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Nursing Care Plan Upper Gastrointestinal / Esophageal Bleeding

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CARE SETTING

Generally, a patient with severe, active bleeding is admitted directly to the critical care unit (CCU); however, a patient may develop GI bleeding on the medical-surgical unit or be admitted there for evaluation/treatment of subacute bleeding.

RELATED CONCERNS
  1. Cirrhosis of the liver
  2. Fluid and electrolyte imbalances, see Nursing Care Plan CD-ROM
  3. Psychosocial aspects of care
  4. Renal failure: acute
  5. Subtotal gastrectomy/gastric resection, see Nursing Care Plan CD-ROM
  6. Patient Assessment Database



ACTIVITY/REST
May report: 
Weakness, fatigue

May exhibit: 
Tachycardia, tachypnea/hyperventilation (response to activity)

CIRCULATION
May report: 
  1. Palpitations
  2. Dizziness with position change
May exhibit: 
  1. Hypotension (including postural)
  2. Tachycardia, dysrhythmias (hypovolemia/hypoxemia)
  3. Weak/thready peripheral pulse
  4. Capillary refill slow/delayed (vasoconstriction)
  5. Skin color: pallor, cyanosis (depending on the amount of blood loss)
  6. Skin/mucous membrane moisture: Diaphoresis (reflecting shock state, acute pain, psychological response)

EGO INTEGRITY
May report: 
Acute or chronic stress factors (financial, relationships, job-related)
Feelings of helplessness

May exhibit: 
Signs of anxiety, e.g., restlessness, pallor, diaphoresis, narrowed focus, trembling,
quivering voice

ELIMINATION
May report: 
Change in usual bowel patterns/characteristics of stool

May exhibit: 
  1. Abdominal tenderness, distension
  2. Bowel sounds often hyperactive during bleeding, hypoactive after bleeding subsides
  3. Character of stool: Diarrhea; dark bloody, tarry, or occasionally bright red stools; frothy, foul-smelling (steatorrhea); constipation may occur (changes in diet, antacid use)
  4. Urine output may be decreased, concentrated

FOOD/FLUID
May report: 
  1. Anorexia, nausea, vomiting (protracted vomiting suggests pyloric outlet obstruction
  2. associated with duodenal ulcer)
  3. Problems with swallowing; belching, hiccups
  4. Heartburn, indigestion, burping with sour taste
  5. Bloating/distension, flatulence
  6. Food intolerances, e.g., spicy food, chocolate; special diet for preexisting ulcer disease
  7. Weight loss
May exhibit: 
  1. Vomitus: coffee-ground or bright red, with or without clots
  2. Mucous membranes dry, decreased mucus production, poor skin turgor (chronic bleeding)
  3. Urine specific gravity may be elevated

NEUROSENSORY
May report: 
  1. Fainting, dizziness/lightheadedness, weakness
  2. Mental status: Level of consciousness (LOC) may be altered, ranging from slight
  3. drowsiness, disorientation/confusion, to stupor and coma (depending on
  4. circulating volume/oxygenation)

PAIN/DISCOMFORT
May report: 
  1. Pain described as sharp, dull, burning, gnawing; sudden, excruciating (can accompany perforation)
  2. Vague sensation of discomfort/distress following large meals and relieved by food (acute
  3. gastritis)
  4. Left to midepigastric pain and/or pain radiating to back, often accompanied by vomiting after eating and relieved by antacids (gastric ulcer)
  5. Localized right to midepigastric pain, gnawing, burning, occurring about 2–3 hr after meals when stomach is empty, and relieved by food or antacids (duodenal ulcers)
  6. Midepigastric pain and burning with regurgitation (chronic gastroesophageal reflux disease [GERD]
  7. Absence of pain (esophageal varices or gastritis)
  8. Precipitating factors may be foods (e.g., milk, chocolate, caffeine), smoking, alcohol, certain drugs (salicylates, reserpine, antibiotics, ibuprofen), psychological stressors
May exhibit: 
Facial grimacing, guarding of affected area, pallor, diaphoresis, narrowed focus

SAFETY
May report: 
Drug allergies/sensitivities, e.g., acetylsalicylic acid (ASA)

May exhibit: 
  1. Temperature elevation
  2. Spider angiomas, palmar erythema (reflecting cirrhosis/portal hypertension)

