Upper Gastrointestinal Bleeding: A Comprehensive Nursing Diagnosis 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 and large intestines (colon), rectum, and anus. GI bleeding is broadly categorized into upper and lower, with the ligament of Treitz, or suspensory ligament of the duodenum, serving as the anatomical dividing line.

Upper GI bleeding (UGIB), originating above the ligament of Treitz, is more frequently encountered than lower GI bleeding. While lower GI bleeding is slightly more prevalent in men due to conditions like vascular disorders and diverticulosis, the overall incidence of GI bleeding, including UGIB, increases with age.

This article delves into the nursing process for upper gastrointestinal bleeding, focusing on assessment, nursing interventions, and relevant nursing diagnoses to guide effective patient care.

Nursing Process

Prompt recognition and management of hematemesis or melena, key indicators of upper GI bleeding, are crucial. This typically necessitates immediate hospitalization in an acute care setting, involving consultations with both a gastroenterologist and a surgeon to pinpoint the bleeding source, determine the underlying cause, and implement timely interventions.

Nurses play a pivotal role in the care of patients with upper gastrointestinal bleeding. Effective nursing care aims to alleviate distressing symptoms, minimize the potential for severe complications, and support the patient’s psychological well-being throughout the diagnostic and treatment process. Nursing interventions are also crucial in proactively addressing and mitigating identified risk factors.

Nursing Assessment

The initial step in providing comprehensive nursing care is a thorough nursing assessment. This involves systematically gathering physical, psychosocial, emotional, and diagnostic data. Specifically concerning upper GI bleeding, the assessment focuses on both subjective and objective findings.

Review of Health History

1. Inquire about current and past GI bleeding episodes. Obtain a detailed history of the patient’s current and any previous instances of GI bleeding. This information is vital for analyzing the pattern of symptoms, identifying potential triggers, and guiding diagnostic and treatment strategies.

2. Scrutinize the patient’s medical history. A comprehensive review of the patient’s medical records, past health history, and pre-existing conditions is essential. Certain comorbidities significantly elevate the risk of upper GI bleeding. These include:

• Variceal bleeding (esophageal or gastric varices)
• Portal hypertension
• Chronic alcohol abuse
• Smoking history
• Peptic ulcers (gastric or duodenal)
• Helicobacter pylori (H. pylori) infection
• History of gastritis or esophagitis
• Stomach or esophageal cancer

3. Analyze the patient’s medication regimen. Several commonly used medications are known to increase the risk of upper GI bleeding. A meticulous review of the patient’s current medications is necessary to identify potential contributing factors:

• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Anticoagulants (e.g., warfarin, heparin)
• Antiplatelet drugs (e.g., aspirin, clopidogrel)
• Corticosteroids

4. Evaluate general symptoms associated with upper GI bleeding: Beyond the hallmark signs of hematemesis and melena, patients with upper GI bleeding may present with a range of other symptoms:

• Epigastric pain or discomfort
• Dysphagia (difficulty swallowing)
• Unexplained weight loss
• Nausea and vomiting
• Retching
• Changes in bowel habits
• Abdominal bloating
• Fatigue and weakness

Physical Assessment

1. Assess for key indicators of upper GI bleeding. A systematic physical examination is crucial to identify objective signs of upper GI bleeding:

• Central Nervous System (CNS): Altered mental status, decreased level of consciousness, lightheadedness, syncope (fainting), dizziness.
• Head, Eyes, Ears, Nose, and Throat (HEENT): Pallor of the conjunctiva, oral mucosa, and lips.
• Respiratory: Decreased oxygen saturation (SpO2), shortness of breath (dyspnea).
• Cardiovascular: Chest pain, tachycardia (rapid heart rate), hypotension (low blood pressure).
• Gastrointestinal: Epigastric tenderness, hematemesis (vomiting bright red blood or coffee-ground emesis), melena (black, tarry stools).
• Hematologic: Signs of anemia such as pallor.
• Integumentary: Skin pallor, clammy skin.

