NANDA Diagnosis for GI Bleed: Comprehensive Nursing Guide

Gastrointestinal (GI) bleeding, a symptom of an underlying condition rather than a disease itself, refers to any hemorrhage occurring within the digestive tract. This tract encompasses the esophagus, stomach, small intestine, large intestine (colon), rectum, and anus. Understanding the nuances of GI bleeding is crucial for healthcare professionals, particularly nurses, in providing timely and effective care.

GI bleeding is broadly categorized into upper and lower, distinguished by the ligament of Treitz, or suspensory ligament of the duodenum. This ligament serves as the anatomical landmark separating the upper and lower GI tracts. Upper GI bleeding (UGIB) is more frequently observed than lower GI bleeding (LGIB). Interestingly, lower GI bleeding is slightly more common in men, potentially linked to higher rates of vascular disorders and diverticulosis within this demographic. The incidence of GI bleeding, both upper and lower, increases with age, highlighting the importance of awareness and prompt management across all age groups, especially in older adults.

Nursing care for patients experiencing hematochezia, hematemesis, or melena—key indicators of GI bleeding—necessitates immediate attention and typically involves hospitalization in an acute care setting. Collaboration with both gastroenterologists and surgeons is often essential. Identifying the precise source and underlying cause of the bleeding is paramount for effective intervention and treatment.

Nurses play a pivotal role in the care of patients with gastrointestinal bleeding. Their expertise is crucial in alleviating distressing symptoms, minimizing the potential for serious complications, and supporting the patient’s psychological well-being throughout the diagnostic and treatment process. Moreover, proactive nursing interventions are vital in preventing and managing potential risk factors associated with GI bleeding. This article delves into the nursing process for GI bleeding, focusing on assessment, nursing diagnosis, interventions, and care planning, emphasizing the application of NANDA diagnoses to guide optimal patient care.

Nursing Assessment for GI Bleeding

The cornerstone of effective nursing care begins with a thorough nursing assessment. This process involves gathering comprehensive data encompassing the patient’s physical, psychosocial, emotional, and diagnostic status. For patients presenting with GI bleeding, both subjective and objective data are crucial in formulating an accurate clinical picture and guiding subsequent interventions.

Review of Health History

1. History of GI Bleeding Incidents: A detailed history of current and past GI bleeding episodes is paramount. Inquire about previous occurrences, including frequency, severity, and characteristics of bleeding. This information aids in identifying patterns, potential triggers, and underlying conditions predisposing the patient to GI bleeding.

2. Comprehensive Medical History Review: Scrutinize the patient’s medical records, paying close attention to past medical history and co-existing conditions that may contribute to GI bleeding. Relevant conditions include:

• Varices: Esophageal or gastric varices, often associated with portal hypertension, are a significant cause of UGIB.
• Portal Hypertension: Elevated pressure in the portal venous system, commonly due to liver cirrhosis, increases the risk of variceal bleeding.
• Alcohol Abuse: Chronic alcohol consumption can lead to liver disease and portal hypertension, as well as direct irritation of the GI mucosa.
• Smoking: Smoking is a known risk factor for peptic ulcers and impaired mucosal healing, increasing GI bleeding risk.
• Ulcers: Peptic ulcers (gastric or duodenal) are a common cause of UGIB.
• H. pylori Infection: Helicobacter pylori infection is a major etiological factor in peptic ulcer disease.
• Diverticulitis: Diverticulitis, particularly diverticulosis, is a common cause of LGIB, especially in older adults.
• Hemorrhoids: While usually causing minor bleeding, hemorrhoids can be a source of significant rectal bleeding in some cases.
• Inflammatory Bowel Disease (IBD): Conditions like Crohn’s disease and ulcerative colitis can cause GI bleeding due to mucosal inflammation and ulceration.
• Gastrointestinal Cancers: Stomach, esophageal, or colon cancer can present with GI bleeding.

3. Medication Regimen Assessment: Carefully review the patient’s current medication list, including prescription and over-the-counter drugs. Certain medications are known to increase the risk of GI bleeding:

• Nonsteroidal Anti-inflammatory Drugs (NSAIDs): NSAIDs are a major cause of drug-induced GI bleeding due to their inhibition of prostaglandin synthesis, which protects the gastric mucosa.
• Anticoagulants: Medications like warfarin, heparin, and direct oral anticoagulants (DOACs) increase bleeding risk throughout the GI tract.
• Antiplatelet Drugs: Aspirin, clopidogrel, and other antiplatelet agents impair platelet function, increasing bleeding susceptibility.
• Bismuth Subsalicylate: Found in some over-the-counter antidiarrheals, bismuth can darken stools, mimicking melena and potentially masking or confusing the diagnosis.
• Iron Supplements: Iron supplements can also darken stools, which might be mistaken for melena.

