Gastrointestinal (GI) bleeding, indicating bleeding within the digestive tract, is a symptom of an underlying condition rather than a disease itself. This bleeding can originate anywhere from the esophagus and stomach to the small and large intestines, rectum, and anus. Understanding the nuances of GI bleeding, particularly the distinctions between upper and lower GI bleeds, is crucial for effective nursing care.
Bleeding in the GI tract is broadly categorized into upper GI bleeding (UGIB) and lower GI bleeding (LGIB). The dividing line, anatomically, is the ligament of Treitz, also known as the suspensory ligament of the duodenum. UGIB is more commonly observed than LGIB. Interestingly, LGIB is more frequently seen in men, potentially due to a higher prevalence of vascular disorders and diverticulosis in this demographic, while the overall incidence of GI bleeding increases with age in both sexes.
Effective nursing care is paramount in managing patients with gastrointestinal bleeding. Prompt recognition and intervention are essential to manage symptoms, minimize complications, and improve patient outcomes. This article delves into the nursing process for GI bleeding, focusing on assessment, diagnosis, interventions, and care planning to optimize patient well-being and recovery.
Nursing Assessment for GI Bleeding
The cornerstone of nursing care is a thorough assessment. For patients with GI bleeding, this involves gathering comprehensive data encompassing physical, psychosocial, emotional, and diagnostic aspects. Let’s explore the subjective and objective data vital for assessing GI bleeding.
Health History Review
1. History of GI Bleeding Episodes: Inquire about current and past instances of GI bleeding. Details regarding the frequency, severity, and characteristics of bleeding episodes are critical for identifying potential patterns and guiding diagnostic and treatment strategies.
2. Comprehensive Medical History: Scrutinize the patient’s medical history for conditions that predispose them to GI bleeding. Key factors include:
- Varices
- Portal hypertension
- History of alcohol abuse
- Smoking habits
- Peptic ulcers
- Helicobacter pylori (H. pylori) infection
- Diverticulitis
- Hemorrhoids
- Inflammatory bowel disease (IBD)
- Cancers of the stomach, esophagus, or colon
3. Medication Review: Certain medications are known to increase the risk of GI bleeding. A meticulous review of the patient’s medication regimen is essential, paying close attention to:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Anticoagulants
- Antiplatelet drugs
- Bismuth-containing medications
- Iron supplements
4. Associated Symptoms: Elicit information about general symptoms that may accompany GI bleeding, helping to paint a broader clinical picture. These symptoms may include:
- Abdominal pain
- Difficulty swallowing (dysphagia)
- Unexplained weight loss
- Nausea
- Retching or vomiting
- Changes in bowel habits
- Abdominal bloating
- Fatigue
Physical Examination Findings
1. Identifying Signs of GI Bleeding: Physical assessment plays a crucial role in identifying overt signs of GI bleeding and its systemic effects:
- Central Nervous System (CNS): Observe for decreased mental acuity, reduced level of consciousness, lightheadedness, syncope (fainting), and dizziness, which can indicate hypovolemia.
- Head, Eyes, Ears, Nose, and Throat (HEENT): Assess mucous membranes, eyes, and lips for pallor, a key indicator of anemia due to blood loss.
- Respiratory System: Monitor oxygen saturation levels and note any shortness of breath (dyspnea), as significant blood loss can compromise oxygen delivery.
- Cardiovascular System: Assess for chest pain, tachycardia (rapid heart rate), and hypotension (low blood pressure), all potential signs of hypovolemia and shock.
- Gastrointestinal System: Evaluate for abdominal pain, cramping, anal fissures, hemorrhoids, or abdominal masses. Critically, note the characteristics of any expelled blood: hematemesis (bright red or coffee-ground blood in vomit) and melena (black, tarry stools).
- Hematologic System: Look for signs of anemia, reflecting blood loss.
- Integumentary System: Observe skin pallor, another indicator of reduced blood volume.
