Upper Gastrointestinal Bleeding : Nursing Management

Nursing Management

• Nursing Assessment
  • Subjective Data
    • Important Health Information
      • Past health history:
        • Precipitating events before bleeding episode
        • Previous bleeding episodes and treatment
        • Peptic ulcer disease
        • Esophageal varices
        • Esophagitis
        • Acute and chronic gastritis
        • Stress-related mucosal disease
      • Medications:
        • Aspirin
        • Nonsteroidal anti-inflammatory drugs
        • Corticosteroids
        • Anticoagulants
    • Functional Health Patterns
      • Health perception–health management:
        • Family history of bleeding
        • Smoking
        • Alcohol use
      • Nutritional-metabolic:
        • Nausea
        • Vomiting
        • Weight loss
        • Thirst
      • Elimination:
        • Diarrhea
        • Black, tarry stools
        • Decreased urine output.
        • Sweating
      • Activity-exercise:
        • Weakness
        • Dizziness
        • Fainting
      • Cognitive-perceptual:
        • Epigastric pain
        • Abdominal cramps
      • Coping–stress tolerance:
        • Acute or chronic stress
  • Objective Data
    • General
      • Fever
    • Integumentary
      • Clammy, cool, pale skin. Pale mucous membranes, nail beds, and conjunctivae. Spider angiomas, jaundice, peripheral edema
    • Respiratory
      • Rapid, shallow respirations
    • Cardiovascular
      • Tachycardia, weak pulse, orthostatic hypotension, slow capillary refill
    • Gastrointestinal
      • Red or “coffee-ground” vomitus.
      • Tense, rigid abdomen, ascites.
      • Hypoactive or hyperactive bowel sounds.
      • Black, tarry stools
    • Urinary
      • Decreased urine output, concentrated urine
    • Neurologic
      • Agitation, restlessness. Decreasing level of consciousness
    • Possible Diagnostic Findings
      • Decreased hematocrit and hemoglobin, hematuria. Guaiac-positive stools, emesis, or gastric aspirate. Decreased levels of clotting factors, ↑ liver enzymes, abnormal endoscopy results
• Nursing Diagnoses
  • Risk for decreased cardiac output related to loss of blood
  • Deficient fluid volume related to acute loss of blood and gastric secretions
  • Ineffective peripheral tissue perfusion related to loss of circulatory volume
  • Anxiety related to upper GI bleeding, hospitalization, uncertain outcome, source of bleeding
• Nursing Planning
  • The overall goals are that the patient with upper GI bleeding will
    • Have no further GI bleeding
    • Have the cause of the bleeding identified and treated
    • Experience a return to a normal hemodynamic state
    • Experience minimal or no symptoms of pain or anxiety