Gastrointestinal (GI) bleeding refers to any hemorrhage occurring within the digestive tract, encompassing the esophagus, stomach, small intestine, large intestine (colon), rectum, and anus. It’s crucial to understand that GI bleeding isn’t a disease itself, but rather a symptom signaling an underlying medical condition.
GI bleeds are broadly categorized based on their origin: upper and lower. The ligament of Treitz, or suspensory ligament of the duodenum, serves as the anatomical landmark distinguishing between upper and lower GI bleeding.
Upper GI bleeding (UGIB) is more frequently encountered than lower GI bleeding (LGIB). Interestingly, lower GI bleeding is observed more often in men, potentially linked to a higher prevalence of vascular disorders and diverticulosis in this demographic. The incidence of GI bleeding, in general, increases with age.
Effective nursing care is paramount in managing patients experiencing gastrointestinal bleeding. Prompt intervention is necessary to address hematochezia (bright red blood in stool), hematemesis (vomiting blood), or melena (dark, tarry stools). Typically, this necessitates immediate admission to an acute care hospital and consultation with both a gastroenterologist and a surgeon. Identifying the source and cause of the bleeding is crucial for initiating appropriate and timely treatment.
The cornerstone of nursing in these cases is to alleviate patient symptoms, minimize the risk of complications, and support their psychological well-being, ultimately improving prognosis. Furthermore, targeted nursing interventions are vital in preventing and mitigating potential risk factors associated with GI bleeding.
Nursing Assessment for GI Bleeding
The initial phase of nursing care revolves around a comprehensive nursing assessment. This involves gathering physical, psychosocial, emotional, and diagnostic data. We will now explore the subjective and objective data pertinent to GI bleeding.
Review of Health History
1. Inquire about Current and Past GI Bleeding Episodes.
Gather detailed information about the patient’s current and any previous experiences with GI bleeding. This history is invaluable in analyzing symptoms, identifying potential triggers, and guiding diagnosis and timely treatment.
2. Examine the Patient’s Medical History.
Thoroughly review the patient’s medical records, past health history, and any co-existing conditions (comorbidities) that might be relevant to the potential causes of GI bleeding. These relevant conditions include:
- Varices (enlarged veins, often in the esophagus or stomach)
- Portal hypertension (high blood pressure in the portal vein system)
- Alcohol abuse
- Smoking
- Ulcers (peptic, gastric, duodenal)
- Helicobacter pylori (H. pylori) infection
- Diverticulitis (inflammation or infection in small pouches in the colon)
- Hemorrhoids (swollen veins in the rectum and anus)
- Inflammatory bowel disease (IBD) such as Crohn’s disease and ulcerative colitis
- 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 essential, paying particular attention to:
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Anticoagulants (blood thinners)
- Antiplatelet drugs
- Bismuth-containing medications (e.g., bismuth subsalicylate – Pepto-Bismol)
- Iron supplements
4. Evaluate General Symptoms Related to GI Bleeding.
Several systemic symptoms can be associated with GI bleeding. Assess the patient for the presence of:
- Abdominal pain
- Difficulty swallowing (dysphagia)
- Unexplained weight loss
- Nausea
- Retching or vomiting
- Changes in bowel habits
- Abdominal bloating
- Fatigue or weakness
Physical Assessment
1. Assess for Manifestations of GI Bleeding.
Carefully observe and document the following physical signs and symptoms indicative of GI bleeding:
- 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, mucous membranes, and lips.
- Respiratory System: Decreased oxygen saturation (SpO2), 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 (e.g., fatigue, pallor).
- Integumentary System: Skin pallor (pale skin).
2. Monitor for Symptoms of Shock.
Severe GI bleeding can lead to hypovolemic shock. Be vigilant for the following shock symptoms:
- Severely low blood pressure
- Orthostatic hypotension (drop in blood pressure upon standing)
- Supine hypotension (low blood pressure when 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 an Abdominal Examination.
Conduct a thorough abdominal examination involving:
- Inspection: Observe for abdominal distension, prominent veins, or skin discoloration.
- Auscultation: Listen for bowel sounds. Hyperactive bowel sounds may be present in GI bleeding.
- Palpation: Palpate for any abdominal tenderness or pain. Localized tenderness could indicate perforation or ischemia.
4. Monitor Vital Signs.
Regularly monitor vital signs as they provide crucial indicators of GI bleeding complications such as shock or hypovolemia. Pay close attention to trends in heart rate (tachycardia), respiratory rate (tachypnea), and blood pressure (hypotension).