2. Monitor for signs and symptoms of shock. Severe upper GI bleeding can lead to hypovolemic shock, a life-threatening condition. Nurses must vigilantly monitor for shock indicators:

• Severely low blood pressure (hypotension)
• Orthostatic hypotension (drop in blood pressure upon standing)
• Supine hypotension (low blood pressure when lying down)
• Resting tachycardia
• Palpitations
• Rapid, weak, or thready pulses
• Oliguria (decreased urine output) or anuria (absent urine output)
• Decreased level of consciousness, confusion
• Syncope

3. Perform a focused abdominal examination. Inspect the abdomen for distension, visible veins, or skin discoloration. Auscultate for bowel sounds; hyperactive bowel sounds may be present initially, while hypoactive or absent sounds can indicate later stages or complications. Palpate for abdominal tenderness, guarding, or rigidity, which may suggest perforation or peritonitis.

4. Closely monitor vital signs. Frequent monitoring of vital signs (heart rate, blood pressure, respiratory rate, temperature, and oxygen saturation) is paramount. These parameters can provide early warnings of complications like hypovolemia and shock. Pay close attention to trends of increasing tachycardia, tachypnea, and decreasing blood pressure.

Diagnostic Procedures

1. Review serum laboratory values. Blood tests play a crucial role in assessing the impact and severity of upper GI bleeding:

• Complete Blood Count (CBC): Hemoglobin (Hgb) and hematocrit (Hct) levels are typically low, reflecting blood loss. Serial CBCs are essential to monitor ongoing bleeding or response to treatment.
• Coagulation Profile: Prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) may be prolonged, especially in patients with liver disease or those on anticoagulants.
• Blood Urea Nitrogen (BUN): BUN may be elevated out of proportion to creatinine due to the digestion of blood in the GI tract and pre-renal azotemia from hypovolemia.
• Liver Function Tests (LFTs): Abnormal liver enzymes may indicate underlying liver disease, which can be a risk factor for variceal bleeding.
• Electrolytes: Imbalances may occur due to fluid loss and vomiting.
• Lactate Levels: Elevated lactate levels may indicate tissue hypoperfusion and shock.
• Blood type and crossmatch: Essential in preparation for potential blood transfusions.

2. Obtain samples for stool examination. While less common in upper GI bleeds compared to lower GI bleeds presenting as hematochezia, stool examination remains relevant. Melena (black, tarry stools) indicates digested blood, suggestive of an upper GI source. A fecal occult blood test (FOBT) can detect hidden blood in the stool if melena is not obvious.

3. Assist with upper endoscopy (esophagogastroduodenoscopy – EGD). EGD is the gold standard diagnostic and therapeutic procedure for upper GI bleeding. A flexible endoscope with a camera is inserted through the mouth to visualize the esophagus, stomach, and duodenum. EGD allows for:

• Identification of the bleeding source (e.g., ulcers, varices, gastritis).
• Biopsy to rule out malignancy or H. pylori infection.
• Therapeutic interventions to stop bleeding, such as injection sclerotherapy, thermal coagulation, or application of hemostatic clips or bands.

4. Consider other imaging studies when appropriate. In specific situations, other imaging modalities may be considered:

• Tagged Red Blood Cell Scan (Nuclear Scintigraphy): Can detect active bleeding, especially if intermittent or slow. Less specific for upper vs. lower GI source.
• Angiography (including CT Angiography – CTA): Useful for identifying and potentially treating active arterial bleeding, particularly if endoscopy is non-diagnostic or bleeding is massive. CTA is less invasive than conventional angiography.
• Upper GI Series (Barium Swallow): Primarily used to evaluate for structural abnormalities but not for active bleeding. Less common in acute UGIB management.

Image: Illustration depicting an upper GI endoscopy procedure, highlighting the insertion of the endoscope through the mouth to visualize the upper digestive tract for diagnosis and treatment of conditions like upper gastrointestinal bleeding.

Nursing Interventions

Nursing interventions are critical for managing upper GI bleeding, focusing on stabilizing the patient, identifying and treating the cause, and preventing recurrence.

Address the Underlying Cause and Control Bleeding

1. Manage active bleeding. While some instances of upper GI bleeding resolve spontaneously, active bleeding requires prompt intervention. The specific approach depends on the bleeding site, severity, and underlying etiology.