2. Monitoring for Shock: Severe GI bleeding can lead to hypovolemic shock, a life-threatening condition. Be vigilant for the following shock symptoms:
- Critically low blood pressure
- Orthostatic hypotension (drop in blood pressure upon standing)
- Supine hypotension (low blood pressure while lying down)
- Tachycardia at rest
- Palpitations
- Rapid, bounding pulse
- Oliguria (low urine output) or anuria (absent urine output)
- Decreased level of consciousness
- Syncope
3. Abdominal Assessment: Perform a detailed abdominal examination:
- Inspection: Look for abdominal distension, visible veins, or skin discoloration.
- Auscultation: Hyperactive bowel sounds are often present in GI bleeding.
- Palpation: Assess for abdominal tenderness or pain, which may suggest perforation or ischemia.
4. Vital Signs Monitoring: Regularly monitor vital signs. Tachycardia, tachypnea (rapid breathing), and hypotension are critical indicators of potential complications like shock or hypovolemia.
Diagnostic Procedures for GI Bleeding
Diagnostic tests are crucial for confirming GI bleeding, identifying the source, and guiding treatment.
1. Serum Lab Values: Blood tests provide valuable insights:
- Complete Blood Count (CBC): Low hemoglobin and hematocrit levels indicate blood loss.
- Coagulation Profile: Abnormal blood clotting is reflected in an increased international normalized ratio (INR), prolonged prothrombin time (PT), and activated partial thromboplastin time (aPTT).
- Lactate Levels: Elevated lactate levels can indicate tissue hypoperfusion due to blood loss.
- Liver Function Tests (LFTs): Abnormal liver enzyme levels may suggest impaired liver function, which can increase bleeding risk due to reduced clotting factor production.
2. Stool Examination: Analyze stool samples for:
- Visible Blood: Bright red blood indicates active bleeding, often from the lower GI tract.
- Melena: Dark, black, tarry stools suggest older blood or bleeding from the upper GI tract.
- Fecal Occult Blood Test (FOBT): A bedside test to detect hidden blood in the stool.
3. Endoscopy: Endoscopic procedures are vital for visualizing the GI tract and often for therapeutic intervention:
- 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.
- Lower GI Endoscopy (Colonoscopy): A similar scope is inserted through the rectum to examine the colon.
- Both procedures allow for direct visualization of bleeding sites and enable interventions such as injection therapy, thermal coagulation, or application of hemostatic clips or bands to stop bleeding.
4. Imaging Scans: Various imaging techniques aid in diagnosis:
- Capsule Endoscopy: A small, swallowable capsule containing a camera images the small intestine, useful for identifying obscure bleeding sources.
- Flexible Sigmoidoscopy: A shorter, flexible scope visualizes the rectum and sigmoid colon.
- Balloon-Assisted Enteroscopy: A specialized endoscope allows deeper visualization and intervention within the small intestine, reaching areas inaccessible by standard endoscopes.
- Angiography: Used to detect and treat active bleeding vessels. Contrast dye is injected into an artery, and X-rays are taken to visualize blood vessels. Bleeding can be managed through embolization or intra-arterial vasopressin.
- CT Angiography (CTA): A CT scan with contrast to visualize active bleeding blood vessels.
- Enteroscopy: A general term for procedures visualizing the small bowel for bleeding.
- Nuclear Scintigraphy: Highly sensitive for detecting active lower GI bleeding, using radiolabeled red blood cells to pinpoint bleeding locations.
Nursing Interventions for GI Bleeding
Effective nursing interventions are crucial for managing GI bleeding, addressing the underlying cause, and providing supportive care.
Identifying and Managing the Underlying Cause
1. Bleeding Management: While GI bleeding often resolves spontaneously, interventions are necessary for persistent or severe bleeding. Treatment strategies are guided by the bleeding location and severity.
2. Addressing the Root Cause: The primary step in acute management is identifying and treating the underlying cause of the bleeding. This may range from simple measures like discontinuing anticoagulant medications to more complex interventions, including surgery.
3. Bowel Rest: Implementing NPO (nothing by mouth) orders is crucial to allow the GI tract to rest and minimize further irritation, promoting healing during treatment.
