Finals MS Lec1

NCM 118A: MEDICAL - SURGICAL NURSING
CHAPTER 13 | Unit 8 Acute Gastrointestinal Bleeding

or Pancreatitis
BSN IV LEININGER - 1st SEMESTER FINALS A.Y. 2023 – 2024
Compiled and transcribed by A.D.
OUTLINE ● Upper gastrointestinal (UGI)

bleeding is classified as variceal
● Gastrointestinal Bleeding or nonvariceal
● Peptic Ulcer Disease (PUD)
● UGI bleeding is twice as common
● Pancreatitis
in males as in females, and
GASTRO-INTESTINAL (GI) increases with age
Bleeding
LOWER gastrointestinal (LGI) bleeding
● Common reason for patient to be
admitted to ICU ● Refers to bleeding originating
● common, costly, and potentially distal to the ligament of Treitz,
● life-threatening medical and is
condition. ● differentiated into bleeding from
● Bleeding occurs: numerous types the small bowel or mid-GI
of lesions anywhere in the GI bleeding, and
tract. ● bleeding from the colon, or lower
● 74-100% of critically ill patients GI bleeding
develop stress-related GI ● ↑ Risk w/ Age
mucosal erosions within 24 hours
of admission that can lead to MANIFESTATION OF GI BLEEDING
serious GI bleeding in 0.6 to 4% ● COMMON:
of patients ○ Hema-teme-sis,
○ Melena
● Risk ↑ NSAIDS &
○ Hema-to-chezia
Antithrombolytic
● GI bleeding in the older adult may
present with signs of dehydration HEMATEMESIS
● vomiting of blood that is
and abdominal cramping. ● either bright red or has a coffee
● Both UGI and LGI bleeders can grounds appearance,
have melena and/or ● Indicating: UGI bleeding.
hematochezia.
● SOURCE OF BLEEDING:
➔ Esophagus, Stomach,
UPPER Gastrointestinal (UGI) bleeding Duodenum
● originates proximal to the
Type:
ligament of Treitz.
or Pancreatitis
● Coffee grounds - caused when severe bleeding,

blood is mixed with digestive Esophagus, Stomach,
juices, and it usually indicates the Duodenum)
bleeding has slowed or stopped.
● Indicated: Slowed or Stopped GUAIAC-POSITIVE STOOL

Bleeding ● Fecal Occult Test → blood from
digestive tract in stool sample
● SOURCE OF BLEEDING:
○ Esophagus, Stomach,
Duodenum ● SOURCE OF BLEEDING
Esophagus, Stomach, Duodenum,
MELENA Right Colon, Left Colon
● Passage of black tarry colored
stool with a very characteristic foul
odor. Anatomy and Physiology of
● Indicated: Active Bleeding
GastroIntestinal
● It reflects the action of intestinal
contents on the blood.
● Melena can result from as little as ● The GI tract begins at the oral
50 mL of blood in the stomach and cavity and ends at the anus
usually suggests an UGI bleed,
● However the source can also arise ● The major functions of the GI
from the small bowel or ascending tract include:
(right) colon. ○ Ingestion
● SOURCE OF BLEEDING
○ Mechanical processing
○ Esophagus, Stomach,
Duodenum ○ Digestion
○ Right Colon ○ Secretion
HEMATOCHEZIA
● usually red or maroon blood in GENERAL STRUCTURE OF GI TRACT
the stool and is most often due to
lower GI bleeding however it can ● Esophagus,
also occur with massive UGI
bleeding which is usually ● Stomach
associated with orthostatic ● Small intestine
hypotension ● Ileocecal valve
● Indicated: Active Bleeding ● Large intestine
● SOURCE OF BLEEDING
○ Right & Left Colon (if
or Pancreatitis
ESOPHAGUS 3 SECTION OF SMALL INTESTINE
● Hollow muscular tube, ● The Duodenum is 10 inches long

approximately 10 inches long and with the terminal landmark, the
1-inch-wide, ligament of Treitz
● Carries solids and liquids from ● Jejunum is 8 feet long
the pharynx to the stomach ● Ileum is 12 feet long.
○ The distal end of the ileum
STOMACH connects to the large
intestine.
● J-shaped organ
● located below the diaphragm ILEOCECAL VALVE
between the esophagus and the
small intestine. ● Marks the transition between the
small and the large intestines
● Functions: (Stomach)
○ storage of food; LARGE INTESTINE
○ mechanical breakdown of
food ● Tubular structure
○ production of gastric ● Approximately 5 to 6 feet long
secretions, hydrochloric and 2 to 4 inches wide.
acid (pH 1.0– 4.0), and
intrinsic factor 5 SECTION OF LARGE INTESTINE
SMALL INTESTINE ● Cecum/Ascending colon

