salt, added sugars, and unhealthy fats.
Ineffective Tissue Perfusion
Ineffective tissue perfusion associated with gastrointestinal bleeding occurs due to blood loss from any part of the GI tract, from the mouth to the anus. The loss of blood reduces the volume of circulating blood, leading to decreased oxygenation and perfusion of tissues throughout the body.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Upper GI bleeding
- Lower GI Bleeding
- Gastrointestinal perforation
- Gastrointestinal ischemia
- Peptic ulcer disease
- Tears or inflammation in the esophagus (e.g., Mallory-Weiss tear, esophagitis)
- Diverticulosis and diverticulitis
- Ulcerative colitis
- Crohn’s disease
- Colonic polyps
- Colon cancer
- Stomach cancer
- Esophageal cancer
As evidenced by:
- Hematochezia
- Hematemesis
- Melena
- Abdominal pain
- Resting tachycardia
- Orthostatic hypotension
- Supine hypotension
- Nausea and/or vomiting
Expected Outcomes:
- Patient will demonstrate effective tissue perfusion, evidenced by hemoglobin and hematocrit levels within normal limits for their baseline.
- Patient will verbalize understanding of gastrointestinal bleeding, their treatment plan, and when to seek medical attention.
Assessments:
1. Assess Vital Signs Continuously: Monitor vital signs frequently to detect indicators of hypoperfusion. Persistent hypotension is a critical sign that can lead to hypoperfusion of abdominal organs and other vital tissues. Pay close attention to:
- Blood pressure
- Heart rate
- Respiratory rate
- Oxygen saturation.
2. Assess for Signs of Bleeding and Hypoperfusion: Evaluate for any conditions or situations that could impair gastrointestinal perfusion and overall circulation. Consider:
- Major trauma with significant blood loss and hypotension
- Septic shock
- Pre-existing conditions that compromise circulation.
- Bowel ischemia and gastrointestinal hypoperfusion may result from blood loss, hypovolemic shock, or both.
3. Review Patient History for Bleeding or Coagulation Disorders: Gather information about the patient’s medical history to identify risk factors for bleeding and impaired tissue perfusion. Determine if the patient has a history of:
- Cancer
- Coagulation abnormalities
- Previous GI bleeding episodes
- Use of anticoagulants or antiplatelet medications.
Interventions:
1. Collaborate with Interdisciplinary Team: Work closely with the healthcare team, including physicians, surgeons, and other specialists, to develop a comprehensive plan of care. Interdisciplinary collaboration enhances communication, ensures continuity of care, and allows for the development of an appropriate and effective treatment plan to improve systemic perfusion and organ function.
2. Administer Fluids, Blood Products, and Electrolytes as Prescribed: Follow medical orders for fluid resuscitation, blood product administration, and electrolyte replacement. The primary goal of fluid resuscitation is to improve tissue perfusion and stabilize hemodynamics. Intravenous fluids, blood products (PRBCs, plasma), and electrolyte solutions are often necessary to compensate for blood and fluid loss and maintain adequate GI circulation and cellular function.
3. Administer Prescribed Medications: Provide prescribed prophylactic medications as ordered. These may include:
- Antiemetics to reduce vomiting and fluid loss
- Anticholinergics to reduce bowel motility in certain situations
- Proton pump inhibitors (PPIs) to reduce gastric acid secretion and protect the GI mucosa
- Antihistamines (H2 receptor antagonists) to reduce acid production
- Antibiotics if infection is suspected or as prophylaxis in specific cases (e.g., cirrhosis).
4. Prepare for Endoscopy or Surgery: Prepare the patient for potential diagnostic and therapeutic procedures. Endoscopy (upper or lower) may be necessary to identify the source and cause of GI bleeding and to provide treatment (e.g., cauterization, clipping). Surgery may be required if bleeding is severe, persistent, and cannot be controlled endoscopically, or if the underlying cause necessitates surgical intervention.
Risk for Decreased Cardiac Output
In severe gastrointestinal bleeding and significant blood loss, patients are at high risk for developing decreased cardiac output due to hypovolemia. Reduced blood volume leads to decreased preload, which can compromise cardiac output and tissue perfusion.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related to:
- Disease process causing GI bleeding
- Blood loss leading to hypovolemia
- Altered afterload
- Altered heart rate
- Altered heart rhythm (potential complication of hypovolemia and electrolyte imbalance)
- Altered stroke volume (reduced by hypovolemia)
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not yet occurred. Nursing interventions are focused on preventing the signs and symptoms of decreased cardiac output.
