Types of upper gastrointestinal bleeding
1/ obvious bleeding: hematemesis, melena
2/ occult bleeding
What is the difference btw hematemesis and melena?
Hematemesis: bloody vomitus
- fresh, bright red blood
- coffee ground appearance (dark, grainy digested food) means blood has been in contact with gastric HCl acid secretion
Melena: stools
- black, tarry stools, often foul smelling
- caused by digestion of blood in GI tract, breakdown of hemoglobin and presence of iron makes stool black color
Occult bleeding
small amounts of blood discovered by guaiac test, appear in gastric secretions, vomitus or stools, not easy to see
Massive upper GI hemorrhage
lost of more than 1500mL of blood or loss of 25% of intravascular blood volume
Clinically important bleeding
- decrease of more than 20mm Hg in SBP
- decrease of more than 10 mm in SBP with pt sitting up
- increase of more than 20 beats/min in the heart rate
- decrease in hemoglobin level of more than 2g/dl
Emergency treatment for upper GI bleeding
- identify the cause
- treatment initiated immediately
- DO NOT ask about what causes of the bleeding until emergency care has been initiated
1/ Physical examination: BP, Pulse (rate and character), capillary refill (peripheral perfusion), neck vein distention (presence or absence), signs and symptoms of shock, respiratory status, abdominal examination (bowel sounds, tense, rigid, boardlike abdoment indicate a perforation and peritonitis)
2/ Monitoring: vital signs q15-30 mins
3/ Interviewing pt or caregiver:
- previous bleeding episodes?
- recent weight loss?
- past blood transfusions? any reactions?
- other illnesses (liver disease, cirrhosis)?
- medication causing bleeding?
- religious preference about blood transfusion?
GI perforation
a hole on the wall of the stomach, small intestine, large bowel, rectum, or gallbladder.
GI peritonitis
inflammation of the peritoneum (lining) of the GI organ
Lab studies for upper GI bleeding
1. CBC
2. BUN
3. serum electrolytes
4. blood glucose
5. PTT
6. liver enzymes
7. ABGs
8. Type and crossmatch for blood transfusion
9. test vomitus and stools for gross and occult blood
10. Urinalysis: specific gravity to check hydration status
Drugs that cause bleeding
aspirin
NSAIDs
corticosteroids
anticoagulants
How to prepare for blood transfusion
- IV lines, referably 2
- 16- or 18- gauge needle are placed for fluid and blood replacement
- oxygen supplement: face mask or nasal cannula to help increase blood oxygen saturation
Complications of blood transfusion
- fluid overload
- immunologic reactions => packed RBCs are preferred over whole blood
What is the first thing you have to do when a pt admitted with upper GI bleeding?
a thorough and accurate nursing assessment, physical needs must be met first!
What are included in the assessment for pt with upper GI bleeding?
- LOC: level of consciousness
- vital signs q15, 30 mins (base line, signs of shock from blood loss), consider pt's age and physical condition. Obtain orthostatic vital signs
- appearance of neck veins
- skin color
- capillary refill
- check abdomen for distention, guarding, and peristalsis
Signs and symptoms that pt is in shock from blood loss
#NAME?
Goals for treatment for pt with upper GI bleeding
1. have no further bleeding
2. causes of bleeding are identified and treated
3. return to a normal hemodynamic state
4. minimal or no symptom of pain or anxiety
Who are at high risk for upper GI bleeding?
chronic gastritic
peptic ulcer disease
previous major bleeding episodes
cirrhosis
How to prevent GI bleeding for people at high risk
#NAME?
Risk of administering sedatives for restless pt
restlessness is one of the signs of shock and may be masked by drugs
What are included in nursing care plan for a pt with upper GI bleeding?
- maintain and check IV lines for fluid and blood replacement
- record intake and output to assess hydration status
- measure urine hourly: 0.5ml/kg/hr is adequate renal perfusion, lesser means renal ischemia secondary to hypovolemia
- measure urine specific gravity: hydration status (1.005 - 1.025) >1.025 indicate high concentration = low blood volume: adjust IV solutions accordingly
- assess fluid volume status: central venous pressure line or pulmonary artery catheter: record reading q1-2 hours
Older adults with cardiovascular disease with IV fluild transfusion at risk for
fluid overload
What does Pt who receice large amounts of IV fluid tranfusions at risk for and how to assess and prevent?
volume overload and pulmonary edema
- assess:
+ ascultate breath sounds
+ observe the respiratory effort
+ ECG for cardiac function
What cause false bloody vomitus? and how to check
beets
swallowed mouthwash
swallowed nosebleed
(give vomitus a bloody appearance)
- use occult blood test
- NG tube: keep in proper position and check aspirate for blood
- if pt has nosebleed, take note because it can cause false diagnosis of GI bleeding
When will bleeding episodes stop?
majority of upper GI bleeding will stop naturally even without intervention
How is lavage used to treat GI bleeding?
- instill 50 - 100mL of fluid ( warm water or normal saline) at a time into the stomach. Then lavage fluid may be aspirated or drain by gravity. NOT to aspirate when resistance is felt (the tip of tube may be up against the lining), use gravity instead for drainage.
- closely monitor vital signs, dysrrhrymias may occur
- keep head of bed elevated to prevent aspiration
what does black, tarry stool indicate?
presence of prolonged bleeding, blood has been in the stomach for long duration
indication of bright red or marroon-colored (hematochezia) stools
from a source in the lower bowel
what can cause false bloody stools?
menses and bleeding hemorrhoids
vomitus contains blood but the stool contains no gross or occult blood
hemorrhage in short duration
hematocrit level indicates
at first hematocrit level may appear falsely high or low and not reflect the amount of blood lost or the amount of blood replacement
What lab values when pt is receiving blood transfusion and how often?
- hemoglobin and hematocrit. Check every 4 -6 hours if pt is active bleeding
- BUN: significant bleeding cause elevated BUN level. Elevated BUN may also indicate renal hypoperfusion or renal disease
How to resume oral intake for pt with upper GI bleeding?
#NAME?
Upper GI bleeding can be caused by chronic alcohol abuse. What are these pt at risk for when withdrawal from alcohol takes place?
delirium tremens
Pt appears agitation, uncontrolled shaking, sweating and vivid hallucinations. What is he experiencing?
delirium tremens, occured after alcohol withdrawal
How to prevent upper GI bleeding?
#NAME?
Most important teaching for pt with upper GI bleeding when discharge
#NAME?
Which pt need surgical therapy for upper GI bleeding?
- bleeding continues regardless of the therapy provided or after rapid transfusion of up to 2000 mL of whole blood
- remains in shock after 24hours
- bleeding sites have been identified
Mortality rates increase in 60s and up
What determines the choice of surgery?
the site of bleeding
What is the first-line of treatment for upper GI bleeding?
endoscopy and endotherapy
What is endoscopy used for?
#NAME?
What can be done before an endoscopy procedure?
#NAME?
Goal of endoscopic hemostasis
coagulate or thrombose the bleeding vessels
Drug therapy for upper GI bleeding
- acute phase: injection of epinephrine (1:10,000 dilution) during endoscopy
Reduce gastric secretion (which interfere with clot stabilization)
- PPI (pantoprazole - Protonix)
- H2-receptor blockers (cimetidine)
Drug therapy used in acute phase of GI bleeding
empiric use of PPI therapy: high-dose bolus and subsequent infusion, started before endoscopy
Disadvantages of lavage use
#NAME?
Do we need to know types of endoscopy?
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