● Transverse colon
● Tubular structure ● Descending colon
● approximately 20 to 25 feet long ● Sigmoid colon
and 11/2 inches wide ● Rectum.
● responsible for most of the ● It functions to eliminate wastes
important digestive and and absorb water and
absorptive functions. electrolytes.
or Pancreatitis
Predisposing FACTORS & CAUSES ● Refers to ulcers in the stomach

and the first part of the
of G.I. HEMORRHAGE
duodenum, also called the
duodenal bulb
● Peptic ulcer disease accounts
● Occur less: Esophagus
for approximately 31% to 67% of
● Addition to ulcers, erosions can
nonvariceal UGI bleeds
form in the GI tract.
● Difference between ulcers and
● Diverticular bleeding accounts
erosions is the depth of
for 20% to 65% of acute LGI
penetration.
bleeds.
● Erosions can form in the GI tract
& superficial and do not involve
● Individuals with LGI bleeding
the smooth muscle layer.
often present with less severity
● Ulcers - Involve smooth muscle
than those with UGI bleeds, and
are less likely to manifest
MAJOR RISK FACTORS
orthostasis or shock or require
blood transfusions.
AGE —more common in older adults
● Mortality from UGI bleeding has ● 60% greater > 60 years
decreased in the past two ● 20% greater > 80 years
decades but still ranges from 2%
Helicobacter Pylori
to 15%
— highly mobile bacterium that
avoids acid by burrowing underneath
the mucosa. It causes the mucosa to
be more susceptible to peptic acid
damage and provokes an
inflammatory response, which results
in further epithelial injury.
PEPTIC ULCER DISEASE (PUD) Nonsteroidal anti-inflammatory

drugs (NSAIDs) and aspirin
(including low dose)
or Pancreatitis
— cause local and systemic effects there is increased permeability of acid.

that promote mucosal damage. Many Rare: hyperactivity of these secretions
studies have compared GI toxicity of can cause ulcers.
different NSAIDS. One study looked at
asymptomatic individuals taking ALCOHOL AND SMOKING
aspirin and found that 4% had ulcers
and 34% had erosions (Feldman &
Das, 2015). NSAIDs have also been LESS FREQUENT CAUSES:
an associated factor in nonhealing ● Erosive esophagitis, gastritis, or
ulcers. duodenitis
Stress-related mucosal damage ● Mallory-Weis tear—a tear of the
(including stress ulcers) tissue of lower esophagus
— develop in hospitalized patients ○ S/S: wrenching and vomiting
with serious illnesses. Patients with GI ● Benign or malignant tumors
bleeding secondary to these lesions ● Vascular abnormalities
have a higher mortality than those
admitted with primary UGI bleeding. CONTRIBUTING FACTORS
1. Smoking - ↑ Risk & Impair healing
Cause: Disproportion in the 2. Alcohol Use Disorder - Impair
production of gastric acid and Healing
mechanisms to protect the gastric
mucosa. PRIORITY MANAGEMENT UPPER G.I.
Mucosal ischemia resulting from ● Secure the Airway and initiate

hypoxia, systemic hypotension, and resuscitation before any other
splanchnic hypoperfusion is thought to procedure
contribute to mucosal injury. ● Goal: Restore circulating blood
volume and prevention of
Risk ↑ in patients: Respiratory failure hypovolemic shock.
and those with coagulopathy. Other ● Endoscopy within 12 to 24 hours of
associations include sepsis, hepatic admission is essential for those
failure, renal failure, burns and major unstable on admission or who
trauma continue to actively bleed after
resuscitation.
Gastric acid and pepsin ● Urgent endoscopy within 12 hours
- co-contributors
is recommended for patients with a
Because of the mucosal impairment,
history concerning for variceal
or Pancreatitis
bleeding and within 24 hours for ● Found: Descending and Sigmoid