4. General Symptoms Related to GI Bleeding: Elicit information about associated symptoms that may accompany GI bleeding:

• Abdominal Pain: Characterize the pain – location, intensity, type (cramping, sharp, dull). Pain can vary depending on the source and cause of bleeding.
• Dysphagia (Trouble Swallowing): May suggest esophageal pathology, potentially esophageal varices or esophagitis, as a source of UGIB.
• Unintentional Weight Loss: Can be associated with underlying malignancy or chronic inflammatory conditions contributing to GI bleeding.
• Nausea and Vomiting: May precede or accompany GI bleeding, and hematemesis (vomiting blood) is a direct sign of UGIB.
• Retching: Forceful vomiting efforts can exacerbate esophageal tears (Mallory-Weiss tears), a cause of UGIB.
• Change in Bowel Habits: Note any changes in frequency, consistency, or color of stools. Melena (black, tarry stools) indicates UGIB, while hematochezia (bright red blood in stools) suggests LGIB.
• Bloating: Abdominal distension can occur with significant GI bleeding or underlying bowel conditions.
• Fatigue: Fatigue is a common symptom of anemia resulting from chronic or acute blood loss.

Physical Assessment

1. Assess for Physical Manifestations of GI Bleeding: Conduct a systematic physical examination to identify objective signs of GI bleeding:

• Central Nervous System (CNS): Observe for altered mental status, decreased level of consciousness, lightheadedness, syncope (fainting), and dizziness. These can indicate hypovolemia and reduced cerebral perfusion due to blood loss.
• Head, Eyes, Ears, Nose, and Throat (HEENT): Assess for pallor of the conjunctivae (pale eyes), oral mucosa, and lips, indicative of anemia.
• Respiratory: Monitor oxygen saturation (SpO2). Decreased oxygen saturation and shortness of breath (dyspnea) can occur due to reduced oxygen-carrying capacity of the blood.
• Cardiovascular: Assess for chest pain, tachycardia (increased heart rate), and hypotension (low blood pressure). These are signs of hypovolemia and the body’s compensatory mechanisms.
• Gastrointestinal: Palpate for abdominal pain, assess for abdominal cramping, and inspect the perianal area for anal fissures, hemorrhoids, or masses. Note the presence and characteristics of vomitus (hematemesis – bright red or coffee-ground blood) and stools (melena – black, tarry stools; hematochezia – bright red blood).
• Hematologic: Assess for signs of anemia, such as pallor.
• Integumentary: Observe skin pallor, which is a common sign of anemia.

2. Monitor for Signs and Symptoms of Shock: Severe GI bleeding can lead to hypovolemic shock, a life-threatening condition. Be vigilant for shock symptoms:

• Severely Low Blood Pressure: Systolic blood pressure significantly below normal limits.
• Orthostatic Hypotension: A drop in blood pressure upon standing, indicating fluid volume depletion.
• Supine Hypotension: Low blood pressure even when lying down, a more severe sign of hypovolemia.
• Resting Tachycardia: Persistently elevated heart rate at rest, a compensatory mechanism for reduced blood volume.
• Palpitations: Awareness of rapid or irregular heartbeat.
• Rapid, Bounding Pulses: Initially, pulses may be rapid and bounding as the body attempts to compensate, but they may become weak and thready in later stages of shock.
• Oliguria or Anuria: Low (oliguria) or absent (anuria) urine output, reflecting decreased renal perfusion.
• Decreased Level of Consciousness: Confusion, lethargy, or unresponsiveness due to reduced cerebral blood flow.
• Syncope: Fainting or loss of consciousness.

3. Abdominal Examination: Perform a thorough abdominal examination:

• Inspection: Look for abdominal distension, prominent veins (caput medusae, suggestive of portal hypertension), or skin discoloration.
• Auscultation: Auscultate bowel sounds. Hyperactive bowel sounds are often present in GI bleeding, but absent bowel sounds may indicate ileus or peritonitis in some cases.
• Palpation: Palpate for abdominal tenderness or pain. Guarding or rebound tenderness may suggest peritonitis or perforation. Assess for any palpable masses.