Diagnostic Procedures
1. Review Serum Lab Values.
Blood tests play a vital role in assessing GI bleeding. Review the following lab values:
- Complete Blood Count (CBC): Low hemoglobin (Hgb) and hematocrit (Hct) levels are indicative of blood loss.
- Coagulation Profile: Assess blood clotting function. Elevated International Normalized Ratio (INR), prolonged prothrombin time (PT), and activated partial thromboplastin time (aPTT) may be observed in GI bleeding, suggesting impaired coagulation.
- Lactate Levels: Elevated lactate levels can indicate tissue hypoperfusion and are often seen in significant GI bleeding.
- Liver Function Tests (LFTs): Abnormal liver enzyme levels may be present, particularly if liver disease is contributing to the bleeding risk (e.g., varices due to portal hypertension). Impaired liver function can reduce the production of clotting factors, increasing bleeding risk.
2. Obtain a Sample for Stool Exam.
Stool examination provides valuable information:
- Visual Inspection: Observe for obvious bright red blood (hematochezia). Dark, black, tarry stools (melena) suggest older blood or bleeding from the upper GI tract.
- Fecal Occult Blood Test (FOBT): This bedside test can detect hidden (occult) blood in the stool, even if not visually apparent.
3. Assist with Endoscopy.
Endoscopic procedures are frequently used to diagnose and sometimes treat GI bleeding:
- 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 or Sigmoidoscopy): A similar scope is inserted through the rectum to visualize the colon and rectum.
Endoscopy allows for direct visualization of the GI tract to identify bleeding sources. Furthermore, therapeutic interventions can often be performed during endoscopy, such as:
- Injection therapy: Injecting medications to stop bleeding.
- Thermal coagulation: Using heat to cauterize bleeding vessels.
- Hemostatic clips or bands: Applying mechanical devices to stop bleeding.
4. Consider Other Imaging Scans.
When endoscopy is not sufficient or feasible, other imaging modalities may be utilized:
- Capsule Endoscopy: A small, disposable capsule containing a camera is swallowed. It captures images as it passes through the small intestine.
- Flexible Sigmoidoscopy: A shorter, flexible scope is used to visualize the rectum and sigmoid colon.
- Balloon-Assisted Enteroscopy: This specialized technique uses a scope with balloons to navigate and visualize deeper portions of the small intestine, which may be inaccessible to standard endoscopes.
- Angiography: This invasive procedure can detect and treat active bleeding vessels. Contrast dye is injected into an artery, and X-rays are taken. Bleeding can be managed through embolization (blocking the bleeding vessel) or intra-arterial vasopressin infusion (medication to constrict blood vessels).
- CT Angiography (CTA): A less invasive alternative to traditional angiography that can also visualize active bleeding blood vessels using CT scanning and contrast dye.
- Enteroscopy: A general term for procedures visualizing the small bowel, which can be helpful in identifying bleeding sources in this region.
- Nuclear Scintigraphy (Tagged Red Blood Cell Scan): This highly sensitive test is often used to detect active lower GI bleeding when the bleeding source is unclear. Radioactively labeled red blood cells are injected, and a scan is performed to identify areas of active bleeding in the GI tract.
Nursing Interventions for GI Bleeding
Nursing interventions and holistic care are vital for the patient’s recovery from GI bleeding. Let’s explore key nursing interventions.
Detect and Manage the Underlying Cause
1. Manage Active Bleeding.
In many instances, gastrointestinal bleeding resolves spontaneously. However, if bleeding persists, the treatment approach is guided by the location and severity of the hemorrhage.
2. Correct the Underlying Etiology.
The primary focus in the acute management of GI bleeding is identifying and addressing the root cause. This can range from simple measures like discontinuing anticoagulant medications to more complex interventions like surgery.
3. Bowel Rest (NPO Status).
Implementing “nothing by mouth” (NPO) orders is crucial to allow the GI tract to rest and minimize further irritation. This promotes healing and recovery during treatment.
Administer Supportive Care
1. Administer Oxygen as Prescribed.
If the patient exhibits hypoxia (low oxygen levels), administer supplemental oxygen as ordered, typically via nasal cannula. Patients with ongoing hematemesis or altered mental status may require more advanced airway management, including intubation.