suspected non-variceal bleeding colon, but they can be throughout
the colon
● Present: 30% ≥ 50 years old
● Prevalence: ↑ 60% in individuals >
CLINICAL FACTORS linked to POORER 80 years old
● Bleeding results from rupture of
Outcomes include:
submucosal arterial vessels at the
neck or the dome of the
● Hemodynamic instability
diverticulum.
● Low initial hemoglobin level
● Multiple blood transfusions
● Presence of bright red blood in
emesis or stool
● Age greater than 60
● Concurrent hospitalization/illnesses
● Coagulopathy
● Continued bleeding or re-bleeding
(especially within72 hours of initial
bleed)
● Emergent surgical intervention
● NSAID ↑ Risk of Diverticular

Bleeding
● Clinical Presentation: acute,
painless passage of bright red blood.
● Such bleeding has not been
correlated with inflammation
Diverticular Disease (diverticulitis)
LESS COMMON CAUSES:

● Results from weak points →
intestinal wall (Large Intestine) that ● Ischemic colitis
herniate (Bulge) to form a saclike ● Vascular ectasis (angiodysplasia,
projection called diverticula angioectasis)
or Pancreatitis
● Anorectal disease (hemorrhoids, ● Nurse assesses hemodynamic

anal fissures) status by looking for S/S of
● Neoplasms (small intestine/large hypovolemia and poor tissue
intestine) perfusion.
● Post-polypectomy bleed ○ Hypotension
● NSAID usage ○ Narrowed pulse pressure
○ Orthostatic hypotension
○ Tachycardia
○ E C G changes
COLLABORATIVE CARE ○ Chest Pain
● Pt should be asked about prior ○ Capillary refill
episodes of UGI bleeding ○ Dry mucous membranes
● 60% of patients with a Hx of UGI ○ Decreased urine output
bleeding will be bleeding from the ○ Mental status changes
same lesion
● Goals are to: ● Laboratory Studies
○ Identify the source, ○ Hemoglobin
○ stop the bleeding, ○ Platelets
○ Prevent recurrent bleeding ○ Electrolytes
○ Prevent and treat ○ Blood urea nitrogen (B U
complications N)/creatinine
○ Prothrombin time (P T)
○ Cardiac enzymes
Assessment of Fluid Volume Status
○ Liver function tests
● Evaluate: extent of blood loss →
○ Type and cross-match
immediate assessment of the
patient’s hemodynamic status.
Nursing Actions
● Calculation of blood loss relative to
the amount of measured melena or ● Goals of resuscitation are to:
hematochezia is difficult and ○ Restore intravascular volume
inaccurate related to being mixed ○ Maintain cardiac output
with stool. ○ Restore blood cells
○ Patients with less than 30% ○ Prevent complications of red
blood loss are more difficult blood cell loss
to recognize.
● Interventions for Restoration of
Normovolemia
or Pancreatitis
○ Pt should have two (2) ● beneficial: promotes gastric

large-bore intravenous emptying
catheters placed
immediately. Acid Suppression: Proton Pump
○ Total fluid deficit cannot be Inhibitors
accurately predicted. ● Proton pump inhibitors (P P Is)
■ Fluid resuscitation cross the parietal cell membrane.
should remain at a ○ Resulting in irreversible
rapid rate as long as inhibition of gastric secretion
the B P remains low. of hydrochloric acid by the
proton pump
● Blood Transfusions
○ Packed Red Blood Cells ● pH of 6.0-6.5 is recommended.
○ Platelets/Fresh Frozen ● Evidence has shown that high-dose
Plasma (F F P P Is administered intravenously in
○ P)/Cryoprecipitate (Factor patients with high-risk ulcers
VIII) receiving therapeutic endoscopy
○ Patient Positioning results in a decrease in hospital
○ Gathering of Additional length of stay, rebleeding rate, and
Assessment Data need for blood transfusions.
Nasogastric Tube Placement Bowel Preparation

● Placement is controversial. ● Recommended prior to a
○ Traditionally, N G T insertion colonoscopy
and lavage have been ● Cleansed colon allows for a safer
utilized to confirm G I procedure and better chance at
bleeding and distinguish visualization.
upper from lower bleeding.
Collaborative Care
● Use for hemodynamically unstable Endoscopy
patients ● Procedure that uses a flexible
● Can help validate U G I bleed fiber-optic endoscope to directly
○ Does not provide information visualize the inside of a hollow organ
about the specific or cavity
○ cause of the bleeding
Erythromycin Administration ● Purpose
or Pancreatitis
○ Diagnose site of bleeding angiotherapy