Supportive Care Measures
1. Oxygen Administration: Administer supplemental oxygen as prescribed, typically via nasal cannula, if the patient is hypoxic. Patients with ongoing hematemesis or altered mental status may require more advanced airway management, including intubation.
2. Hydration Maintenance: Establish at least two large-bore peripheral intravenous (IV) lines to ensure adequate IV access. Fluid resuscitation is typically initiated with normal saline or lactated Ringer’s solution.
3. Blood Product Transfusion: Transfusions are essential to restore blood volume and components lost due to bleeding.
- Packed Red Blood Cells (PRBCs): Transfusion is generally indicated when hemoglobin levels fall below 7 g/dL.
- Platelet Transfusion: Initiated when platelet counts drop below 50,000/microL.
4. Anticoagulation Reversal: For patients on warfarin or heparin, reversal agents like vitamin K or protamine sulfate may be necessary to counteract the effects of blood-thinning medications and control bleeding.
5. Medication Administration: Various medications play a role in managing and stopping GI bleeding:
- Proton Pump Inhibitors (PPIs): Used for upper GI bleeding to suppress acid production, which can exacerbate bleeding. PPIs may be continued or discontinued once the bleeding source is identified.
- Prokinetic Agents (e.g., Erythromycin, Metoclopramide): Promote gastric emptying, clearing the stomach of blood, clots, and food to improve visualization during endoscopy.
- Somatostatin and Octreotide (Analogs): Vasoactive medications used to manage variceal bleeding by inhibiting the release of vasodilatory hormones, reducing portal pressure.
- Antibiotics: Prophylactic antibiotics are considered in patients with cirrhosis to prevent bacterial translocation, especially before endoscopy.
Preparation for Procedures
1. Blood and Clot Removal: Prior to endoscopy, nasogastric tube (NGT) lavage may be performed to drain fresh blood and clots from the stomach, improving visualization during the procedure.
2. Sengstaken-Blakemore Tube: In cases of massive GI bleeding from varices unresponsive to other treatments, a Sengstaken-Blakemore tube, which applies pressure to esophageal and gastric varices, may be considered as a last resort.
3. Surgical Anticipation: Prepare for potential surgical intervention in patients with significant, uncontrolled bleeding or hemodynamic instability despite other treatments. Procedures may include bowel resection or colectomy.
4. Diverticular Bleeding Management: Colonoscopy with bipolar probe coagulation, epinephrine injection, or metal clips are techniques used to stop bleeding from diverticulitis.
5. Thermal Therapy: For lower GI bleeds caused by angiodysplasia, thermal therapies like electrocoagulation and argon plasma coagulation can be effective.
6. Complication Prevention: Untreated or poorly managed GI bleeding can lead to severe complications:
- Respiratory distress
- Myocardial infarction (heart attack)
- Infection or sepsis
- Shock
- Death
Patient Education for Preventing Recurrence
1. NSAID Limitation: Educate patients about the risks of long-term NSAID and aspirin use, which can cause mucosal injury and bleeding. Advise them to avoid or limit these medications as directed by their healthcare provider.
2. Smoking Cessation: Smoking increases the risk of peptic ulcers and impairs healing, raising the likelihood of GI bleeds. Encourage and support smoking cessation.
3. Alcohol Reduction: Excessive alcohol intake irritates the GI tract and damages the liver, impairing clotting and increasing GI bleeding risk. Counsel patients to reduce alcohol consumption.
4. Management of Inflammatory and Infectious Conditions: Educate patients on managing conditions like H. pylori infection, diverticulitis, Crohn’s disease, or colitis, as these can lead to GI bleeding if uncontrolled. Emphasize adherence to prescribed medication regimens.
Gastrointestinal Bleeding Nursing Care Plans
Nursing care plans are vital for structuring and prioritizing care for patients with GI bleeding. They guide assessments and interventions to achieve short-term and long-term goals. Common nursing diagnoses and associated care plans include:
Acute Pain
Nursing Diagnosis: Acute Pain related to gastrointestinal perforation or ischemia.
