Med Surg: GI Bleed – Flashcards
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Who is GI bleeding most common in?
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-Older adults -Women -NSAID therapy
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Most serious blood loss is characterized by what?
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Sudden onset of UGI bleed (upper GI bleed)
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Severity of UGI bleed depends on what?
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-Venous -Capillary -Arterial
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Types of UGI bleeding
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-Hematemesis -Melena -Occult
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Hematemesis
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Bloody vomit that appears fresh, bright red, or "coffee grounds"
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Melena
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Black, tarry stools caused by digestion of blood in GI tract
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What causes the black appearance of Melena
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Breakdown of hemoglobin and release of iron - that's why it can cause iron deficiency anemia
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Issue with melena
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Cause of bleeding may be difficult to pinpoint
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How can you tell the difference between arterial bleeding and non-arterial bleeding?
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Arterial bleeding is profuse, and the blood is bright red, indicating blood has not been in contact with gastric HCl acid (unlike "coffee grounds," which has been digested partially)
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What does "coffee ground" vomit reveal?
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The blood has been in the stomach for some time, and has been changed by gastric secretions
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Occult bleeding
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-Small (trace) amounts of blood in gastric secretions, vomit, or stool -Undetectable by appearance
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How do you detect occult bleeding?
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Guaiac test
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"Massive upper GI hemorrhage"
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Loss of more than 1500 mL of blood or more than 25% of intravascular blood volume
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Common causes of UGI bleed
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-Esophageal origin -Stomach and duodenal origin -Drug-induced -Systemic disease
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Causes of esophageal bleeding
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-GERD -Mucosa-irritating drugs -Alcohol -Cigarettes -Chronic esophagitis -Mallory-Weiss tear -Esophageal varices
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Mallory Weiss tear
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Tear in the lower esophagus or upper stomach, or where they meet. Often caused by forceful cough or long-term vomiting
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Esophageal varices
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Large, abnormal veins in the esophagus that may bleed when irritated
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What is the most common cause of esophageal varices?
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LIVER DISEASE!! Usually from chronic alcoholism - causes portal HTN, blood backs up into esophagus
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Drugs that induce UGI bleed
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-Aspirin -NSAIDS -Corticosteroids
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Duodenal or stomach bleeding sources
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-GI peptic ulcers (PUD) -H. pylori -NSAIDS / drugs -Gastric cancer -Hemorrhagic gastritis -Polyps -Stress-related mucosal disease (SRMD)
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Peptic Ulcer disease accounts for ____% of cases of UGI bleeding
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40%
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About ___% of people taking long term NSAIDS will develop ulcers
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25% (a quarter!)
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Stress-related mucosal disease (SRMD)
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Physiologic stress ulcers that occur in patients with severe burns, trauma, or major surgery due to ischemic trauma to GI
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Diagnostic studies for GI bleed
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-Endoscopy -Colonoscopy -Angiography -Lab studies
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Primary diagnosing tool for GI bleed
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Endoscopy
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Endoscopy: what to do before procedure
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-Lavage (washing) to get clearer view -NG or orogastric tube placed, room temp water or saline used -Stomach contents aspirated through a large-bore (Ewald) tube to remove clots
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Warning for Lavage
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Do NOT advance tube against resistance!!
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Use of angiography in UGI bleed
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Used only to diagnose when endoscopy cannot be done
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Angiography
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-Invasive procedure -Catheter placed into left gastric or superior mesenteric artery until site of bleeding is discovered -Not appropriate for high-risk or unstable patient
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Lab studies to diagnose UGI bleed
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-CBC -BUN -Serum electrolytes -PTT, PT -Liver enzymes -ABG's -Occult or gross blood -Type/crossmatching for possible blood transfusions -Vomit -Stool -Urinalysis
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Why may hematocrit may not be a good diagnosis of GI bleed?
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Initial hct may be normal and not reflect loss until 4-6 hours after fluid replacement, because initial losses of plasma and RBC's are equal
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Why can BUN indicate GI bleed?
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During significant hemorrhage, blood proteins are broken down by GI tract bacteria, resulting in elevated BUN
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What will be tested in urinalysis for GI bleed?