○ Assess risk of re-bleeding
○ Perform interventions to stop Nursing Care
bleeding ● Maintain safety.
● Provide nutrition.
Colonoscopy ● Enhance comfort.
● Insertion of endoscope into anus to ● Provide patient and family centered
examine colon or large intestine care.
from the rectum to the ileocecal ● Monitor for potential complications
valve
Other Diagnostic Tests
Sigmoidoscopy
● If colonoscopy cannot be performed
● Inspection and visualization of only
or does not yield a bleeding site,
the rectal-sigmoid area of the colon
other diagnostic options can assist.
○ Angiography
Categories of Therapeutic Interventions
○ Radionuclide imaging
● Injection Therapy
○ Helical computer tomography
○ Agents may sclerose
scan
(harden), vasoconstrict, or
● Surgical Consult
cause a tamponade effect.
○ Most definitive
○ Most commonly used agent
○ May be the final option for
is epinephrine.
some bleeding lesions
○ Surgery has a high morbidity
● Thermal Coagulation
and mortality.
● Mechanical Techniques
■ Generally reserved
○ Endoclips (hemoclips)
for patients whose
bleeding is not
● New Endoscopic Technologies
controlled by
○ Application/injection of tissue
endoscopic treatment
adhesive or fibrin glue
○ Depending on the acuity of
○ Over the scope clips
the patient, every effort
○ Endoscopic suturing
should be made to accurately
○ Radio frequency ablation
localize the bleeding site
○ Cryotherapy
prior to surgery to avoid
○ Endoscopic
increased mortality and
ultrasound-guided
morbidity.
or Pancreatitis
Prevention of Complications
● Acute G I bleeding needs to be
● Identification and Prevention of systematically assessed and treated.
Recurrent Bleeding ● Vigilant assessment, interventions,
○ Certain patients with an initial and evaluation of the patient’s
severe bleed are at high risk response to the interventions are
for re-bleeding. critical.
● Risks include: ● Monitor for evidence of:
○ Older age ○ Myocardial
○ Comorbid disease states ischemia/infarction
○ Hemodynamic instability ○ Cerebral
○ Coagulopathy/anticoagulants ischemia/thrombosis
○ Endoscopic ○ Respiratory
diagnosis/stigmata insufficiency/failure
○ Acute renal injury
Collaborative Care ○ Hepatic failure
● Acid Suppression: Proton Pump ○ Disseminated intravascular
Inhibitors coagulation
● Elimination of Precipitating Factors ○ Sepsis
○ N S A I Ds should be ○ Multisystem organ failure (M
discontinued. S O F)
○ Aspirin plus a PPI is
recommended for preventing
ulcer reoccurrence and
PANCREATITIS
re-bleeding. ● Sudden nonbacterial inflammatory
○ All patients presenting with a process of the pancreas
U G I bleed should ● Occurs from the activation of
○ be tested for Helicobacter digestive enzymes found inside the
pylori. acinar cells that compromise the
pancreatic gland, nearby tissues,
Nursing Care and other organs
● Clinical course: mild interstitial
● Maintaining Safety
self-limiting illness to a severe
● Providing Nutrition
life-threatening disorder.
● Enhancing Comfort
● Common CAUSE: Gallstone
● Fostering Patient and
disease and excessive alcohol
Family-Centered Care
or Pancreatitis
● Pancreatic necrosis and the Major types of Pancreatic