2. Treat the underlying cause. Identifying and addressing the root cause of the bleeding is paramount for long-term management. This may involve simple measures like discontinuing NSAIDs or complex interventions such as surgery for refractory ulcers or variceal bleeding.

3. Bowel rest (NPO status). Maintaining the patient NPO (nothing by mouth) is often necessary, especially in the acute phase. This reduces stimulation of gastric acid secretion and allows the GI tract to rest and heal, minimizing further irritation and promoting clot formation.

Provide Supportive Care

1. Administer supplemental oxygen. Hypoxia is a potential complication of significant blood loss. Administer oxygen as prescribed, typically via nasal cannula. Patients with ongoing hematemesis or altered mental status may require more advanced airway management, including intubation.

2. Maintain hemodynamic stability with intravenous fluids. Establish at least two large-bore peripheral intravenous (IV) lines for rapid fluid resuscitation. Isotonic crystalloid solutions, such as normal saline (0.9% NaCl) or lactated Ringer’s solution, are preferred for initial volume replacement to restore intravascular volume and tissue perfusion.

3. Transfuse blood products as indicated. Blood transfusions are crucial to replace lost blood volume and improve oxygen-carrying capacity.

• Packed Red Blood Cells (PRBCs): Transfuse PRBCs when hemoglobin levels fall below 7 g/dL or as clinically indicated based on patient status and ongoing bleeding.
• Platelets: Platelet transfusions may be necessary if the platelet count is below 50,000/µL, particularly in patients with active bleeding or coagulopathy.
• Fresh Frozen Plasma (FFP): May be administered to correct coagulopathies, especially in patients with liver disease or those on warfarin.

4. Reverse anticoagulation if necessary. For patients taking anticoagulants like warfarin or heparin, reversal agents (vitamin K for warfarin, protamine sulfate for heparin) may be required to counteract the effects of these medications and facilitate hemostasis.

5. Administer medications as prescribed. Pharmacological agents play a vital role in managing upper GI bleeding:

• Proton Pump Inhibitors (PPIs): IV PPIs are a cornerstone of medical management for most causes of upper GI bleeding (except variceal bleeding). They potently suppress gastric acid secretion, promoting ulcer healing and clot stability.
• Prokinetics (e.g., erythromycin, metoclopramide): These medications enhance gastric emptying and clear blood, clots, and food debris from the stomach, improving visualization during endoscopy. They are often administered prior to EGD.
• Vasoactive Drugs (e.g., octreotide, somatostatin): These medications are specifically used for variceal bleeding. They reduce splanchnic blood flow and portal pressure, thereby decreasing variceal bleeding.
• Antibiotics: In patients with cirrhosis and variceal bleeding, prophylactic antibiotics are often administered to prevent bacterial infections (spontaneous bacterial peritonitis) and improve outcomes.

Image: A visual representation of various medications commonly used in the treatment of upper gastrointestinal bleeding, including PPIs, prokinetics, vasoactive drugs, and antibiotics, emphasizing their roles in acid suppression, gastric emptying, portal pressure reduction, and infection prevention.

Prepare for Diagnostic and Therapeutic Procedures

1. Gastric lavage (if indicated). In cases of massive hematemesis, nasogastric tube (NGT) lavage with cool saline solution may be performed prior to endoscopy to remove blood and clots from the stomach, improving visualization during the procedure. However, routine lavage is not always necessary and may be contraindicated in certain situations.

2. Consider Sengstaken-Blakemore tube or Minnesota tube for refractory variceal bleeding. In patients with massive variceal bleeding unresponsive to medical therapy and endoscopy, esophageal balloon tamponade using a Sengstaken-Blakemore or Minnesota tube may be considered as a temporizing measure to control bleeding until definitive therapy can be implemented (e.g., TIPS – Transjugular Intrahepatic Portosystemic Shunt). These tubes require specialized training and careful monitoring due to potential complications.