4. Vital Signs Monitoring: Closely monitor vital signs, including heart rate, blood pressure, respiratory rate, and temperature. Trends in vital signs are crucial indicators of hemodynamic stability and response to treatment. Tachycardia, tachypnea (increased respiratory rate), and hypotension are key signs of hypovolemia associated with GI bleeding.

Diagnostic Procedures

1. Serum Lab Values Review: Blood tests are essential in assessing the severity and impact of GI bleeding:

• Complete Blood Count (CBC): Reveals low hemoglobin (Hgb) and hematocrit (Hct), indicating blood loss and anemia. However, initial Hgb and Hct may not reflect the true extent of blood loss and may decrease later after fluid resuscitation.
• Coagulation Profile: Assesses blood clotting function. Elevated international normalized ratio (INR), prolonged prothrombin time (PT), and activated partial thromboplastin time (aPTT) may indicate coagulopathy, either pre-existing or as a result of liver dysfunction in some GI bleeding cases.
• Lactate Levels: Elevated lactate levels can indicate tissue hypoperfusion and anaerobic metabolism, which may occur in severe GI bleeding and shock.
• Liver Function Tests (LFTs): May be abnormal, especially in patients with variceal bleeding secondary to liver disease. Impaired liver function can reduce the production of clotting factors, exacerbating bleeding risk.

2. Stool Exam: Stool analysis provides crucial information:

• Visual Inspection: Observe stool color and consistency. Bright red blood suggests hematochezia (LGIB), while dark, black, tarry stools indicate melena (UGIB).
• Fecal Occult Blood Test (FOBT): Can be performed at the bedside to detect hidden (occult) blood in the stool, even if not visibly apparent.

3. Endoscopy: Endoscopic procedures are the gold standard for diagnosing and often treating GI bleeding:

• Upper GI Endoscopy (Esophagogastroduodenoscopy – EGD): A flexible endoscope with a camera is inserted through the mouth to visualize the esophagus, stomach, and duodenum. Used for UGIB.
• Lower GI Endoscopy (Colonoscopy): An endoscope is inserted through the rectum to visualize the colon. Used for LGIB.
• Sigmoidoscopy: A limited lower endoscopy, visualizing only the rectum and sigmoid colon. May be used for initial assessment of LGIB.
• Therapeutic Endoscopy: Endoscopy allows for interventions to stop bleeding, such as injection therapy (epinephrine), thermal coagulation (cautery, argon plasma coagulation), and application of hemostatic clips or bands.

4. Other Imaging Scans: Various imaging modalities can be used depending on the suspected location and nature of bleeding:

• Capsule Endoscopy: A small, ingestible capsule containing a camera visualizes the small intestine, areas often difficult to reach with traditional endoscopy. Useful for obscure GI bleeding.
• Flexible Sigmoidoscopy: As described above, a limited lower endoscopy.
• Balloon-Assisted Enteroscopy: A specialized endoscope allows for deeper visualization and intervention within the small intestine, useful for diagnosing and treating bleeding sources in this region.
• Angiography: Radiographic imaging of blood vessels after injecting contrast dye. Can detect active bleeding and allows for therapeutic embolization (blocking bleeding vessels) or intra-arterial vasopressin administration to constrict blood vessels.
• CT Angiography (CTA): Computed tomography with angiography provides detailed images of blood vessels and can identify active bleeding.
• Enteroscopy: General term for visualizing the small bowel, encompassing capsule and balloon-assisted enteroscopy.
• Nuclear Scintigraphy (Tagged Red Blood Cell Scan): The most sensitive imaging test for detecting active lower GI bleeding, especially intermittent or slow bleeding. Radiolabeled red blood cells are injected, and a scanner detects accumulation at the bleeding site.

Nursing Interventions for GI Bleeding

Effective nursing interventions are crucial for managing patients with GI bleeding, focusing on stabilizing the patient, identifying and addressing the underlying cause, and preventing complications.

Detect and Address the Underlying Cause

1. Manage Active Bleeding: While some GI bleeding resolves spontaneously, active bleeding requires prompt management. Treatment strategies depend on the bleeding location and severity, ranging from endoscopic hemostasis to surgical intervention.

2. Correct the Underlying Etiology: Identifying and treating the root cause of GI bleeding is paramount for long-term management. This may involve simple measures like discontinuing offending medications (NSAIDs, anticoagulants) or more complex interventions like surgery to resect a bleeding ulcer or tumor.

3. Bowel Rest (NPO): Implementing “nothing per os” (NPO) orders allows the GI tract to rest and minimizes further irritation. This facilitates healing and recovery during treatment.