presence, timing, and duration of
organ failure influence morbidity and enzymes are:
mortality. ● Amylase
● Risk of death doubles when patients ○ Responsible for breaking
have both infected necrosis and down certain starches
persistent organ failure. ● Lipase
○ Responsible for breaking
Anatomy and Physiology Review down certain complex fats
● Proteases
Pancreas ○ Responsible for breaking
● Elongated, lobulated gland down proteins
● Lies behind the stomach in the
retroperitoneal space Pancreatic Ductal System
● Extends from the duodenum to the
● Duct of Wirsung
spleen
○ Main pancreatic duct
● Divided into three segments:
○ Runs the whole length of
○ Head
○ Body the pancreas
○ Tail ● Papilla of Vater
● Sphincter of Oddi
The head of the pancreas is tucked into
a C-shaped curve of the duodenum that Predisposing Factors and Causes of
begins at the Pylorus of the stomach. Acute Pancreatitis
Cellular Systems of the Pancreas ● Most common risk factors include
gallstone disease and excessive
● Exo-crine cells alcohol use.
○ Make up 98% to 99% of the ● Other less common causes include:
pancreatic tissues ○ Infections
○ Responsible for the ○ Medications
production of pancreatic ○ Toxins
juices and digestive enzymes ○ Developmental abnormalities
● Aci-ni cells ○ Autoimmune disorders
○ Mechanical obstruction of the
ducts
or Pancreatitis
● Other less common causes include: ○ likely to develop severe

○ Hypertriglyceridemia disease is critical to positive
○ Hypercalcemia ○ patient outcomes.
○ Trauma
○ Heredity Mild
○ Vascular abnormalities
● Absence of organ failure and local or
○ Idiopathic causes
systemic complications
● Determination of the cause is critical
● 85% of acute pancreatitis
for decision making and directing
● Inflammation without hemorrhage or
immediate interventions.
necrosis
● Usually discharged within 3 to 5
Autodigestion days
● Damaged acinar cells cause
activation of trypsinogen to trypsin.
Moderately severe
● Trypsin activates enzymes that
begin digestive process in the ● No organ failure or transient organ
pancreas. failure (< 48 hours) and/or local
● Results in inflammation and tissue complications
damage ● Frequently have extended length of
● Increased vascular permeability stay
causing edema, hemorrhage, and ● May exacerbate comorbidities
necrosis ● Have lower mortality rates than the
severe form
Determination of the Severity of
Severe
Pancreatitis
● 15% of acute pancreatitis
● Accepted criteria for clinical
● Persistent organ failure (>48 hours)
diagnosis require the presence of
that may involve one or multiple
two out of three features:
organs
○ Characteristic epigastric or
● Most have pancreatic necrosis
left upper quadrant pain
● 30% mortality rate
○ Serum amylase and/or lipase
● The most severe cases, the
greater than or equal to three
pancreas becomes hemorrhagic.
times the upper limit of
normal.
○ Establishing the severity and
identifying those patients
or Pancreatitis
Assessment and management Severe necrotizing pancreatitis

focuses on: indicated by:
● Correcting underlying cause
● Hemodynamic stability and fluid Cullen’s sign
resuscitation
● Bluish discoloration around the
● Pain control
umbilicus from the escape of blood
● Electrolyte balances
into the peritoneum
● Nutritional support
● Preventing and recognizing
complications Grey-Turner’s sign
● Bluish brown discoloration around
the flanks from blood in the
Assessment of Hypovolemia
retroperitoneal space
● Nurse anticipates patient will
experience severe volume depletion.
Laboratory tests
● Signs and symptoms include:
○ Poor skin turgor with dry ● Hematocrit
mucous membranes ● Leukocytes
○ Cool, clammy skin ● Serum electrolytes
○ Flat jugular veins ● Blood urea nitrogen (B U N)
○ Hypotension or orthostatic ● Creatinine
hypotension with ● Liver enzymes
○ dizziness ● Calcium
○ Narrowed pulse pressure ● Glucose
○ Tachycardia ● Abdominal ultrasound
○ Decreased capillary refill ● Abdominal imaging-C T scan and/or
○ Decreased urine output MRI
○ Mental status changes
Maintain Hemodynamic Stability
and Normovolemia
● Invasive hemodynamic monitoring
may be utilized to determine fluid
volume status.
● Treatment for hypovolemia involves:
○ Aggressive fluid resuscitation
or Pancreatitis
○ Boluses of N S S, 1-2 liters ○ Crackles, wheezes, or

followed by 250-500 mL/hr decreased lung sounds
for 24-48 hours ● Restlessness, anxiety, or decreased
○ Blood transfusions level of consciousness
● Successful fluid resuscitation results ● Cardiac dysrhythmias
in normalization of vital signs & ● Respiratory insufficiency/failure
hemodynamics. necessitating intubation ventilation
Assessment and Management of Collaborative Care

