Gastrointestinal (GI) bleeding, referring to any hemorrhage within the digestive tract, is not a disease itself but rather a symptom indicating an underlying condition. This bleeding can originate anywhere from the esophagus to the anus, encompassing organs like the stomach, small and large intestines, rectum, and anus. GI bleeds are broadly categorized into upper and lower, divided by the ligament of Treitz in the duodenum. Upper GI bleeds (UGIB) are more common, while lower GI bleeds (LGIB) are slightly more prevalent in men, often linked to vascular issues and diverticulosis. The incidence of GI bleeding increases with age, highlighting the importance of prompt recognition and intervention.
Prompt assessment and management of hematemesis, hematochezia, or melena are crucial in cases of suspected gastrointestinal bleeding. Typically, this necessitates immediate hospitalization in an acute care setting, involving consultations with both a gastroenterologist and a surgeon to pinpoint the bleeding source and initiate appropriate treatment. Effective nursing care plays a pivotal role in managing patients with GI bleeding. It is essential for alleviating distressing symptoms, minimizing the potential for severe complications, and supporting the patient’s psychological well-being throughout their treatment and recovery. Furthermore, targeted nursing interventions are crucial in preventing and mitigating identified risk factors associated with GI bleeding.
Nursing Assessment for Acute GI Bleed
The nursing process begins with a thorough nursing assessment, where nurses gather critical physical, psychosocial, emotional, and diagnostic data. This comprehensive evaluation is essential in formulating an accurate Acute Gi Bleed Nursing Diagnosis and guiding subsequent interventions. The following sections outline subjective and objective data collection pertinent to GI bleeding.
Review of Health History
1. Elicit Details of Current and Past GI Bleeding Episodes:
Gather detailed information about the patient’s present and previous experiences with GI bleeding. This history is invaluable for symptom analysis and identifying potential triggers or underlying causes, thereby facilitating accurate diagnosis and timely treatment.
2. Scrutinize the Patient’s Medical History and Comorbidities:
Thoroughly review the patient’s medical records, encompassing past illnesses and existing comorbidities that could be relevant to the etiology of GI bleeding. Key conditions to consider 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. 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 crucial. Pay particular attention to:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Anticoagulants
- Antiplatelet drugs
- Bismuth-containing medications
- Iron supplements
4. Investigate General Symptoms Associated with GI Bleeding:
Inquire about the presence of common symptoms that may indicate GI bleeding. These include:
- Abdominal pain
- Difficulty swallowing (dysphagia)
- Unexplained weight loss
- Nausea
- Retching or vomiting
- Changes in bowel habits
- Abdominal bloating
- Fatigue and weakness
Physical Assessment
1. Systematically Assess for Manifestations of GI Bleeding:
Conduct a detailed physical examination to identify objective signs of GI bleeding. Key indicators to observe across different body systems include:
- Central Nervous System (CNS): Changes in mental status, decreased level of consciousness, lightheadedness, syncope (fainting), dizziness.
- Head, Eyes, Ears, Nose, and Throat (HEENT): Pallor of the eyes, oral mucosa, and lips.
- Respiratory System: Reduced oxygen saturation levels, shortness of breath (dyspnea).
- Cardiovascular System: Chest pain, tachycardia (rapid heart rate), hypotension (low blood pressure).
- Gastrointestinal System: Abdominal pain, abdominal cramping, presence of anal fissures, hemorrhoids, palpable masses, hematemesis (bright red blood or coffee-ground appearance in vomit), melena (black, tarry stools).
- Hematologic System: Signs of anemia, such as pallor.
- Integumentary System: Skin pallor.
2. Monitor for Signs and Symptoms of Shock:
Be vigilant for the development of shock, a life-threatening complication of severe GI bleeding. Monitor for the following shock indicators:
- Severely low blood pressure
- Orthostatic hypotension (drop in blood pressure upon standing)
- Supine hypotension (low blood pressure while lying down)
- Resting tachycardia
- Palpitations (awareness of rapid, strong, or irregular heartbeat)
- Rapid, bounding pulses
- Oliguria (low urine output) or anuria (absence of urine output)
- Decreased level of consciousness
- Syncope
3. Perform a Thorough Abdominal Examination:
Inspect the abdomen for distension, prominent veins, or any skin discoloration. Auscultate for bowel sounds; hyperactive bowel sounds are often present in GI bleeding. Palpate the abdomen to assess for tenderness or pain, which could suggest perforation or ischemia.