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-BUN (broken down blood proteins) -Specific gravity: hydration status
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Of patients who have a massive hemorrhage, _____ to ______% spontaneously stop bleeding
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80-85%
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Emergency assessment of UGI bleed
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-BP -Rate and character of pulse -Peripheral perfusion with cap refill -Observation of neck vein distention -VS every 15 min -S/S of shock -Tx ASAP -Resp status
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S/S of shock
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-Tachycardia -Weak, rapid pulse -Hypotension (low BP) -Cool extremities -Prolonged cap refill -Apprehension
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Abd examination in emergency GI bleed assessment
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-Bowel sounds -Tense, rigid abd
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What does a tense, rigid abdomen indicate? **
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Perforation and peritonitis
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Nursing management upon start of immediate intervention with GI bleed
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Document complete history of events leading up to bleeding episode: -Previous bleeding episodes -Weight loss -Receipt of blood transfusion -Other illnesses (liver dz, cirrhosis) -Medication use -Religious preferences (blood transfusions)
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Fluid replacement in emergency management of GI bleed
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-IV should be established for fluid and blood replacement -Preferably 2 IV lines -16-18 gauge catheter -Usually begin with isotonic crystalloid (lactated ringer's)
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When is blood replacement indicated?
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When massive hemorrhage causes major loss of blood volume
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Types of blood replacements
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-Whole blood -Packed RBC's -Fresh frozen plasma
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What blood replacement is preferred?
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Packed RBC's (over whole blood) because of fluid overload and immune reactions with whole blood
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What labs provide baseline for further tx?
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Hgb and Hct (but Hct may be normal and may not reflect loss until after 4-6 hours after fluid replacement)
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Fluid replacement for less profuse upper GI bleed
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Isotonic saline (normal saline) followed by packed RBC's - enables restoration of Hct more quickly and does not create complications related to fluid volume overload
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Further emergency management of UGI bleed
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-Supplemental O2 to increase blood O2 sat -Indwelling urinary catheter -CVP
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Why would a patient benefit from an indwelling urinary catheter in an upper GI bleed?
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It allows accurate urine volume assessment, which allows more accurate tx
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CVP line purpose (central venous pressure)
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To monitor the patient's fluid volume status closely
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Indications for a pulmonary catheter in emergency upper GI bleed
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-Valvular heart disease -Coronary artery disease -Heart failure
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Drugs pre-endoscopy during acute phase of upper GI bleed
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Empirical PPI therapy with a high-dose bolus and subsequent infusion to decrease amount of bleeding during endoscopy
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Endoscopic hemostasis therapy
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Therapy used to achieve coagulation or thrombosis in bleeding artery
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Indications for endoscopic hemostasis therapy
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-Gastritis -Mallory-Weiss tear -Esophageal and gastric varices -Bleeding peptic ulcers -Polyps
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Types of endoscopic hemostasis therapies
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-Thermal (heat) probe -Electrocoagulation probe (multipolar and bipolar) -Argon plasma coagulation (APC) -Neodymium yttrium-aluminum-garnet (Nd-YAG) laser
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How does the thermal (heat) probe help coagulate tissues in GI bleed?
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It directly applies heat to the bleeding site, stopping the bleeding
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When is surgery indicated for upper GI bleed?
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When bleeding continues regardless of therapy provided, or if the site of bleeding is identified
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Usual indication for surgery
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When patient continues to bleed after rapid transfusion of up to 2000 mL (2L) of whole blood or remains in shock after 24 hours
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A high % of GI bleed patients will hemorrhage massively again within ___ years of first bleeding episode
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5 years
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Mortality rates of GI surgery increase in patients older than ___
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60
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Drug uses during acute GI bleeding phase
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-Decrease bleeding -Decrease HCl acid secretion -Neutralize HCl acid that is present
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Drugs for acute GI bleed
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-Epinephrine -Acid reducers -Somatostatins
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Drug given during endoscopy
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Epinephrine, for acute hemostasis
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Drug given for bleeding due to ulceration (acute tx)
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Epinephrine: produces tissue edema, applying pressure on the bleeding source (and vasoconstrict)
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Indications for acid reducers in acute GI bleed
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Acidic environments can alter platelet function and clot stabilization; inhibiting acid may allow patient to clot better by allowing platelets to function properly
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Acid reducer drug in acute GI bleed
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-H2 blockers to inhibit acid secretion -PPI's to inhibit acid production
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H2 blocker drugs
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-Ranitidine (Zantac) -Famotidine (Pepcid) -Cimetidine (Tagamet)
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PPI drugs
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-Pantoprozole (Protonix) -Lansoprazole (Prevacid) -Esomeprazole (Nexium) -Omeprazole (Prilosec)
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Downside of acid reducers in GI bleed
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No proven ability to control active bleeding
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Somatostatin use in GI bleed ( or somatostatin analog: ocreotide/sandostatin)
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-Used for upper GI bleed -Reduces blood flow to GI organs -Reduces acid secretion
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Somatostatin administration
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Given in IV boluses for 3-7 days after onset of bleeding
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Nursing assessment of GI bleed
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-LOC -VS every 15-30 mins -Orthostatic htn -Subjective and objective data -H&P -Appearance of neck veins -Skin color -Cap refill -Abd distension, rigid abd -Guarding -Peristalsis and bowel sounds
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Why are taking vital signs immediately so important?