Related Factors:
- Gastrointestinal perforation
- Gastrointestinal ischemia
Evidenced By:
- Changes in blood pressure, pulse, and respiratory rate
- Guarding behavior of the affected area
- Restlessness
- Report of abdominal pain
- Report of heartburn
Expected Outcomes:
- Patient will verbalize pain relief or control.
- Patient will appear relaxed and able to rest adequately.
Nursing Assessments:
- Pain Characteristics: Assess pain location, quality, severity, aggravating/relieving factors using pain assessment tools. Determine if pain is constant, aching, stabbing, or burning.
- Pain Cues: Examine verbal and nonverbal pain indicators. Discrepancies may reveal pain severity and intervention effectiveness.
- Coping Mechanisms: Assess patient’s coping strategies for managing pain and stress.
Nursing Interventions:
- Pharmacologic Pain Management: Administer prescribed analgesics. Acetaminophen is often preferred over NSAIDs due to lower GI side effects. Antacids and PPIs may alleviate heartburn.
- Evaluate Pain Management Effectiveness: Assess pain relief within one hour of medication administration. If nonverbal, assess physiological and nonverbal pain cues.
- Comfort Measures and Non-pharmacologic Pain Management: Provide comfort measures (positioning, back rubs, pillows). Utilize relaxation techniques, guided imagery, and diversional activities.
- Rest and Environment: Plan rest periods and create a conducive environment for sleep. Minimize interruptions and group nursing tasks.
Deficient Fluid Volume
Nursing Diagnosis: Deficient Fluid Volume related to GI hemorrhage.
Related Factors:
- GI hemorrhage
- Hematochezia
- Hematemesis
- Abdominal cancer
- Bleeding ulcers
- Abdominal or rectal fistulas
Evidenced By:
- Hematochezia
- Hematemesis
- Melena
- Abdominal pain
- Resting tachycardia
- Orthostatic hypotension
- Weakness
- Nausea and/or vomiting
- Decreased skin turgor
Expected Outcomes:
- Patient will maintain adequate fluid volume (stable vital signs, balanced intake/output, capillary refill).
- Patient will demonstrate effective fluid volume (stable hemoglobin and hematocrit).
Nursing Assessments:
- Nutritional Status: Assess dietary intake, weight changes, oral intake issues, supplement use, and factors affecting fluid intake (nausea, vomiting).
- Intake and Output (I&O): Monitor and document precise I&O, including oral, IV intake, and losses (vomiting, urine, bloody stools).
- Laboratory Results: Closely monitor hemoglobin and hematocrit levels as indicators of blood loss.
Nursing Interventions:
- Address Underlying Issues: Collaborate with the healthcare provider to identify and treat the cause of fluid volume deficit and bleeding.
- Fluid and Nutrition Support: Provide sufficient free water with meals and a balanced diet or enteral feedings. Avoid hyperosmolar formulas.
- Medication Review and Administration: Review medications (prescribed, OTC, herbal) that may affect fluid balance or contribute to bleeding. Administer prescribed medications like PPIs.
- Blood Product Administration: Prepare for and administer PRBC transfusions as ordered.
Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to gastrointestinal disorders and GI bleeding.
Related Factors:
- Disease process
- Nausea and vomiting
- Food aversion
- Loss of appetite
- NPO status
- Nutrient malabsorption
Evidenced By:
- Abdominal pain
- Abdominal cramping
- Abdominal distension
- Body weight less than ideal
- Hyperactive bowel sounds
- Lethargy
- Pale mucous membranes
- Vomiting
Expected Outcomes:
- Patient will maintain stable albumin, iron, and electrolyte levels.
- Patient will maintain weight within acceptable parameters.
Nursing Assessments:
- Eating Pattern and Diet: Assess eating habits and dietary intake to identify nutritional deficits.
- Medication Use: Assess use of medications (corticosteroids, NSAIDs) that can impact GI health and nutrient absorption.
- Laboratory Studies: Monitor lab values, including fluid and electrolyte levels, to identify nutritional imbalances and anemia.