4. Continuously Monitor Vital Signs:
Regularly assess vital signs as they can provide crucial insights into the patient’s hemodynamic status and detect complications like shock or hypovolemia. Pay close attention to trends in heart rate (tachycardia), respiratory rate (tachypnea), and blood pressure (hypotension).
Diagnostic Procedures
1. Review Serum Laboratory Values:
Blood tests are essential for assessing the severity and impact of GI bleeding. Key lab values to review include:
- Complete Blood Count (CBC): Low hemoglobin (Hgb) and hematocrit (Hct) levels are indicative of blood loss and anemia.
- Coagulation Profile: Abnormal blood clotting is reflected in coagulation studies. Expect to see 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 secondary to blood loss.
- Liver Function Tests (LFTs): Abnormal liver enzyme levels may suggest liver dysfunction, which can impair the production of clotting factors and increase bleeding risk.
2. Obtain a Stool Sample for Examination:
Stool samples provide valuable information about the nature and location of GI bleeding. Observe for:
- Bright red blood: Suggests lower GI bleeding.
- Dark, black, tarry stools (melena): Indicate upper GI bleeding or older blood.
- Fecal Occult Blood Test (FOBT): A bedside test to detect hidden blood in the stool.
3. Assist with Endoscopic Procedures:
Endoscopy is a crucial diagnostic and therapeutic tool for GI bleeding.
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Upper GI Endoscopy (Esophagogastroduodenoscopy or EGD): A flexible endoscope with a camera is inserted through the mouth to visualize the esophagus, stomach, and duodenum to identify bleeding sources. Therapeutic interventions like injection, thermal coagulation, or hemostatic clips/bands can be performed during the procedure.
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Lower GI Endoscopy (Colonoscopy or Sigmoidoscopy): An endoscope is inserted through the rectum to examine the colon and rectum for bleeding. Similar therapeutic interventions can be applied as in upper endoscopy.
4. Consider Other Imaging Scans:
Various imaging modalities can aid in diagnosing GI bleeding, particularly when endoscopy is not feasible or inconclusive.
- Capsule Endoscopy: A small, swallowable capsule containing a camera captures images of the small intestine.
- Flexible Sigmoidoscopy: A less invasive procedure than colonoscopy, visualizing only the lower portion of the colon.
- Balloon-Assisted Enteroscopy: Allows for deeper visualization and intervention in the small intestine, reaching areas inaccessible to standard endoscopes.
- Angiography: Identifies and treats actively bleeding vessels by injecting contrast dye into an artery and taking X-rays. Bleeding can be managed through embolization or intra-arterial vasopressin.
- CT Angiography (CTA): A non-invasive imaging technique 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 sites.
Nursing Interventions for Acute GI Bleed
Effective acute GI bleed nursing interventions are paramount for patient recovery, focusing on managing the bleeding, providing supportive care, and preparing for necessary procedures.
Detect the Underlying Cause
1. Manage Active Bleeding:
GI bleeding often resolves spontaneously. However, if bleeding persists, treatment strategies are tailored to the bleeding location and severity.
2. Correct the Underlying Cause:
Identifying and addressing the root cause of the bleeding is the primary step in acute management. This may range from discontinuing offending medications like anticoagulants to more complex interventions such as surgical procedures.
3. Bowel Rest:
Implement NPO (nothing by mouth) orders to allow the GI tract to rest and minimize further irritation, promoting healing during treatment.
Administer Supportive Care
1. Oxygen Administration:
Provide supplemental oxygen, typically via nasal cannula, if the patient is hypoxic. Patients with ongoing hematemesis or altered mental status may require endotracheal intubation.
2. Maintain Hydration:
Establish at least two large-bore peripheral intravenous (IV) lines for efficient IV access. Administer isotonic crystalloid solutions like normal saline or lactated Ringer’s solution for fluid resuscitation.
3. Transfuse Blood Products:
Blood transfusions are crucial to restore lost blood components.
- Packed Red Blood Cell (PRBC) Transfusions: Prescribed when hemoglobin levels fall below 7 g/dL.
- Platelet Transfusion: Initiated if the platelet count drops below 50,000/microL.
4. Reverse Anticoagulation:
For patients on anticoagulants like warfarin or heparin, reversal agents such as vitamin K or protamine sulfate may be necessary to counteract the effects of these medications.
5. Administer Medications as Prescribed:
Pharmacological agents play a key role in managing and stopping GI bleeding.