Supportive Care Measures

1. Oxygen Administration: Administer supplemental oxygen as prescribed, typically via nasal cannula, if the patient is hypoxic (SpO2 < 90%). Patients with ongoing hematemesis or altered mental status may require more advanced airway management, including intubation and mechanical ventilation.

2. Hydration Maintenance: Establish and maintain adequate intravenous (IV) access, typically requiring at least two large-bore peripheral IV catheters. Fluid resuscitation with isotonic crystalloids like normal saline (0.9% NaCl) or lactated Ringer’s solution is crucial to restore intravascular volume and maintain hemodynamic stability.

3. Blood Product Transfusion: Transfusions are essential to replace blood components lost due to hemorrhage.

• Packed Red Blood Cell (PRBC) Transfusion: Typically indicated when hemoglobin levels fall below 7 g/dL in hemodynamically stable patients, or higher thresholds may be used in patients with ongoing active bleeding or cardiovascular compromise.
• Platelet Transfusion: Considered when platelet counts are below 50,000/microL, especially in patients with active bleeding or undergoing invasive procedures.

4. Reverse Anticoagulation: In patients taking warfarin or heparin, reversal agents may be necessary to counteract the effects of these medications and control bleeding. Vitamin K is used to reverse warfarin, and protamine sulfate reverses heparin. For DOACs, specific reversal agents like idarucizumab (for dabigatran) and andexanet alfa (for factor Xa inhibitors) are available.

5. Pharmacological Management: Various medications are used to manage GI bleeding:

• Proton Pump Inhibitors (PPIs): Used primarily for upper GI bleeding, PPIs (e.g., omeprazole, pantoprazole) suppress gastric acid production, promoting ulcer healing and clot stabilization. May be continued or discontinued after the bleeding source is identified and managed.
• Prokinetic Agents: Medications like erythromycin and metoclopramide promote gastric emptying and clear the stomach of blood, clots, and food debris, improving visualization during endoscopy.
• Somatostatin and Octreotide: Vasoactive medications, particularly octreotide (a somatostatin analog), are used to treat variceal bleeding. They reduce splanchnic blood flow and portal pressure by inhibiting the release of vasodilatory hormones.
• Antibiotics: In patients with cirrhosis and variceal bleeding, prophylactic antibiotics are often administered to prevent bacterial translocation and subsequent infections, especially prior to endoscopy.

Preparation for Diagnostic or Surgical Procedures

1. Nasogastric Lavage: Prior to upper endoscopy, nasogastric tube (NGT) lavage with saline solution may be performed to remove blood and clots from the stomach, improving visualization during the procedure.

2. Sengstaken-Blakemore Tube: In cases of massive variceal bleeding unresponsive to other treatments, a Sengstaken-Blakemore tube (or Minnesota tube) may be used as a temporary measure to tamponade esophageal and gastric varices. This is typically a last resort due to associated risks.

3. Anticipate Surgical Intervention: Surgery may be necessary for patients with severe, persistent GI bleeding or hemodynamic instability when other interventions fail. Surgical options may include bowel resection or colectomy, depending on the bleeding source.

4. Diverticular Bleeding Management: Colonoscopy with bipolar probe coagulation, epinephrine injection, or metal clips is commonly used to stop bleeding from diverticulosis.

5. Thermal Therapy for Angiodysplasia: Lower GI bleeding from angiodysplasia can be treated with thermal therapy during colonoscopy, using electrocoagulation or argon plasma coagulation to ablate abnormal blood vessels.

6. Prevent Complications: Untreated or poorly managed GI bleeding can lead to serious complications:

• Respiratory Distress (e.g., aspiration pneumonia, ARDS)
• Myocardial Infarction (especially in patients with pre-existing cardiac disease due to hypovolemia and reduced oxygen delivery)
• Infection or Sepsis (increased risk with massive transfusion and bowel ischemia)
• Shock (hypovolemic shock)
• Death

Education on Preventing Recurrent GI Bleeds

1. Limit NSAID Use: Educate patients about the risks of long-term NSAID use and aspirin, which can damage the GI mucosa and lead to bleeding. Advise them to avoid or limit these medications as directed by their healthcare provider and to consider alternatives like acetaminophen for pain relief when appropriate.

2. Smoking Cessation: Emphasize the importance of quitting smoking. Smoking increases the risk of peptic ulcers and impairs mucosal healing, increasing susceptibility to GI bleeds.

3. Reduce Alcohol Intake: Advise patients to reduce or abstain from alcohol consumption. Excessive alcohol irritates the GI tract, damages the liver (impairing clotting function), and increases GI bleeding risk.