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Indicates whether patient is in shock from blood loss, and also provides a baseline BP and pulse to determine progress of tx
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S/S of shock
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-Low BP -Rapid, weak pulse -Increased thirst -Cold, clammy skin -Restlessness
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Nursing diagnosis for GI bleed
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-Decreased cardiac output r/t blood loss -Deficient fluid volume r/t acute blood loss -Ineffective peripheral tissue perfusion -Anxiety
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Goals of nursing management of GI bleed
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-Stop GI bleed -Identify cause of bleeding and tx -Return to normal hemodynamic state -Minimal or no symptoms of pain or anxiety
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Patients at high risk for GI bleed
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-Chronic gastritis -PUD -Have had one major bleeding episode -Cirrhosis (varices) -Previous UGI bleed
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Why does liver dz and cirrhosis put patient at risk for GI bleed?
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It causes blood to back up due to portal HTN, causing varices (esophageal, splenic, mesenteric..) and jugular distension
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Patient teaching for GI bleed
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-Disease process -Drug therapy -Avoid gastric irritants (alcohol, smoking, stress) -Take only prescribed meds -Methods of testing for occult blood -Potential complications of GI bleed -Prompt tx of resp infection with esophageal varices pt
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Why are OTC potentially dangerous for GI bleed?
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May contain ingredients like aspirin that can cause GI bleed
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Why is it important to treat an upper resp infection promptly in a pt with esophageal varices
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At high risk of bleeding, may cause blood infection
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If aspirin MUST be prescribed, what can prevent GI bleed?
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-Enteric coated tablets -Concurrent administration of PPI or high dose H2 blocker -Misoprostol to protect the lining
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Patient teaching for medication administration
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Taking meds with meals or snacks lessens potential irritating effects of NSAIDs
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Acute nursing intervention in GI bleed
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-Approach calmly -Assure them to decrease anxiety -Use caution when administering sedatives for restlessness -IV fluid maintenance -Accurate I/O record -CVP or PAC readings every 1-2 hours -Monitor EKG -Vital signs
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Why is it important to administer sedatives cautiously for restlessness?
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The warning signs of shock may be masked by the drugs
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How often to monitor I/O in GI bleed pt
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Urine output hourly
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Indication of adequate renal perfusion
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At least 0.5mL/kg/hr (should be 1500mL/24 hours, or 60mL/hr)
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How can specific gravity indicate GI bleed?
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Specific gravity will be higher if dehydrated from bleeding, because urine will be more concentrated (should be from 1.003-1.030)
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How often to measure CVP / PAC readings (central venous pressure / peripheral arterial pressure)
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Every 1-2 hours, to provide an accurate and quick assessment of blood flow and pressure within the CV system
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Complications of fluid replacement
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Fluid overload and pulmonary edema (crackles!!)
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How to monitor for fluid overload due to fluid replacement
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Auscultate breath sounds (crackles) and closely observe respiratory efforts, keeping HOB elevated and preventing possible aspiration
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Nursing management for NG tube (if indicated)
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-Keep upright -Observe aspirate for blood -May need gastric lavage (questionable)
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Amount of fluid used for lavage (washing)
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50-100 mL of fluid instilled into the stomach, then aspirated from stomach or drained by gravity
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Types of blood in stool
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-Hematochezia (bright red, fresh) -Melena (black, tarry, digested)
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What needs to be ruled out for GI bleed, especially if in stool?
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-Menses (period) -Bleeding hemorrhoids
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Nursing management: nutritional intervention for GI bleed
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-Observe for nausea/vomit -Look for recurrence of bleeding -Initially give clear fluids hourly -Gradually reintroduce food as tolerated
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Nursing observation for pt with GI bleed due to chronic alcohol abuse
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-Observe for delirium tremens (withdrawal) -Agitation -Uncontrolled shaking -Sweating -Vivid hallucinations
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Patient teaching for GI bleed ambulatory / home care
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-How to avoid future bleeding -Consequences of noncompliance with drug and diet therapy -NO OTC DRUGS!! -No smoking or alcohol -Long-term follow-ups -Instruction for acute hemorrhage in the future
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Overall goals for GI bleed pt
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-No further bleeding -Maintain normal fluid volume -Experience return to normal hemodynamic state