- Proton Pump Inhibitors (PPIs): Used for upper GI bleeding to suppress acid production. Their use may be continued or discontinued after identifying the bleeding source.
- Prokinetics (e.g., erythromycin, metoclopramide): Enhance gastric emptying, clearing the stomach of blood, clots, and food to improve visualization for endoscopy.
- Somatostatin and Octreotide: Vasoactive medications used to manage variceal bleeding by inhibiting the release of vasodilatory hormones.
- Antibiotics: Considered prophylactically in patients with cirrhosis to prevent bacterial translocation, typically administered before endoscopy.
Prepare for Diagnostic or Surgical Procedures
1. Remove Blood and Clots:
Prior to endoscopy, perform nasogastric tube (NGT) lavage to drain fresh blood and blood clots from the stomach, improving visualization during the procedure.
2. Consider Sengstaken-Blakemore Tube Placement:
In cases of massive GI bleeding due to varices, a Sengstaken-Blakemore tube may be considered as a temporary measure of last resort to tamponade bleeding.
3. Anticipate Potential Surgery:
Surgery may be necessary for patients with significant bleeding or hemodynamic instability that does not respond to other interventions. Procedures may include bowel resection or colectomy.
4. Manage Diverticular Bleeding:
Colonoscopy with bipolar probe coagulation, epinephrine injection, or metal clips is used to control bleeding from diverticulitis.
5. Apply Thermal Therapy:
Thermal therapies like electrocoagulation and argon plasma coagulation can treat lower GI bleeds caused by angiodysplasia.
6. Prevent Complications of Bleeding:
Untreated or improperly managed GI bleeding can lead to serious complications:
- Respiratory Distress
- Myocardial Infarction
- Infection or Sepsis
- Shock
- Death
Educate on Preventing Recurrent GI Bleeds
1. Limit NSAID Use:
Chronic NSAID and aspirin use can cause mucosal damage, increasing bleeding risk. Educate patients to avoid or limit these medications as advised by their healthcare provider.
2. Smoking Cessation:
Smoking increases the risk of peptic ulcers and impairs healing, predisposing individuals to GI bleeds. Encourage smoking cessation.
3. Reduce Alcohol Intake:
Excessive alcohol consumption irritates the GI tract and damages the liver, affecting clotting and raising the risk of GI bleeding. Advise moderation or abstinence.
4. Manage Inflammatory and Infectious Conditions:
H. pylori infection and inflammatory conditions like diverticulitis, Crohn’s disease, or ulcerative colitis can lead to GI bleeding if not well-managed. Emphasize adherence to prescribed medication regimens.
Nursing Care Plans for Acute GI Bleed
Once a nurse establishes an acute GI bleed nursing diagnosis, developing tailored nursing care plans becomes essential. These plans prioritize assessments and interventions to achieve short-term and long-term care goals. Examples of nursing care plans relevant to GI bleeding are outlined below.
Acute Pain
Acute pain associated with GI bleeding can arise from gastrointestinal perforation or ischemia due to reduced blood flow and oxygen supply to the GI system.
Nursing Diagnosis: Acute Pain
Related to:
- Gastrointestinal perforation
- Gastrointestinal ischemia
As 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 relief or effective control of pain.
- Patient will appear relaxed and achieve adequate rest or sleep.
Assessment:
- Assess Pain Characteristics: Evaluate pain location, quality, severity, alleviating and aggravating factors using appropriate pain assessment tools. Determine if the pain is constant, aching, stabbing, or burning and identify the precise abdominal location.
- Examine Pain Indicators: Observe both verbal and nonverbal cues of pain. Discrepancies between these cues may reveal information about pain severity, need for further management, and intervention effectiveness.
- Assess Coping Mechanisms: Identify the patient’s coping strategies for managing stressful situations and pain. Observe and inquire about coping mechanisms used by the patient.
Interventions:
- Administer Pharmacologic Pain Management: Provide prescribed analgesics. Acetaminophen is often preferred over other nonopioid pain relievers due to a lower risk of GI side effects. Antacids without aspirin and PPIs can alleviate heartburn.
- Evaluate Effectiveness of Pain Management: Reassess pain within one hour of medication administration to gauge effectiveness. If the patient cannot communicate, rely on physiological and nonverbal pain cues.