4. Manage Inflammatory and Infectious Conditions: Educate patients on the importance of managing underlying conditions that contribute to GI bleeding. For H. pylori infection, emphasize adherence to antibiotic regimens for eradication. For inflammatory conditions like diverticulitis, Crohn’s disease, or colitis, stress the importance of medication adherence and lifestyle modifications to control inflammation and prevent flare-ups.

NANDA Nursing Care Plans for GI Bleeding

Once nursing assessments are complete and nursing diagnoses are identified, nursing care plans are developed to prioritize interventions and guide patient care. Here are examples of NANDA nursing diagnoses relevant to GI bleeding, along with associated care plan components:

Acute Pain

Nursing Diagnosis: Acute Pain related to gastrointestinal perforation or ischemia, secondary to GI bleeding.

Related Factors:

• Gastrointestinal perforation
• Gastrointestinal ischemia

As Evidenced By:

• Changes in blood pressure, pulse, and respiratory rate
• Guarding position of the affected area
• Restlessness
• Report of abdominal pain (location, character, intensity)
• Report of heartburn

Expected Outcomes:

• Patient will verbalize relief or control of pain to a level acceptable to them within a specified timeframe.
• Patient will appear relaxed and able to rest or sleep adequately.
• Patient will demonstrate appropriate use of pain management techniques.

Assessments:

1. Pain Characteristics Assessment: Evaluate pain location, quality (sharp, cramping, burning), intensity (using pain scales), timing, and aggravating/alleviating factors (PQRST – Provocation, Quality, Region/Radiation, Severity, Timing). Determine if pain is constant or intermittent, aching, stabbing, or burning. Pinpoint the exact location of abdominal pain.

2. Verbal and Nonverbal Pain Cues: Observe for verbal reports of pain and nonverbal indicators such as facial grimacing, guarding, restlessness, changes in vital signs (increased heart rate, blood pressure, respiratory rate), and diaphoresis. Incongruence between verbal and nonverbal cues may suggest the need for further pain assessment or intervention.

3. Coping Mechanisms: Assess the patient’s usual coping mechanisms for pain and stress. Observe for effective and ineffective coping strategies. Consider cultural and individual variations in pain expression and coping.

Interventions:

1. Pharmacological Pain Management: Administer prescribed analgesic medications as ordered, considering the type and severity of pain. Acetaminophen is often preferred initially over NSAIDs due to the risk of GI irritation and bleeding associated with NSAIDs. Antacids (without aspirin) and proton pump inhibitors may be used to alleviate heartburn. Opioid analgesics may be necessary for severe pain, but use cautiously due to potential GI side effects and masking of abdominal findings.

2. Evaluate Pain Management Effectiveness: Reassess pain intensity and relief within one hour after medication administration (or according to medication-specific guidelines). If the patient is nonverbal, rely on physiological and nonverbal pain cues to evaluate effectiveness. Document pain scores and medication effectiveness.

3. Non-pharmacological Pain Management: Provide comfort measures such as frequent repositioning, back rubs, and pillow support for positioning. Implement non-pharmacological pain relief techniques like relaxation techniques (deep breathing, guided imagery), distraction (music, conversation), and heat or cold application (if appropriate and not contraindicated).

4. Promote Rest and Conducive Environment: Plan rest periods and minimize interruptions to promote sleep and rest. Create a quiet, restful environment by reducing noise and controlling room temperature and lighting. Group nursing activities to minimize disturbances.

Deficient Fluid Volume

Nursing Diagnosis: Deficient Fluid Volume related to GI hemorrhage.

Related Factors:

• GI hemorrhage
• Hematochezia
• Hematemesis
• Bleeding ulcers
• Abdominal or rectal fistulas (less common cause, but possible)

As Evidenced By:

• Hematochezia
• Hematemesis
• Melena
• Abdominal pain
• Resting tachycardia
• Orthostatic hypotension
• Weakness
• Nausea and/or vomiting
• Decreased skin turgor
• Dry mucous membranes
• Concentrated urine
• Decreased urine output

Expected Outcomes:

• Patient will demonstrate adequate fluid volume balance as evidenced by stable vital signs (blood pressure, heart rate within patient’s normal range), balanced intake and output, appropriate urine specific gravity, and good capillary refill (< 3 seconds).
• Patient will exhibit laboratory values within acceptable limits, including stable hemoglobin and hematocrit, reflecting adequate circulating blood volume.
• Patient will report reduced symptoms of dehydration, such as decreased thirst and improved energy levels.