Pain ● Supplemental Oxygen
○ Administered usually for the
● Patients frequently experience
first 24 to 48 hours or until
sudden severe onset of pain.
there is no threat of
● Adequate pain relief is a critical goal
hypoxemia.
because the pain is severe.
○ Progressive desaturation
○ Increases the patient’s
should be treated
anxiety level
aggressively as respiratory
○ Unrelieved pain may indicate
insufficiency/failure.
disease progression.
■ Patient should be
● IV administration of opiods and
intubated and
nonsteroidal anti-inflammatory
ventilated
medications.
● Use morphine, dilaudid, or fentanyl.
● Assessment and Management
of Infection
○ Infection is a constant risk
Nursing Actions
and significant cause of late
mortality.
Assess for signs of hypoxemia. ○ Treatment includes: fluid
● Decreased oxygen saturation/pulse resuscitation, early enteral
oximetry feeding, antibiotics.
○ Less than 92% ● Evidence-Based Interventions
● Increased or decreased respiratory ● Debridement of Necrosis
rate (Necrosectomy)/Surgery
● Labored breathing, shortness of ○ Surgical debridement of
breath necrotic tissue.
● Abnormal lung sounds ○ E R C P is used to remove
obstruction and create a
or Pancreatitis
○ passageway for ductile Goals of a prompt E R C P are to:

drainage.
● Remove the obstruction
● Create a passageway for sludge and
Building Technology Skills other stones
● Improve pancreatitis
Endoscopic Retrograde ● Prevent cholangitis
Cholangiopancreatography (E R C
P)
● Invasive, endoscopic, and
radiological procedure
● Involves oral intubation with a
flexible fiber-optic endoscope and
advancing it into the duodenum to
directly view the ampulla/papilla of
Vater
● Direct visualization of the ducts is
accomplished by injecting
radiographic contrast medium and
taking a series of x-ray films.
or Pancreatitis
ADDITIONAL INFO IN GI BLEEDING !! ➢ may have a very low

baseline hemoglobin but are
Assess for manifestations of generally hemodynamically
stable.
Hypovolemia and Poor tissue
❖ Recognize: resuscitation efforts
perfusion, including: causing overhydration can lead to
○ Hypotension falsely low hemoglobin
○ Narrowed pulse pressure
○ Orthostatic hypotension ❖ PLATELETS
○ Tachycardia ❖ low platelet
○ Electrocardiogram (ECG) ➢ Indicate thrombocytopenia
changes, dysrhythmias, and ■ Low platelet
ST changes in response to ➢ presence of Portal
ischemia. Hypertension
○ Chest pain ■ Elevated pressure in
○ Capillary refill > 3 seconds w/ the portal venous
cold clammy skin & weak system. The portal
peripheral pulses. vein is a major vein
○ Dry mucous membranes, that leads to the liver.
poor skin turgor, and flat
○ jugular veins.
○ Decreased urine output (less ❖ ELECTROLYTES
than 30 cc/hour). ➢ Abnormal r/t to vomiting &
○ Mental status changes. diarrhea
LABORATORY STUDIES BLOOD UREA

NITROGEN(BUN)/creatinine
❖ HEMOGLOBIN ❖ —To assess hydration status and
➢ Initial → not reflect the renal function
degree of blood loss→ delay ❖ To differentiate between a UGI and
in intravascular equilibrium LGI bleed.
that will not immediately ❖ Pt w/ acute UGI bleeding have
reflect blood loss. decreased renal perfusion and
typically have an elevated BUN to
creatinine ratio (20:1).
❖ Patients with chronic slow bleeding
or Pancreatitis
❖ High ↑ Ratio, the more likely ● Evaluate need for intubation and
bleeding is from an upper source Ventilation
● BP: less than 90 mmHg systolic
Prothrombin time (PT)/international ○ Supine with legs elevated to
normalization ratio (INR)— facilitate venous blood return
❖ Coagulopathy (INR greater than 1.5) to the right atrium.
➢ that needs to be treated
➢ Marker: liver disease Interventions for RESTORATION of
NORMO- VOLEMIA
CARDIAC ENZYME
● Consider - w/ massive bleeding
➔ Two large bore intravenous
● Elderly patients with hypotension to
catheters placed immediately
exclude myocardial infarction
◆ short large-bore:
capable of faster flow rates
LIVER FUNCTION TEST
than longer central line
● Assess for the presence of liver
catheters of the same gauge
disease
➔ Hemodynamic instability
◆ Rapid administration of a
TYPE AND CROSS- MATCH
crystalloid solution,
● To Determine Blood type
◆ generally normal saline
(lactated Ringer’s) LR !!
NURSING ACTIONS
● To replace
● 1st Treat HYPOVOLEMIA intravascular volume
○ Lose/ Low fluids and prevent shock !!
● Resuscitation (Rapid & Con’ts - if BP
remain Low)
○ restore intravascular volume, 💡 Crystalloid solution provides
adequate circulation for the remaining
maintain CO, restore blood
erythrocytes until the type and
cells, and prevent cross-matched blood is obtained.
complications of RBC loss.
● Monitors: cardiovascular and