- Provide Comfort Measures and Non-Pharmacologic Pain Management: Implement comfort measures like frequent repositioning, back rubs, and pillow support. Utilize non-pharmacologic pain management techniques such as relaxation exercises, guided imagery, and appropriate diversional activities to distract and reduce pain perception.
- Plan Rest Periods and Create a Conducive Environment: Promote rest to reduce fatigue and conserve energy, enhancing coping abilities. Minimize interruptions and cluster nursing tasks to create a quiet, restful environment.
Deficient Fluid Volume
Deficient fluid volume in GI bleeding results from blood loss, leading to decreased blood volume, reduced blood flow, and ineffective tissue perfusion within 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
- Nausea and/or vomiting
- Decreased skin turgor
Expected outcomes:
- Patient will maintain adequate fluid volume, evidenced by stable vital signs, balanced intake and output, and normal capillary refill.
- Patient will demonstrate effective fluid volume status, evidenced by stable hemoglobin and hematocrit levels.
Assessment:
- Assess Nutritional Status: Evaluate current dietary intake, weight changes, oral intake issues, supplement use, tube feedings, and factors like nausea and vomiting that impact fluid intake.
- Monitor Intake and Output: Accurately measure and document all fluid intake (oral and IV) and output (urine, vomit, bloody stools) to track trends and fluid balance.
- Evaluate Lab Results: Closely monitor hemoglobin and hematocrit levels, which are critical indicators of blood loss. Low Hgb and Hct signal significant blood loss.
Interventions:
- Assist in Treating Underlying Issues: Collaborate with the healthcare provider to identify and address the root cause of fluid volume deficit and bleeding. Treating the source of GI bleeding is crucial for controlling fluid loss.
- Provide Adequate Free Water and Balanced Diet: Ensure sufficient free water intake with meals and a nutritionally balanced diet or enteral feedings. Avoid overly hyperosmolar or high-protein formulas. Proper nutrition supports overall health and reduces anemia risk.
- Review and Administer Prescribed Medications: Review all medications, including OTC, herbal, and supplements, for potential impacts on fluid and electrolyte balance or as potential causes of GI bleeding. Administer prescribed medications like PPIs to reduce stomach acid production.
- Administer Blood Products: Prepare for and administer PRBC transfusions as ordered. Ensure patient is appropriately typed and cross-matched for blood transfusion.
Imbalanced Nutrition: Less Than Body Requirements
GI bleeding, associated with various gastrointestinal disorders, leads to nutrient malabsorption, fluid volume deficit, anemia, and other GI symptoms, contributing to imbalanced nutrition.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Disease process
- Nausea and vomiting
- Food aversion
- Loss of appetite
- NPO status
- Nutrient malabsorption
As evidenced by:
- Abdominal pain
- Abdominal cramping
- Abdominal distension
- Body weight less than ideal for age and gender
- 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.
Assessment:
- Assess Eating Patterns and Diet: Identify the patient’s usual eating patterns and dietary habits, as GI disorders associated with bleeding often affect appetite and food intake.
- Assess Medication Use: Review past and current medication use, noting drugs like corticosteroids and NSAIDs that can cause GI toxicity, ulcers, and nutrient malabsorption.
- Assess Laboratory Studies: Evaluate relevant lab results, including fluid and electrolyte levels, as GI bleeding leads to blood, fluid, and electrolyte loss, potentially causing conditions like iron-deficiency anemia.
Interventions:
- Administer Fluid and Electrolyte Replacement: Initiate fluid and electrolyte replacement therapy to correct hypovolemia and electrolyte imbalances resulting from GI bleeding.
- Minimize NPO Status: Keep NPO status as short as possible (typically 48-72 hours) to improve GI pH, reduce rebleeding risk, and stabilize clots. Consider early enteral nutrition for low-risk patients.
- Provide Small, Frequent Feedings: Offer small, frequent meals to reduce early satiety, minimize vomiting, and facilitate GI tract healing, particularly if nausea and vomiting are present.
- Encourage Avoidance of Gastric Irritants: Advise patients to avoid caffeine, alcohol, soda, and spicy foods, as these can irritate the GI tract and increase rebleeding risk.
- Refer to a Dietitian: Consult a dietitian to develop personalized, balanced meal plans that address nutritional deficits and include iron-rich foods (meat, seafood, nuts), whole grains, fruits, and vegetables, while limiting salt, added sugars, and fats.
Ineffective Tissue Perfusion
Ineffective tissue perfusion in GI bleeding arises from blood loss, reducing oxygenation and perfusion to tissues throughout the body, depending on the bleeding location.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- 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
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 within normal limits.