3. Anticipate potential surgical intervention. Surgery may be necessary for patients with severe, refractory upper GI bleeding that cannot be controlled endoscopically or medically. Surgical options include:

• Oversewing bleeding ulcers.
• Resection of bleeding lesions or tumors.
• Ligation of bleeding vessels.
• Shunt surgery (e.g., TIPS) for refractory variceal bleeding.

4. Endoscopic hemostasis techniques. Endoscopy is the primary modality for achieving hemostasis in upper GI bleeding. Common techniques include:

• Injection therapy: Epinephrine injection to vasoconstrict bleeding vessels.
• Thermal coagulation: Electrocautery or argon plasma coagulation to cauterize bleeding points.
• Mechanical hemostasis: Application of hemostatic clips or bands to physically close bleeding vessels.

5. Manage potential complications. Upper GI bleeding carries a risk of serious complications if not promptly and effectively managed. Potential complications include:

• Aspiration pneumonia
• Respiratory distress
• Myocardial infarction (especially in patients with pre-existing cardiac disease)
• Infection and sepsis
• Hypovolemic shock
• Death

Educate on Preventing Recurrent Upper GI Bleeds

1. Limit NSAID use. Chronic NSAID use is a major risk factor for peptic ulcers and subsequent upper GI bleeding. Educate patients about the risks of NSAIDs and advise them to avoid or limit their use, especially long-term, unless specifically prescribed and monitored by a healthcare provider. Consider alternative pain management strategies.

2. Smoking cessation. Smoking impairs mucosal healing and increases the risk of peptic ulcers. Encourage patients to quit smoking and provide resources and support for smoking cessation.

3. Reduce alcohol intake. Excessive alcohol consumption can irritate the GI mucosa and contribute to liver disease, which increases the risk of variceal bleeding. Advise patients to reduce or abstain from alcohol intake.

4. Manage H. pylori infection. H. pylori infection is a leading cause of peptic ulcers. Ensure patients with H. pylori-related ulcers receive appropriate eradication therapy and confirm eradication with follow-up testing.

5. Adherence to medication regimens. For patients with conditions predisposing to upper GI bleeding (e.g., GERD, gastritis), emphasize the importance of adhering to prescribed medications, such as PPIs or H2 receptor antagonists, to prevent recurrence.

Nursing Care Plans

Once nursing diagnoses are identified, nursing care plans provide a structured framework for prioritizing assessments and interventions, setting both short-term and long-term goals for patient care. Here are examples of nursing care plans relevant to upper gastrointestinal bleeding:

Acute Pain

Acute pain in upper GI bleeding can arise from gastric or duodenal ulceration, gastritis, or esophageal inflammation.

Nursing Diagnosis: Acute Pain

Related to:

• Gastric or duodenal mucosal irritation and ulceration
• Esophageal inflammation
• Gastritis

As evidenced by:

• Verbal report of epigastric pain, heartburn, or abdominal discomfort
• Guarding behavior
• Restlessness and irritability
• Changes in vital signs (increased heart rate, blood pressure, respiratory rate) in response to pain

Expected Outcomes:

• Patient will report a reduction in pain intensity using a pain scale within a specified timeframe.
• Patient will demonstrate relaxed body language and engage in rest and comfort measures.

Assessments:

1. Pain Assessment: Conduct a comprehensive pain assessment, including location, character, onset, duration, exacerbating/relieving factors, and severity using a validated pain scale.
2. Verbal and Nonverbal Pain Cues: Observe for verbal and nonverbal indicators of pain, such as facial grimacing, moaning, and changes in posture.
3. Coping Mechanisms: Evaluate the patient’s usual coping strategies for pain and stress.

Interventions:

1. Pharmacologic Pain Management: Administer prescribed analgesics, such as antacids, mucosal protectants (e.g., sucralfate), or pain medications, as ordered. Avoid NSAIDs due to their ulcerogenic potential.
2. Evaluate Pain Management Effectiveness: Reassess pain intensity and relief within one hour after medication administration and adjust interventions as needed.
3. Non-pharmacologic Pain Management: Implement comfort measures such as positioning, back rubs, cool compresses, and relaxation techniques (e.g., deep breathing, guided imagery).
4. Promote Rest: Provide a quiet and comfortable environment to facilitate rest and sleep, minimizing interruptions.

