Upper Gastrointestinal Bleeding : Nursing Implementation

Nursing Implementation
- Health Promotion
  - Patient with a history of chronic gastritis, cirrhosis, or peptic ulcer disease is at high risk
  - Patient who has had previous upper GI bleeding episode is more likely to have another bleed
  - Patient on daily low-dose aspirin to reduce cardiovascular disease risk are at risk
  - Patient teaching
    - Avoidance of gastric irritants
      - Alcohol
      - Smoking
      - Stress-inducing situations
    - Take only prescribed medications
    - Methods of testing vomitus/stools for occult blood
    - Potential need for prophylactic PPI
    - Prompt treatment of upper respiratory infection in patient with esophageal varices
    - Take drugs that produce gastroduodenal toxicity with meals or snacks
- Acute Care
  - Place IV lines
    - Preferably 2, with 16- or 18-guage needle for fluid and blood replacement
  - Administer fluid and blood replacement as ordered
  - Accurate I/O record
    - Record urine output hourly
    - At least 0.5 mL/kg/hr indicates adequate renal perfusion
    - Measure urine specific gravity
  - Maintain NG patency and position
  - CVP line or PAC readings every 1–2 hours
  - Observe older adults and patients with history of cardiovascular problems closely
    - ECG monitoring
    - Vital signs
  - Approach in calm, assured manner to decrease anxiety
  - Use caution when administering sedatives for restlessness
    - Warning sign of shock may be masked by drugs
  - Emergency management

Assessment Findings
Abdominal and GI Findings	Hypovolemic Shock
Hematemesis Melena Nausea Abdominal pain Abdominal rigidity	Decreased BP Decreased pulse pressure Tachycardia Cool, clammy skin Decreased level of consciousness Decreased Urine output (<0.5 mL/kg/hr) Slow capillary refill
Interventions
Initial	Ongoing Monitoring
If unresponsive, assess circulation, airway, and breathing. If responsive, monitor airway, breathing, and circulation. Establish IV access with large-bore catheter and start fluid replacement therapy. Insert additional large-bore catheter if shock present. Give O2 via nasal cannula or non-rebreather mask. Initiate ECG monitoring. Obtain blood for CBC, clotting studies, and type and crossmatch as appropriate. Insert NG tube as needed. Insert indwelling urinary catheter. Give IV proton pump inhibitor (PPI) therapy to decrease acid secretion.	Monitor vital signs, level of consciousness, O2 saturation, ECG, bowel sounds, and intake/output. Assess amount and character of emesis. Keep patient NPO. Provide reassurance and emotional support to patient and caregiver

- - Assess stools and NG output for blood
  - Rule out other sources of bleeding
  - When vomitus contains blood but stool does not, hemorrhage is considered to be of short duration
  - Nutrition
    - Observe for symptoms of nausea and vomiting
    - Recurrence of bleeding
    - Feedings: initially clear fluids given hourly
    - Gradually introduce of foods as tolerated
  - Hemorrhage that is result of chronic alcohol abuse
    - Closely observe for delirium tremens
      - Agitation
      - Uncontrolled shaking
      - Sweating
      - Vivid hallucinations
- Ambulatory Care
  - Patient teaching
    - Patient/family taught how to avoid future bleeding episodes
    - Made aware of consequences of not adhering to drug therapy
    - Emphasize that no drugs other than those prescribed should be taken
    - No smoking or alcohol
    - Need for long-term follow-up care
    - Instruction if an acute hemorrhage occurs in future
Nursing Evaluation
- The expected outcomes are that the patient with upper GI
- bleeding will
  - Have no upper GI bleeding
  - Maintain normal fluid volume
  - Experience a return to a normal hemodynamic state
  - Understand potential etiologic factors and make appropriate lifestyle modifications

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