● PROTECT Airway
respiratory status for tolerance of
● Assess O2 Sat (Report <92%)
rapid infusion rates.
● O2 Therapy
● Pts w/ Hx of heart failure,valvular
● NPO maintain
disease, pulmonary disease, and
other comorbidities may need a PA
or Pancreatitis
line for a more accurate indication of NURSING ACTIONS CON’T

volume status and to minimize risk
for Fluid overload. BLOOD TRANSFUSION
● Guidelines recommend a restrictive
strategy (less than or equal to 7 g/dl
- REVIEW! - hemoglobin threshold) for initiation
of blood transfusions in patients with
S/S FLUID OVERLOAD
acute gastrointestinal bleeding.
● Abnormal lung sounds
● Tachypnea/shortness of breath PACKED RED BLOOD CELLS
● Peripheral edema and neck vein INDICATION:
distention ● prevent or alleviate S/S of
● Weight gain inadequate oxygen tissue delivery
● Chest pain
● Tachycardia ● Maintain adequate tissue perfusion
● Oxygen desaturation ● prevent end organ damage.
MONITOR:
● serial hemoglobins levels after initial
ABDOMINAL ASSESSMENT crystalloid resuscitation, the plasma
volume maybe overexpanded, and
● Bowel sound an immediate post transfusion
○ blood acts as an irritant ● blood is delivered through a blood
stimulating peristalsis warmer to prevent a decrease in
● UGI bleed: Have Hyperactive
body temperature (hypothermia).
bowel sounds
● LGI bleed: normoactive bowel
sounds
● Abdominal tenderness/pain
○ Bowel ischemia,
perforation, or obstruction
● Evidence of liver disease: Ascites

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NCM 118A: MEDICAL - SURGICAL NURSING

CHAPTER 13 | Unit 8 Acute Gastrointestinal Bleeding

OUTLINE ● Upper gastrointestinal (UGI)

● Coffee grounds - caused when severe bleeding,

● Indicated: Slowed or Stopped GUAIAC-POSITIVE STOOL

ESOPHAGUS 3 SECTION OF SMALL INTESTINE

● Hollow muscular tube, ● The Duodenum is 10 inches long

SMALL INTESTINE ● Cecum/Ascending colon

Predisposing FACTORS & CAUSES ● Refers to ulcers in the stomach

PEPTIC ULCER DISEASE (PUD) Nonsteroidal anti-inflammatory

— cause local and systemic effects there is increased permeability of acid.

Mucosal ischemia resulting from ● Secure the Airway and initiate

bleeding and within 24 hours for ● Found: Descending and Sigmoid

● NSAID ↑ Risk of Diverticular

LESS COMMON CAUSES:

● Anorectal disease (hemorrhoids, ● Nurse assesses hemodynamic

○ Pt should have two (2) ● beneficial: promotes gastric

Nasogastric Tube Placement Bowel Preparation

○ Diagnose site of bleeding angiotherapy

● Pancreatic necrosis and the Major types of Pancreatic

● Other less common causes include: ○ likely to develop severe

Assessment and management Severe necrotizing pancreatitis

○ Boluses of N S S, 1-2 liters ○ Crackles, wheezes, or

Assessment and Management of Collaborative Care

○ passageway for ductile Goals of a prompt E R C P are to:

ADDITIONAL INFO IN GI BLEEDING !! ➢ may have a very low

LABORATORY STUDIES BLOOD UREA

● Monitors: cardiovascular and

line for a more accurate indication of NURSING ACTIONS CON’T

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