Deficient Fluid Volume

Deficient fluid volume is a significant risk in upper GI bleeding due to blood loss from hematemesis and melena.

Nursing Diagnosis: Deficient Fluid Volume

Related to:

• Active blood loss secondary to upper GI hemorrhage
• Vomiting
• Decreased oral intake

As evidenced by:

• Hematemesis and/or melena
• Tachycardia
• Hypotension (orthostatic or supine)
• Decreased urine output
• Dry mucous membranes
• Poor skin turgor
• Weakness and dizziness
• Elevated BUN and hematocrit (initially, then decreased H&H with fluid resuscitation)

Expected Outcomes:

• Patient will demonstrate adequate fluid volume, as evidenced by stable vital signs, urine output > 30 mL/hr, and improved skin turgor and mucous membrane hydration.
• Patient will maintain hemoglobin and hematocrit within acceptable limits (considering baseline).

Assessments:

1. Fluid Balance Assessment: Monitor intake and output accurately, noting all sources of fluid loss (vomitus, stool, urine).
2. Vital Signs Monitoring: Assess vital signs frequently, paying attention to trends in heart rate, blood pressure, and orthostatic changes.
3. Laboratory Data Review: Monitor hemoglobin, hematocrit, electrolytes, and BUN levels.
4. Nutritional Status: Assess for factors that may affect fluid intake, such as nausea and vomiting.

Interventions:

1. Collaborate with Healthcare Provider: Work with the physician to identify and treat the underlying cause of bleeding and fluid volume deficit.
2. Fluid Replacement: Administer IV fluids as prescribed (isotonic crystalloids, blood products).
3. Monitor Fluid Status: Continuously monitor vital signs, urine output, and laboratory values to assess response to fluid resuscitation.
4. Administer Blood Products: Prepare for and administer blood transfusions as ordered to replace blood loss.
5. Medication Review: Review medications that may contribute to fluid loss or bleeding.

Imbalanced Nutrition: Less Than Body Requirements

Imbalanced nutrition can occur due to NPO status, nausea, vomiting, and potential malabsorption related to GI disorders.

Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements

Related to:

• NPO status during acute bleeding episode
• Nausea and vomiting
• Anorexia and decreased appetite
• Potential nutrient malabsorption

As evidenced by:

• Reported decreased oral intake
• Nausea and vomiting
• Anorexia
• Weight loss (potential, if chronic issue)
• Pale mucous membranes
• Weakness and fatigue

Expected Outcomes:

• Patient will demonstrate improved nutritional intake and tolerance of oral feedings as tolerated.
• Patient will maintain stable weight (or prevent further weight loss).
• Patient will exhibit laboratory values within acceptable limits (albumin, electrolytes, iron studies).

Assessments:

1. Nutritional History: Assess the patient’s usual eating patterns, dietary intake, food preferences, and any factors affecting nutrition (nausea, vomiting, anorexia).
2. Weight Monitoring: Monitor daily weights.
3. Laboratory Studies: Review albumin, prealbumin, electrolytes, and iron studies.
4. Gastrointestinal Symptoms: Assess for nausea, vomiting, abdominal distension, and changes in bowel sounds.

Interventions:

1. Fluid and Electrolyte Replacement: Address fluid and electrolyte imbalances.
2. Minimize NPO Status: Progress diet as tolerated once bleeding is controlled and bowel sounds return, starting with clear liquids and advancing to a soft, bland diet.
3. Small, Frequent Feedings: Offer small, frequent meals to improve tolerance and reduce nausea.
4. Avoid Gastric Irritants: Advise the patient to avoid caffeine, alcohol, spicy foods, and other gastric irritants as diet progresses.
5. Dietitian Consultation: Refer to a dietitian for nutritional assessment and individualized dietary planning.

Ineffective Tissue Perfusion (Gastrointestinal)

Ineffective tissue perfusion can result from hypovolemia secondary to blood loss in upper GI bleeding, potentially compromising oxygen delivery to the GI tissues.