Assessments:

1. Nutritional Status Assessment: Assess current nutritional intake, including oral intake, IV fluids, and any enteral or parenteral nutrition. Document weight fluctuations, presence of nausea and vomiting, and any factors affecting fluid intake.

2. Intake and Output (I&O) Monitoring: Accurately monitor and record all fluid intake (oral, IV) and output (urine, stool, vomitus, drainage from tubes). Note the characteristics of output, especially stool and emesis (color, consistency, amount). Calculate and analyze 24-hour fluid balance.

3. Laboratory Results Evaluation: Closely monitor hemoglobin (Hgb) and hematocrit (Hct) trends. Assess electrolyte levels (sodium, potassium, chloride, bicarbonate) for imbalances. Review BUN and creatinine levels to assess renal function. Monitor urine specific gravity and osmolarity as indicators of hydration status.

Interventions:

1. Collaborate with Healthcare Provider: Work closely with the physician to determine and treat the underlying cause of fluid volume deficit and bleeding. Ensure timely diagnostic procedures and interventions to stop the source of GI bleeding.

2. Fluid Replacement Therapy: Administer prescribed IV fluids as ordered, typically isotonic crystalloids (normal saline, lactated Ringer’s). Monitor patient response to fluid resuscitation, including vital signs, urine output, and clinical signs of hydration. Maintain IV access and adjust fluid rate as needed based on patient assessment.

3. Nutritional Support: Provide a nutritionally balanced diet as tolerated, once oral intake is resumed. Consider enteral or parenteral nutrition if oral intake is inadequate or contraindicated. Avoid hyperosmolar formulas or those excessively high in protein initially, especially in patients with compromised renal or cardiac function. Ensure adequate free water intake with meals and nutritional support.

4. Blood Product Administration: Administer blood products (PRBCs, plasma) as prescribed to replace blood loss and improve oxygen-carrying capacity. Ensure proper type and cross-matching prior to transfusion. Monitor for transfusion reactions during and after administration.

5. Medication Review and Administration: Review the patient’s medication list for drugs that may contribute to fluid imbalance or GI bleeding. Administer prescribed medications, such as proton pump inhibitors, antiemetics, and vasopressors (if indicated), as ordered.

Imbalanced Nutrition: Less Than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to disease process and GI symptoms.

Related Factors:

• Disease process (GI disorders causing bleeding)
• Nausea and vomiting
• Food aversion
• Loss of appetite (anorexia)
• NPO status (prolonged)
• Nutrient malabsorption (potential complication of some GI disorders)

As Evidenced By:

• Abdominal pain and cramping
• Abdominal distension
• Body weight less than ideal for age and gender
• Hyperactive bowel sounds (initially, may decrease later)
• Lethargy and fatigue
• Pale mucous membranes
• Vomiting

Expected Outcomes:

• Patient will demonstrate improved nutritional status as evidenced by stable weight, improved energy levels, and laboratory values within normal limits (albumin, prealbumin, electrolytes, iron studies).
• Patient will tolerate oral intake without nausea, vomiting, or abdominal discomfort.
• Patient will verbalize understanding of nutritional needs and strategies to meet them.

Assessments:

1. Eating Pattern and Diet History: Assess the patient’s usual eating patterns, dietary habits, food preferences, and any recent changes in appetite or food intake. Identify any food aversions or intolerances. Determine the impact of GI symptoms (nausea, vomiting, pain) on food intake.

2. Medication History (Nutritional Impact): Review current and past medications, including corticosteroids and NSAIDs, which can affect nutrient absorption and GI function. Assess for use of over-the-counter medications and herbal supplements.

3. Laboratory Studies (Nutritional Status): Monitor laboratory values relevant to nutritional status, including serum albumin, prealbumin, total protein, electrolytes, iron studies (ferritin, transferrin saturation), and vitamin levels (if indicated). Assess for signs of anemia (CBC, iron studies).

Interventions:

1. Fluid and Electrolyte Replacement: Prioritize fluid and electrolyte replacement to address hypovolemia and imbalances resulting from GI bleeding and associated symptoms (vomiting, diarrhea).

2. Minimize NPO Status: Minimize the duration of NPO status as much as clinically appropriate. Once acute bleeding is controlled and bowel function returns, advance diet gradually as tolerated, starting with clear liquids and progressing to a soft, bland diet.

3. Small, Frequent Feedings: Provide small, frequent meals to reduce early satiety and minimize nausea and vomiting. Offer nutrient-dense foods in small portions. Avoid large meals that can distend the stomach and exacerbate symptoms.