2. Maintain Hydration.
Establishing adequate intravenous (IV) access is essential. Insert at least two large-bore peripheral IV catheters to facilitate fluid resuscitation. Normal saline or lactated Ringer’s solution are the preferred isotonic crystalloid solutions for restoring intravascular volume.
3. Transfuse Blood Products.
Blood transfusions are critical to replace lost blood components and maintain hemodynamic stability.
- Packed Red Blood Cell (PRBC) Transfusions: Generally indicated when hemoglobin levels fall below 7 g/dL. The specific transfusion threshold may be adjusted based on the patient’s clinical condition and comorbidities.
- Platelet Transfusion: Initiated when the platelet count drops below 50,000/microL, particularly in patients with active bleeding or at high risk of bleeding.
4. Reverse Anticoagulation.
For patients taking warfarin or heparin, reversal agents may be necessary to counteract the effects of these blood-thinning medications and control bleeding. Vitamin K is used to reverse warfarin, and protamine sulfate is used to reverse heparin.
5. Administer Medications as Ordered.
Various medications are used to manage or stop GI bleeding, depending on the suspected cause and location:
- Proton Pump Inhibitors (PPIs): Primarily used for upper GI bleeding to suppress gastric acid production. PPI therapy may be continued or discontinued once the bleeding source is identified and addressed.
- Prokinetic Agents (e.g., Erythromycin, Metoclopramide): These medications promote gastric emptying and help clear the stomach of blood, clots, and food debris, improving visualization during endoscopy.
- Somatostatin and its Analog Octreotide: Vasoactive medications used to manage variceal bleeding. They work by reducing blood flow to the splanchnic circulation and decreasing pressure in varices.
- Antibiotics: In patients with cirrhosis and suspected variceal bleeding, prophylactic antibiotics are often administered to prevent bacterial translocation and subsequent infections, particularly before endoscopic procedures.
Prepare for Diagnostic or Surgical Procedures
1. Remove Blood and Clots.
Prior to endoscopy, nasogastric tube (NGT) lavage may be performed to evacuate fresh blood and blood clots from the stomach, improving visualization during the procedure.
2. Consider Sengstaken-Blakemore Tube Placement.
In patients with massive GI bleeding due to varices that is unresponsive to initial therapies, a Sengstaken-Blakemore tube (or similar esophageal balloon tamponade device) may be considered as a temporary measure to control bleeding. This is typically a last resort before more definitive interventions.
3. Anticipate Possible Surgery.
Patients with ongoing significant bleeding or hemodynamic instability that does not respond to other treatments may require urgent surgical intervention. Depending on the bleeding source, surgical procedures may include bowel resection or colectomy.
4. Stop Bleeding from Diverticulitis.
For diverticular bleeding, colonoscopic hemostasis techniques are often employed, such as bipolar probe coagulation, epinephrine injection, or application of metal clips.
5. Apply Thermal Therapy.
Lower GI bleeds caused by angiodysplasia can be treated with thermal therapy during colonoscopy, including electrocoagulation and argon plasma coagulation to ablate abnormal blood vessels.
6. Prevent Complications of Bleeding.
Untreated or inadequately managed gastrointestinal bleeding can lead to serious complications. Potential sequelae include:
- Respiratory Distress
- Myocardial Infarction (Heart Attack)
- Infection or Sepsis
- Shock (Hypovolemic Shock)
- Death
Educate on Preventing Recurrent GI Bleeds
Patient education is crucial to prevent future GI bleeding episodes:
1. Limit NSAID Use.
Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin can cause mucosal injury and increase the risk of bleeding. Educate patients to avoid or limit NSAID use as directed by their healthcare provider. Discuss safer alternatives for pain management.
2. Smoking Cessation.
Smoking increases the risk of peptic ulcers and impairs healing, predisposing individuals to GI bleeds. Strongly encourage smoking cessation and provide resources to support quitting.
3. Reduce Alcohol Intake.
Excessive alcohol consumption can irritate and erode the GI tract and damage the liver, which impairs clotting function and elevates GI bleeding risk. Advise patients to reduce or eliminate alcohol intake.
4. Manage Inflammatory and Infectious Conditions.
H. pylori infection is a major cause of peptic ulcers and increases GI bleeding risk. Inflammatory conditions like diverticulitis, Crohn’s disease, or ulcerative colitis can also lead to GI bleeding if not well-managed. Emphasize the importance of adherence to prescribed medication regimens for managing these conditions.