Nursing Diagnosis: Ineffective Tissue Perfusion (Gastrointestinal)

Related to:

• Hypovolemia secondary to upper GI bleeding
• Decreased blood flow and oxygen delivery to gastrointestinal tissues

As evidenced by:

• Hematemesis and/or melena
• Abdominal pain or cramping
• Tachycardia
• Hypotension
• Altered mental status (confusion, dizziness)
• Decreased bowel sounds

Expected Outcomes:

• Patient will demonstrate improved tissue perfusion, as evidenced by stable vital signs, palpable peripheral pulses, warm and dry skin, and resolution of altered mental status.
• Patient will maintain hemoglobin and hematocrit within acceptable parameters.
• Patient will verbalize understanding of upper GI bleeding and treatment plan.

Assessments:

1. Vital Signs and Hemodynamic Monitoring: Closely monitor blood pressure, heart rate, peripheral pulses, and capillary refill.
2. Assessment for Bleeding: Continuously monitor for signs of ongoing bleeding (hematemesis, melena, abdominal distension).
3. History of Bleeding/Coagulation Disorders: Review patient history for risk factors and bleeding tendencies.
4. Neurological Status: Assess level of consciousness and mental status.

Interventions:

1. Interdisciplinary Collaboration: Collaborate with the medical team to optimize the plan of care.
2. Fluid and Blood Administration: Administer IV fluids, blood products, and electrolytes as prescribed to restore intravascular volume and oxygen-carrying capacity.
3. Medication Administration: Administer prescribed medications (PPIs, vasoactive drugs, prokinetics) to manage bleeding and underlying conditions.
4. Prepare for Endoscopy/Surgery: Prepare the patient for diagnostic and therapeutic procedures as indicated.
5. Patient Education: Educate the patient about upper GI bleeding, treatment plan, and when to seek medical attention for recurrent symptoms.

Risk for Decreased Cardiac Output

Severe upper GI bleeding and subsequent blood loss place patients at risk for decreased cardiac output due to hypovolemia.

Nursing Diagnosis: Risk for Decreased Cardiac Output

Related to:

• Hypovolemia secondary to blood loss from upper GI bleeding
• Altered preload (decreased circulating volume)

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms but by risk factors. Risk factors here are active upper GI bleeding and potential for ongoing blood loss.

Expected Outcomes:

• Patient will maintain adequate cardiac output, as evidenced by stable vital signs, urine output > 30 mL/hr, strong peripheral pulses, and absence of signs of hypoperfusion.
• Patient will maintain a stable cardiac rhythm.

Assessments:

1. Heart Rate and Rhythm Monitoring: Assess heart rate and rhythm, noting tachycardia or irregularities.
2. Complete Blood Count (CBC) Monitoring: Monitor hemoglobin and hematocrit trends.
3. BUN Level Monitoring: Assess BUN levels, which may be elevated out of proportion to creatinine in UGIB.
4. Urine Output Monitoring: Strictly monitor urine output as an indicator of renal perfusion and cardiac output.

Interventions:

1. Hemodynamic Monitoring: Continuously monitor vital signs, including blood pressure, heart rate, and central venous pressure (if indicated).
2. Supplemental Oxygenation: Administer oxygen as needed to maintain adequate oxygen saturation.
3. Intravenous Fluid Administration: Administer IV fluids (crystalloids, colloids) as prescribed to restore intravascular volume.
4. Blood Transfusion Preparation and Administration: Prepare for and administer blood transfusions as ordered.
5. Prepare for Surgical Intervention: Anticipate potential need for endoscopic or surgical intervention for bleeding control.
6. Medication Administration: Administer medications as prescribed to manage bleeding and support hemodynamic stability.

References

• [Any references from the original article would be listed here, and additional relevant, high-quality nursing and medical sources could be added to enhance EEAT.]

This comprehensive nursing guide provides a framework for understanding and managing upper gastrointestinal bleeding from a nursing perspective. By utilizing thorough assessment, evidence-based interventions, and well-developed care plans, nurses can significantly impact patient outcomes and improve the care of individuals experiencing this critical gastrointestinal emergency.