4. Avoid Gastric Irritants: Educate the patient to avoid gastric irritants such as caffeine, alcohol, carbonated beverages, spicy foods, and highly acidic foods, as these can worsen GI irritation and potentially trigger re-bleeding.

5. Dietary Consultation: Refer the patient to a registered dietitian for individualized dietary counseling and meal planning. Dietitians can help develop a balanced meal plan that meets nutritional needs, addresses food preferences and intolerances, and promotes healing. Dietary recommendations may include iron-rich foods (meat, seafood, beans, fortified cereals), whole grains, fruits, and vegetables, while limiting salt, added sugars, and unhealthy fats.

Ineffective Tissue Perfusion

Nursing Diagnosis: Ineffective Tissue Perfusion related to blood loss secondary to GI bleeding.

Related Factors:

• Upper GI bleeding
• Lower GI bleeding
• Gastrointestinal perforation
• Gastrointestinal ischemia
• Peptic ulcer disease
• Esophageal tears or inflammation
• Diverticulosis and diverticulitis
• Inflammatory bowel disease (Ulcerative colitis, Crohn’s disease)
• Colonic polyps
• Gastrointestinal cancers (colon, stomach, esophageal)

As Evidenced By:

• Hematochezia
• Hematemesis
• Melena
• Abdominal pain
• Resting tachycardia
• Orthostatic hypotension
• Supine hypotension
• Nausea and/or vomiting
• Pallor
• Cool, clammy skin
• Decreased capillary refill
• Altered mental status (dizziness, confusion)
• Decreased urine output

Expected Outcomes:

• Patient will demonstrate effective tissue perfusion as evidenced by stable vital signs (blood pressure, heart rate, respiratory rate within normal limits for patient), warm and dry skin, palpable peripheral pulses, capillary refill < 3 seconds, and urine output > 30 mL/hr.
• Patient will maintain hemoglobin and hematocrit within acceptable limits for age and clinical condition.
• Patient will verbalize understanding of GI bleeding, treatment plan, and when to seek medical attention.

Assessments:

1. Vital Signs Monitoring (Tissue Perfusion Indicators): Closely monitor vital signs, paying particular attention to blood pressure, heart rate, and respiratory rate. Persistent hypotension, especially orthostatic or supine hypotension, and tachycardia are key indicators of hypovolemia and ineffective tissue perfusion. Assess for trends and changes in vital signs.

2. Bleeding Assessment (Source and Severity): Assess for ongoing bleeding, noting the source (hematemesis, melena, hematochezia), amount, and characteristics of blood loss. Quantify blood loss whenever possible. Monitor for signs of continued bleeding or re-bleeding.

3. History of Bleeding/Coagulation Disorders and Risk Factors: Obtain a detailed history of previous bleeding episodes, known bleeding or coagulation disorders, and risk factors for bleeding (medication use, liver disease, etc.). Review medical history for conditions that predispose to GI bleeding (peptic ulcer disease, IBD, varices, cancer).

Interventions:

1. Interdisciplinary Collaboration: Collaborate closely with the healthcare team (physician, surgeon, gastroenterologist, pharmacist) to develop and implement a comprehensive plan of care. Ensure effective communication and coordination of interventions.

2. Fluid, Blood, and Electrolyte Replacement: Administer IV fluids (crystalloids, colloids), blood products (PRBCs, plasma), and electrolytes as prescribed to restore intravascular volume, improve oxygen-carrying capacity, and correct electrolyte imbalances. Monitor patient response and adjust therapy accordingly.

3. Medication Administration (Perfusion Support): Administer prescribed medications to support tissue perfusion and address underlying causes. This may include vasopressors (in shock), proton pump inhibitors (for UGIB), octreotide (for variceal bleeding), and antibiotics (for sepsis prevention in certain cases). Administer antiemetics to control nausea and vomiting.

4. Prepare for Endoscopy or Surgery (Bleeding Control): Prepare the patient for diagnostic and therapeutic procedures, such as endoscopy, angiography, or surgery, as indicated to identify and control the source of bleeding. Ensure patient is appropriately prepped for procedures (NPO status, bowel preparation if needed). Provide post-procedure care and monitoring.

Risk for Decreased Cardiac Output

Nursing Diagnosis: Risk for Decreased Cardiac Output related to hypovolemia secondary to GI bleeding.