- Patient will verbalize understanding of GI bleeding, treatment plan, and when to seek medical attention.
Assessment:
- Assess Vital Signs: Monitor for persistent hypotension, which can lead to hypoperfusion of abdominal organs. Track blood pressure and pulse rate changes as indicators of bleeding severity.
- Assess for Bleeding: Identify any conditions that may impair GI perfusion and circulation, such as trauma with blood loss or septic shock. Note that bowel ischemia and GI hypoperfusion can result from blood loss and shock.
- Assess Bleeding/Coagulation History: Determine the patient’s history of cancer, coagulation disorders, or previous GI bleeding to assess bleeding risk. Review health history and interview the patient to identify risk factors and bleeding history.
Interventions:
- Collaborate with Interdisciplinary Team: Work with the healthcare team to create a comprehensive plan of care to improve communication, ensure care continuity, and develop an appropriate treatment plan for improving systemic perfusion and organ function.
- Administer Fluids, Blood, and Electrolytes: Provide fluid resuscitation to improve tissue perfusion and stabilize hemodynamics. Administer IV fluids, blood products, and electrolytes to compensate for blood and fluid loss and maintain GI circulation and cellular function.
- Administer Prescribed Medications: Provide prophylactic medications such as antiemetics, anticholinergics, PPIs, antihistamines, and antibiotics as prescribed to reduce fluid loss and neutralize stomach acid, preventing further GI mucosa irritation.
- Prepare for Endoscopy or Surgery: Prepare the patient for potential endoscopy to locate the bleeding source and cause. Surgery may be necessary if bleeding is severe and cannot be visualized or controlled through endoscopy.
Risk for Decreased Cardiac Output
In severe GI bleeding and significant blood loss, hypovolemia can lead to decreased cardiac output.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related to:
- Disease process
- Blood loss
- Altered afterload
- Altered heart rate
- Altered heart rhythm
- Altered stroke volume
As evidenced by:
A risk diagnosis does not have defining signs and symptoms as the problem has not yet occurred. Nursing interventions are focused on prevention.
Expected outcomes:
- Patient will maintain vital signs within normal limits, adequate urine output, and sufficient tissue perfusion.
- Patient will maintain a stable cardiac rhythm without signs and symptoms of decreased cardiac output.
Assessment:
- Assess Heart Rate and Rhythm: Monitor heart rate and rhythm for compensatory tachycardia, a common response to low blood pressure and bleeding.
- Monitor Complete Blood Count: Track CBC results, although initial hemoglobin and hematocrit levels may not immediately reflect the extent of blood loss. These provide a baseline for guiding treatment. Hematocrit may initially be normal but will decline 4-6 hours post fluid replacement.
- Assess BUN Level: Monitor blood urea nitrogen (BUN) levels, which typically increase significantly in GI bleeding due to the breakdown of proteins by gastrointestinal bacteria during significant hemorrhage.
Interventions:
- Monitor Urine Output: Measure urine output as a key indicator of vital organ perfusion. Insert an indwelling catheter for accurate monitoring. Decreased urine output can indicate reduced cardiac output and kidney perfusion.
- Perform Hemodynamic Monitoring: Utilize hemodynamic monitoring to assess blood circulation and heart function, especially in patients with GI bleeding. Accurately and promptly assess blood pressure and fluid resuscitation effectiveness.
- Administer Supplemental Oxygenation: Provide supplemental oxygen to prevent and correct hypoxemia in patients at risk for decreased cardiac output, increasing blood oxygen saturation.
- Administer Intravenous Fluids: Administer IV fluids, typically isotonic crystalloid solutions like lactated Ringer’s, to address fluid and electrolyte imbalances and prevent decreased cardiac output.
- Prepare and Initiate Blood Transfusions: Prepare for and initiate blood transfusions as ordered, using whole blood, packed red blood cells, or fresh frozen plasma for fluid volume replacement to prevent decreased cardiac output.
- Prepare for Surgical Intervention: Prepare the patient for possible surgical intervention, such as endoscopy to repair and resolve bleeding, if GI bleeding is severe and to prevent further circulatory compromise.
- Administer Drug Therapy: Administer prescribed medications during the acute phase to reduce bleeding, decrease hydrochloric acid secretion, and neutralize stomach acid, as an acidic environment can impair platelet function and worsen bleeding and cardiac output.