Nursing Care Plans for GI Bleeding
Once nursing diagnoses are identified for a patient with gastrointestinal bleeding, nursing care plans provide a structured framework for prioritizing assessments and interventions to achieve both short-term and long-term care goals. Here are examples of nursing care plans for common nursing diagnoses related to GI bleeding.
Acute Pain
Acute pain associated with gastrointestinal bleeding can stem from gastrointestinal perforation or ischemia, resulting from 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 abdominal area
- Restlessness
- Patient report of abdominal pain
- Patient report of heartburn
Expected outcomes:
- Patient will verbalize relief or control of pain within a specified timeframe (e.g., within 1-2 hours after intervention).
- Patient will appear relaxed and able to rest or sleep adequately.
Assessment:
1. Assess Pain Characteristics.
Evaluate the pain’s location, quality (e.g., sharp, dull, cramping), severity (using a pain scale), onset, duration, aggravating and relieving factors (palliative and precipitating factors). Determine if the pain is constant, intermittent, aching, stabbing, or burning. Pinpoint the exact location of abdominal pain.
2. Examine Verbal and Nonverbal Pain Cues.
Observe for both verbal reports of pain and nonverbal indicators (e.g., facial grimacing, guarding, restlessness). Discrepancies between verbal and nonverbal cues can provide insights into pain severity and the need for further management.
3. Assess Coping Mechanisms.
Identify the patient’s usual coping strategies for pain and stress. Observe for both adaptive and maladaptive coping mechanisms.
Interventions:
1. Administer Pharmacologic Pain Management as Ordered.
Administer prescribed analgesics, considering the type, route, and dosage. Acetaminophen is often preferred for mild to moderate pain as it has a lower risk of GI side effects compared to NSAIDs. Antacids (without aspirin) and proton pump inhibitors (PPIs) may be used to alleviate heartburn if present.
2. Evaluate Effectiveness of Pain Management.
Reassess pain levels within one hour after administering pain medication (or according to established protocols). If the patient cannot communicate verbally, assess physiological and nonverbal pain cues to evaluate pain relief.
3. Provide Comfort Measures and Non-Pharmacologic Pain Management.
Implement comfort measures such as frequent repositioning, back rubs, and pillow support for positioning. Offer non-pharmacologic pain management techniques like relaxation exercises, guided imagery, and appropriate diversional activities (e.g., reading, music) to promote distraction and reduce pain perception.
4. Plan Rest Periods and Create a Conducive Environment.
Schedule rest periods to minimize fatigue and conserve energy. Create a quiet, restful environment by reducing interruptions and clustering nursing tasks to minimize disturbances.
Deficient Fluid Volume
Deficient fluid volume in GI bleeding arises from blood loss, leading to decreased circulating blood volume and potentially ineffective tissue perfusion in 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 as evidenced by stable vital signs (blood pressure, heart rate within normal limits for patient), balanced intake and output, and good capillary refill (less than 3 seconds).
- Patient will demonstrate effective fluid volume status as evidenced by stable hemoglobin and hematocrit levels within patient’s baseline range.
Assessment:
1. Assess Nutritional Status.
Evaluate the patient’s current nutritional intake, recent weight changes, oral intake difficulties, use of supplements, tube feedings (if applicable), and factors like nausea and vomiting that may affect fluid intake.
2. Monitor Intake and Output (I&O).
Maintain accurate and hourly intake and output records to track fluid balance trends. Document all oral and IV intake, as well as fluid losses from vomiting, urine, and bloody stools.
3. Evaluate Lab Results.
Closely monitor hemoglobin (Hgb) and hematocrit (Hct) levels, as these are key indicators of blood loss. Low Hgb and Hct levels signal blood loss and fluid volume deficit. Also, monitor electrolyte levels, BUN, and creatinine to assess overall fluid and renal status.
Interventions:
1. Assist with Treatment of Underlying Cause.
Collaborate with the healthcare provider to identify and treat the underlying cause of GI bleeding and fluid volume deficit. Addressing the source of bleeding is essential to controlling fluid loss.
2. Provide Adequate Free Water and Nutritional Support.
Ensure adequate fluid intake, including free water, with meals (when oral intake is resumed). Provide a nutritionally balanced diet or enteral nutrition as prescribed. Avoid hyperosmolar or high-protein formulas, which can worsen dehydration. 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, over-the-counter (OTC), herbal, and nutritional supplements, to identify any substances that could contribute to fluid and electrolyte imbalances or GI bleeding. Administer proton pump inhibitors (PPIs) as prescribed to reduce gastric acid production.