Expected Outcomes:
- Patient will maintain vital signs within normal limits for their baseline, including heart rate, blood pressure, and respiratory rate.
- Patient will maintain adequate urine output, reflecting sufficient renal perfusion and cardiac output.
- Patient will demonstrate adequate peripheral tissue perfusion, evidenced by warm, dry skin, palpable peripheral pulses, and normal capillary refill.
- Patient will maintain a stable cardiac rhythm without signs and symptoms of decreased cardiac output (e.g., chest pain, shortness of breath, dizziness).
Assessments:
1. Assess Heart Rate and Rhythm: Monitor the patient’s heart rate and rhythm regularly. Compensatory tachycardia (rapid heart rate) is a common early response to decreased blood pressure and bleeding as the heart attempts to maintain cardiac output. Assess for:
- Heart rate (rate and regularity)
- Presence of arrhythmias or palpitations.
2. Monitor Complete Blood Count (CBC): Track hemoglobin and hematocrit levels, although these may not immediately reflect the extent of acute blood loss. Initial hematocrit may be within normal limits and will decline 4-6 hours after fluid replacement as hemodilution occurs. CBC provides a baseline for guiding further treatment and assessing the severity of blood loss over time.
3. Assess Blood Urea Nitrogen (BUN) Level: Monitor BUN levels. Blood urea nitrogen often increases significantly in patients with gastrointestinal bleeding due to the breakdown of blood proteins in the intestine and reduced renal perfusion. Elevated BUN can be an indicator of the severity of bleeding and the body’s response to it.
Interventions:
1. Monitor Urine Output Closely: Urine output is a crucial indicator of vital organ perfusion, including renal perfusion, which is directly related to cardiac output. Insert an indwelling urinary catheter to ensure accurate and continuous urine output monitoring, especially in unstable patients. Decreasing urine output can signal declining cardiac output and reduced kidney perfusion due to hypovolemia.
2. Perform Hemodynamic Monitoring: Implement hemodynamic monitoring, especially in patients with severe GI bleeding or hemodynamic instability. This may include:
- Continuous blood pressure monitoring (arterial line if necessary)
- Central venous pressure (CVP) monitoring to assess fluid volume status
- Pulmonary artery catheterization (in complex cases) to assess cardiac function and pressures.
Hemodynamic monitoring provides real-time data on circulatory status and the effectiveness of fluid resuscitation.
3. Administer Supplemental Oxygenation as Needed: Provide supplemental oxygen to prevent or correct hypoxemia, which can further compromise cardiac function. Oxygen therapy increases blood oxygen saturation and improves oxygen delivery to the myocardium and other tissues.
4. Administer Intravenous Fluids as Indicated: Administer intravenous fluids as prescribed to restore intravascular volume and improve preload. Isotonic crystalloid solutions, such as lactated Ringer’s solution or normal saline, are typically used for initial fluid resuscitation. The rate and volume of fluid administration are guided by the patient’s hemodynamic status and response to treatment.
5. Prepare and Initiate Blood Transfusions as Ordered: Prepare for and initiate blood transfusions as indicated by the patient’s hemoglobin level, hemodynamic status, and ongoing bleeding. Blood transfusions are essential to replace lost red blood cells, improve oxygen-carrying capacity, and prevent decreased cardiac output. Whole blood, packed red blood cells (PRBCs), or fresh frozen plasma may be used for volume replacement and to correct coagulopathies.
6. Prepare Patient for Surgical Intervention if Necessary: In cases of severe or uncontrolled gastrointestinal bleeding, surgical intervention, such as endoscopy with hemostasis or open surgery, may be necessary to stop the bleeding and prevent further circulatory compromise. Prepare the patient physically and emotionally for potential surgical procedures.
7. Administer Drug Therapy as Indicated: Administer medications as prescribed to manage GI bleeding and support cardiac function. Medications may include:
- Vasopressors to improve blood pressure and systemic vascular resistance in hypotensive patients.
- Inotropes to enhance myocardial contractility and cardiac output if indicated.
- Medications to reduce gastric acid secretion (PPIs, H2 blockers) and promote mucosal healing.
- Anti-emetics to control nausea and vomiting.