TEACHING/LEARNING
May report: 
  1. Recent use of prescription/over-the-counter (OTC) drugs containing ASA,
  2. alcohol/recreational drugs, steroids, or nonsteroidal anti-inflammatory drugs (NSAIDs) (leading cause of drug-induced GI bleeding)
  3. Current complaint may reveal admission for related (e.g., anemia) or unrelated (e.g., head trauma) diagnosis, intestinal flu, or severe vomiting episode; long-standing health problems, e.g., cirrhosis, alcoholism, hepatitis, eating disorders
  4. History of previous hospitalizations for GI bleeding or related GI problems, e.g., peptic/gastric ulcer, gastritis, gastric surgery, irradiation of gastric area
  5. Discharge plan
  6. DRG projected mean length of inpatient stay: 5.3 days
  7. May require changes in therapeutic/medication regimen.
  8. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

  1. Esophagogastroduodenoscopy (EGD): Key diagnostic test for upper and lower GI bleeding, done to visualize site of bleeding/ degree of tissue ulceration/injury.
  2. Gastrointestinal nuclear scan: Radionuclide uptake at sites of bleeding identifies site (not cause) of bleeding. Test is considered to be more sensitive than EGD, upper GI studies with barium, or angiography in detecting sites of lower GI bleeding or persistent bleeding anywhere in GI tract.
  3. Helicobacter pylori breath test: Patient drinks a carbon-enriched urea solution. If H. pylori is present, it breaks down the compound and releases CO2. H. pylori can also be detected by blood or tissue tests with blood test now being the most common.
  4. Barium swallow with x-ray: Done after bleeding has ceased for differential diagnosis of cause/site of lesion, presence of structural defects such as strictures.
  5. Gastric aspirate analysis: May be done in suspected peptic ulcer disease as indicated by low to normal pH and/or presence of blood; also in suspected gastric cancer (abnormal acidity, blood and/or abnormal cells on cytological examination).
  6. Gastric cultures: Determine presence of H. pylori (Gram-negative urease-producing bacteria), currently accepted as organism responsible for 90% of duodenal and 70%–80% of gastric ulcers.
  7. Angiography: GI vasculature may be reviewed if endoscopy is inconclusive or impractical. Demonstrates collateral circulation and possibly bleeding site.
  8. Stools: Testing for blood will be positive.
  9. Complete blood count (CBC), hemoglobin (Hb)/hematocrit (Hct): Decreased levels occur 6–24 hr after acute bleeding begins. Red blood cells (RBCs) and platelets may also be decreased. White blood cell (WBC) count may be elevated, reflecting body’s response to injury.
  10. Prothrombin time (PT) and activated partial thromboplastin time (aPTT); coagulation profile: Prolonged in active bleeding. May indicate need for replacement of coagulation factors (fresh frozen plasma [FFP]). Increased platelets with decreased clotting times may be the body’s attempt to restore hemostasis. Severe abnormalities may reveal coagulopathy, e.g., DIC, as cause of bleeding.
  11. Blood urea nitrogen (BUN): Elevated within 24–48 hr as blood proteins are broken down in the GI tract and kidney filtration is decreased.
  12. Creatinine (Cr): Usually not elevated if renal perfusion is maintained.
  13. Ammonia: May be elevated when severe liver dysfunction disrupts the metabolism and proper excretion of urea or when massive whole blood transfusions have been given.
  14. Arterial blood gases (ABGs): May reveal initial respiratory alkalosis (compensating for diminished blood flow through lungs). Later, metabolic acidosis develops in response to sluggish liver flow/accumulation of metabolic waste products.
  15. Sodium: May be elevated as a hormonal compensation to conserve body fluid.
  16. Potassium: May initially be depleted because of massive gastric emptying/vomiting or bloody diarrhea. Elevated potassium levels may occur after multiple transfusions of stored blood or with acute renal impairment.
  17. Serum gastrin analysis: Elevated level suggests Zollinger-Ellison syndrome or possible presence of multiple poorly healed ulcers. Normal or low in type B gastritis.
  18. Serum amylase: Elevated with posterior penetration of duodenal ulcer.
  19. Pepsinogen level: Increased by duodenal ulcer; low level suggestive of gastritis.
  20. Serum parietal cell antibodies: Presence suggestive of chronic gastritis.

NURSING PRIORITIES
  1. Control hemorrhage.
  2. Achieve/maintain hemodynamic stability.
  3. Promote stress reduction.
  4. Provide information about disease process/prognosis, treatment needs, and potential complications.

DISCHARGE GOALS

  1. Hemorrhage curtailed.
  2. Hemodynamically stable.
  3. Anxiety/fear reduced to manageable level.
  4. Disease process/prognosis, therapeutic regimen, and potential complications understood
  5. Plan in place to meet needs after discharge.
di 02.02 - Label: -

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