4. Administer Blood Products.
Prepare for and administer blood products, such as packed red blood cells (PRBCs), as ordered to replace blood loss and improve oxygen-carrying capacity. Ensure the patient is typed and cross-matched before blood transfusion.
Imbalanced Nutrition: Less Than Body Requirements
GI bleeding is often associated with gastrointestinal disorders that can impair nutrition, leading to nutrient malabsorption, fluid volume deficits, anemia, and other GI symptoms.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Disease process (e.g., PUD, IBD, GI cancers)
- 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 not experience further alterations in albumin, iron levels, or electrolytes.
- Patient will maintain weight within acceptable parameters for their condition.
Assessment:
1. Assess Eating Patterns and Diet.
Thoroughly 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.
2. Assess Medication Use.
Review past and current medication use, particularly medications known to affect GI function or nutrition, such as corticosteroids and NSAIDs, which can cause GI toxicity and nutrient malabsorption.
3. Assess Laboratory Studies.
Monitor relevant laboratory values, including serum albumin, prealbumin, iron studies (ferritin, serum iron, total iron-binding capacity), electrolytes, and vitamin levels. GI bleeding can lead to iron-deficiency anemia and electrolyte imbalances.
Interventions:
1. Administer Fluid and Electrolyte Replacement.
Provide fluid and electrolyte replacement therapy as prescribed to correct hypovolemia and electrolyte imbalances resulting from GI bleeding.
2. Minimize NPO Status.
Minimize the duration of NPO status whenever clinically appropriate. Early enteral nutrition (tube feeding) may be considered for patients at low risk of re-bleeding, typically after 48-72 hours of NPO.
3. Provide Small, Frequent Feedings.
When oral intake is resumed, offer small, frequent meals to reduce early satiety, minimize nausea and vomiting, and facilitate gradual reintroduction of food.
4. Encourage Avoidance of Gastric Irritants.
Advise the patient to avoid gastric irritants such as caffeine, alcohol, carbonated beverages (soda), and spicy foods, as these can exacerbate GI irritation and potentially trigger re-bleeding.
5. Refer to a Dietitian.
Consult with a registered dietitian for comprehensive nutritional assessment and individualized dietary planning. The dietitian can help create a balanced meal plan to address nutritional deficits and promote healing. Dietary recommendations should include iron-rich foods (meat, seafood, nuts, legumes), whole grains, fruits, and vegetables, while limiting salt, added sugars, and unhealthy fats.
Ineffective Tissue Perfusion
Ineffective tissue perfusion in GI bleeding results from blood loss, which reduces oxygen delivery and perfusion to tissues throughout the body, including the gastrointestinal tract.
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
- 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 as evidenced by hemoglobin and hematocrit levels within normal limits for the patient and absence of signs/symptoms of hypoperfusion (e.g., stable vital signs, adequate urine output, warm and dry skin).
- Patient will verbalize understanding of GI bleeding, the treatment plan, and when to seek medical attention.
Assessment:
1. Assess Vital Signs.
Monitor vital signs closely and frequently, paying particular attention to blood pressure and heart rate. Persistent hypotension can lead to hypoperfusion of abdominal organs. Tachycardia is an early compensatory mechanism for decreased tissue perfusion.
2. Assess for Presence of Bleeding and Risk Factors.
Evaluate for ongoing signs of bleeding (hematemesis, melena, hematochezia). Assess for factors that may impair GI perfusion, such as major trauma with blood loss, septic shock, or pre-existing cardiovascular conditions. Bowel ischemia and GI hypoperfusion can result from blood loss, hypovolemic or hypotensive shock, or a combination of both.
3. Assess History of Bleeding or Coagulation Disorders.
Obtain a thorough history of previous bleeding episodes, known bleeding or coagulation disorders, cancer, or liver disease, as these factors increase the risk of bleeding and ineffective tissue perfusion. Review the patient’s medication history for use of anticoagulants or antiplatelet agents.
Interventions:
1. Collaborate with Interdisciplinary Team.
Participate in interdisciplinary team meetings to develop and implement a comprehensive plan of care. Collaboration ensures effective communication and continuity of care, optimizing systemic perfusion and organ function.
2. Administer Fluids, Blood, and Electrolytes.
Administer intravenous fluids (crystalloids), blood products (PRBCs, plasma), and electrolytes as prescribed to restore intravascular volume, improve tissue perfusion, and stabilize hemodynamics.