Nursing Interventions:
- Fluid and Electrolyte Replacement: Administer fluid and electrolyte replacement to correct hypovolemia and imbalances.
- Minimize NPO Status: Minimize prolonged NPO status. Early enteral nutrition may be appropriate for low-risk patients.
- Small Frequent Feedings: Provide small, frequent meals to reduce nausea, early satiety, and promote healing.
- Avoid Gastric Irritants: Advise patients to avoid caffeine, alcohol, soda, and spicy foods.
- Dietitian Referral: Refer patients to a dietitian for personalized meal planning and nutritional counseling.
Ineffective Tissue Perfusion
Nursing Diagnosis: Ineffective Tissue Perfusion related to blood loss from GI bleeding.
Related Factors:
- Upper GI bleeding
- Lower GI bleeding
- Gastrointestinal perforation
- Gastrointestinal ischemia
- Peptic ulcer disease
- Esophageal tears or inflammation
- Diverticulosis and diverticulitis
- Ulcerative colitis
- Crohn’s disease
- Colonic polyps
- Colon cancer
- Stomach cancer
- Esophageal cancer
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 (hemoglobin and hematocrit within normal limits).
- Patient will verbalize understanding of GI bleeding, treatment plan, and when to seek medical attention.
Nursing Assessments:
- Vital Signs: Monitor vital signs for hypotension, which can indicate organ hypoperfusion.
- Bleeding Assessment: Identify factors impairing GI perfusion (trauma, shock). Assess for bowel ischemia or hypoperfusion.
- Bleeding/Coagulation History: Assess patient history of bleeding disorders, cancer, or prior GI bleeding to determine bleeding risk.
Nursing Interventions:
- Interdisciplinary Collaboration: Collaborate with the healthcare team to develop a comprehensive care plan.
- Fluid, Blood, and Electrolyte Administration: Administer fluids, blood products, and electrolytes to improve tissue perfusion and stabilize hemodynamics.
- Medication Administration: Administer prescribed medications (antiemetics, PPIs, etc.) to reduce fluid loss and gastric acid.
- Procedure Preparation: Prepare patient for endoscopy or surgery as indicated to identify and treat bleeding source.
Risk for Decreased Cardiac Output
Nursing Diagnosis: Risk for Decreased Cardiac Output related to hypovolemia secondary to GI bleeding.
Related Factors:
- Disease process
- Blood loss
- Altered afterload
- Altered heart rate
- Altered heart rhythm
- Altered stroke volume
Evidenced By:
- (Risk diagnosis – no defining signs/symptoms)
Expected Outcomes:
- Patient will maintain vital signs within normal limits, adequate urine output, and tissue perfusion.
- Patient will maintain asymptomatic cardiac rhythm without signs of decreased cardiac output.
Nursing Assessments:
- Heart Rate and Rhythm: Monitor heart rate and rhythm. Tachycardia is a compensatory response to low blood pressure and bleeding.
- Complete Blood Count (CBC): Monitor hemoglobin and hematocrit as baseline indicators of blood loss.
- BUN Level: Assess BUN levels, which may be elevated due to protein breakdown in GI bleeding.
Nursing Interventions:
- Urine Output Monitoring: Monitor urine output as a key indicator of organ perfusion. Use an indwelling catheter for accurate measurement.
- Hemodynamic Monitoring: Implement hemodynamic monitoring to assess circulation and heart function.
- Supplemental Oxygenation: Administer oxygen to prevent or correct hypoxemia.
- Intravenous Fluid Administration: Administer isotonic crystalloid solutions (e.g., lactated Ringer’s) to address fluid loss.
- Blood Transfusion: Prepare for and initiate blood transfusions (whole blood, PRBCs, fresh frozen plasma) as ordered.
- Surgical Preparation: Prepare patient for potential surgical intervention to repair bleeding.
- Drug Therapy: Administer medications to decrease bleeding, reduce acid secretion, and neutralize stomach acid.
References
References from the original article are assumed to be listed here if present.