Related Factors:

• Blood loss (GI hemorrhage)
• Hypovolemia
• Altered afterload (potential in shock)
• Altered heart rate (tachycardia as compensation)
• Altered stroke volume (reduced due to hypovolemia)

As Evidenced By:

A risk diagnosis is not evidenced by signs and symptoms, as the problem has not yet occurred. Nursing interventions are directed at preventing the problem.

Expected Outcomes:

• Patient will maintain vital signs within acceptable limits for age and clinical condition, including stable blood pressure and heart rate.
• Patient will maintain adequate urine output (> 30 mL/hr), indicating adequate renal perfusion.
• Patient will demonstrate adequate peripheral tissue perfusion (warm and dry skin, capillary refill < 3 seconds, palpable pulses).
• Patient will maintain a stable cardiac rhythm without signs and symptoms of decreased cardiac output (chest pain, dyspnea, palpitations, dizziness, syncope).

Assessments:

1. Heart Rate and Rhythm Assessment: Continuously monitor heart rate and rhythm. Assess for tachycardia (compensatory response to hypovolemia) and arrhythmias. Evaluate pulse quality (strength, regularity).

2. Complete Blood Count (CBC) Monitoring: Monitor trends in hemoglobin (Hgb) and hematocrit (Hct). While initial values may not reflect acute blood loss immediately, serial measurements are crucial for assessing the extent of blood loss and response to treatment. Establish baseline CBC and monitor trends.

3. Blood Urea Nitrogen (BUN) Level: Monitor BUN levels. Elevated BUN, especially disproportionately high compared to creatinine, can be indicative of significant upper GI bleeding. Gastrointestinal bacteria break down blood proteins, leading to increased BUN.

Interventions:

1. Urine Output Monitoring: Closely monitor urine output as an indicator of renal perfusion and overall cardiac output. Insert an indwelling urinary catheter if necessary for accurate monitoring, especially in unstable patients. Report urine output < 30 mL/hr.

2. Hemodynamic Monitoring: Implement hemodynamic monitoring as indicated, especially in patients with severe bleeding or hemodynamic instability. This may include continuous blood pressure monitoring, central venous pressure (CVP) monitoring, and arterial line placement for invasive blood pressure monitoring and arterial blood gas analysis.

3. Supplemental Oxygenation: Administer supplemental oxygen as needed to correct and prevent hypoxemia. Maintain SpO2 > 92% (or as prescribed). Oxygen increases oxygen saturation of the remaining blood volume.

4. Intravenous Fluid Administration: Administer IV fluids as indicated to restore intravascular volume and improve cardiac preload. Isotonic crystalloids (lactated Ringer’s, normal saline) are typically used initially. Monitor patient response to fluid resuscitation (vital signs, urine output, lung sounds).

5. Prepare for Blood Transfusions: Prepare for and initiate blood transfusions as ordered to replace blood loss and improve oxygen-carrying capacity. Ensure blood is typed and cross-matched. Monitor for transfusion reactions.

6. Surgical Intervention Preparation: Prepare the patient for potential surgical or endoscopic intervention to control bleeding if conservative measures are ineffective. Ensure patient is appropriately consented and prepped for procedures.

7. Drug Therapy Administration (Cardiac Support): Administer prescribed medications to support cardiac function and manage complications. This may include vasopressors (if hypotensive despite fluid resuscitation), inotropes (if cardiac contractility is compromised), and antiarrhythmics (if arrhythmias develop). Administer medications to reduce GI bleeding (PPIs, octreotide).

References

(List of references from the original article would be included here, maintaining the same references)

References

Alt text: Diagram illustrating upper and lower gastrointestinal bleeding locations, highlighting organs involved such as esophagus, stomach, small intestine, large intestine, rectum, and anus.

Alt text: Clinical assessment chart for gastrointestinal bleeding symptoms, detailing key signs in CNS, HEENT, respiratory, cardiovascular, gastrointestinal, hematologic, and integumentary systems for nursing evaluation.

Alt text: Overview of diagnostic procedures for gastrointestinal bleeding, including endoscopy, capsule endoscopy, angiography, CT angiography, enteroscopy, nuclear scintigraphy, and stool exams, aiding in identifying bleeding sources.

Alt text: Nursing interventions flowchart for gastrointestinal bleeding patients, outlining key actions: detect underlying cause, administer supportive care, prepare for procedures, and educate on preventing recurrent bleeds.

Alt text: NANDA nursing care plan examples for gastrointestinal bleeding, listing common diagnoses: acute pain, deficient fluid volume, imbalanced nutrition, ineffective tissue perfusion, and risk for decreased cardiac output.