3. Administer Prescribed Medications.
Administer prescribed medications, such as antiemetics to reduce vomiting, anticholinergics to reduce bowel motility (sometimes used cautiously), proton pump inhibitors (PPIs) to reduce gastric acid secretion, and antibiotics (prophylactically in certain cases, e.g., variceal bleeding). These medications can help reduce fluid loss, neutralize stomach acid, and prevent further irritation of the GI mucosa.
4. Prepare for Endoscopy or Surgery.
Prepare the patient for potential endoscopic procedures (EGD, colonoscopy) to identify and treat the source of GI bleeding. Prepare the patient for possible surgical intervention if bleeding is severe, uncontrolled by other methods, or if tests cannot visualize the bleeding source adequately.
Risk for Decreased Cardiac Output
In severe GI bleeding with significant blood loss, patients are at risk for decreased cardiac output due to hypovolemia.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related to:
- Disease process (GI bleeding)
- Blood loss
- Altered afterload (due to hypovolemia)
- Altered heart rate (compensatory tachycardia)
- Altered heart rhythm (potential arrhythmias)
- Altered stroke volume (decreased 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 prevention.
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 (at least 30 mL/hour or 0.5 mL/kg/hour) and adequate tissue perfusion (warm and dry skin, capillary refill < 3 seconds, absence of confusion or altered mental status).
- Patient will maintain a stable cardiac rhythm without signs and symptoms of decreased cardiac output (e.g., no chest pain, shortness of breath, dizziness, or syncope).
Assessment:
1. Assess Heart Rate and Rhythm.
Monitor heart rate and rhythm frequently. Compensatory tachycardia is a common response to hypovolemia and decreased cardiac output. Assess for irregular heart rhythms or palpitations.
2. Assess Complete Blood Count (CBC).
Monitor hemoglobin (Hgb) and hematocrit (Hct) levels. While initial Hgb/Hct may not immediately reflect the extent of blood loss (due to hemoconcentration), they provide a baseline and trend information to guide treatment and assess ongoing blood loss. Note that initially, hematocrit may be within normal limits and will decline 4-6 hours after fluid replacement as plasma and RBC loss become more evident after fluid resuscitation.
3. Assess Blood Urea Nitrogen (BUN) Level.
Monitor BUN levels. In significant GI hemorrhage, BUN levels often increase disproportionately to creatinine due to the breakdown of blood proteins in the GI tract and subsequent urea production.
Interventions:
1. Monitor Urine Output.
Closely monitor urine output as a key indicator of vital organ perfusion. Insertion of an indwelling urinary catheter may be necessary for accurate hourly urine output monitoring. Decreasing urine output can signal decreased cardiac output and reduced kidney perfusion.
2. Perform Hemodynamic Monitoring.
Implement hemodynamic monitoring, including frequent blood pressure measurements and potentially more invasive monitoring (e.g., arterial line, central venous pressure monitoring) in unstable patients. Hemodynamic monitoring is essential to assess blood circulation and heart function and guide fluid resuscitation.
3. Administer Supplemental Oxygenation.
Administer supplemental oxygen as needed to correct and prevent hypoxemia, which can further compromise cardiac output. Oxygen therapy increases blood oxygen saturation and improves oxygen delivery to tissues.
4. Administer Intravenous Fluids.
Administer intravenous fluids as indicated to restore intravascular volume and improve cardiac preload and stroke volume. Isotonic crystalloid solutions like lactated Ringer’s solution or normal saline are typically used for initial fluid resuscitation.
5. Prepare and Initiate Blood Transfusions.
Prepare for and initiate blood transfusions as ordered to replace blood loss and improve oxygen-carrying capacity. Whole blood, packed red blood cells (PRBCs), or fresh frozen plasma may be used depending on the patient’s specific needs and coagulation status.
6. Prepare for Surgical Intervention.
If GI bleeding is severe and uncontrolled, prepare the patient for potential surgical or endoscopic intervention to repair the bleeding source and prevent further circulatory compromise.
7. Administer Drug Therapy as Indicated.
Administer medications as prescribed to reduce bleeding, decrease gastric acid secretion (PPIs), and neutralize existing stomach acid (antacids). An acidic gastric environment can impair platelet function and clot stabilization, worsening bleeding and potentially decreasing cardiac output.
(References – To be added based on original article’s sources and further research if needed)
