GASTROINTESTINAL BLEEDING

Gastrointestinal bleeding is a symptom of many upper or lower gastrointestinal (GI) disorders. It may be obvious (in emesis or stool) or occult (hidden).
It refers to any bleeding that starts in the gastrointestinal tract. The level of bleeding can range from mild to severe and can be life-threatening. Gastrointestinal
(GI) bleeding is a potentially life-threatening abdominal emergency that remains a common cause of hospitalization

Gastrointestinal bleeding can fall into two broad categories: upper and lower sources of bleeding. The anatomic landmark that separates upper and lower
bleeds is the ligament of Treitz, also known as the suspensory ligament of the duodenum. This peritoneal structure suspends the duodenojejunal flexure from the
retroperitoneum. Bleeding that originates above the ligament of Treitz usually presents either as hematemesis or melena whereas bleeding that originates below
most commonly presents as hematochezia.

May occur anywhere in the GI tract

● Upper GI bleeding that occurs above the ligament of Treitz (where the duodenum meets the jejunum); includes bleeding in the esophagus, stomach, and
duodenum
● Bleeding below Treitz ligament considered lower GI bleeding, with the most common site being the colon

DIAGNOSTIC TEST RESULTS

● Upper GI endoscopy reveals the source of the bleeding such as an ulcer.

● Complete blood count may reveal a decrease in hemoglobin (Hb) level and hematocrit (HCT) (usually 6 to 8 hours after the initial symptoms), increased
reticulocyte and platelet levels, and decreased red blood cell (RBC) count.

● Arterial blood gas analysis reveals low pH and bicarbonate levels, indicating lactic acidosis.

● Electrocardiogram reveals evidence of cardiac ischemia secondary to hypoperfusion.

● Abdominal X-ray indicates air under the diaphragm, suggesting ulcer perforation.

● Angiography aids in visualizing the site of bleeding (if it’s from an artery or large vein).

● The ratio of BUN to creatinine has been used to predict upper GI bleeding. A BUN/creatinine ratio > 30 and hemoglobin level < 8.0 g/dL indicate severe
upper GI bleeding. A BUN/creatinine ratio > 36 distinguishes upper from lower GI bleeding.

PRIORITY NURSING CARE PLAN

1. Fluid Volume Deficit related to blood volume loss secondary to GI bleeding as evidenced by hematemesis, hematochezia, and lightheadedness.
2. Acute Pain related to abdominal muscle spasms secondary to bleeding peptic ulcers.
3. Ineffective Tissue Perfusion (Gastrointestinal Peripheral)

ASSESSMENT ANALYSIS/ PLANNING IMPLEMENTATION CLIENT EVALUATIO REPORTING

NURSING EDUCATION N OF AND
DIAGNOSIS OUTCOME DOCUMENTATIO
OF CARE N
Subjective Data: Fluid Volume Planning for ▪ Independent: Be sure to cover (with ● At the end Lower
Deficit related health ✔ Physiologic the patient’s family): of 24 hours gastrointestinal
History: to blood promotion 1. Check for the appearance of nursing bleeding: Ranges
● Previous episodes volume loss Within the 24 of vomitus, stool, or intervention from relatively
of GI bleeding or secondary to hours of nursing drainage. It helps in , the goals trivial hematochezia
ulcer. ● The disorder, its
GI bleeding as intervention, the differentiating the cause were met. to massive
● History findings course, treatment,
evidenced by patient will: of gastric distress; bright hemorrhage with
include weakness, and medications 1. Maintained
hematemesis, 1. Maintain red blood may be caused shock, and it
dizziness, ordered, including patient’s
hematochezia, hemodynam by arterial bleeding;dark accounts for up to
syncope intended effects, hemodynam
and ic stability red blood may be due to 24% of all cases of
associated with dosage, and adverse ic stability.
lightheadedne 2. Exhibit no esophageal bleeding; GI bleeding. This
hematemesis effects to report.
ss. or minimal coffee ground may be condition is
(coffee ground 2. Exhibited
signs of because of partly associated with
vomitus), and minimal
bleeding. digested blood from significant
melena (black bleeding.
3. Increase slowly oozing area. ● The signs and morbidity and
stools with a fluid symptoms of actual mortality (10%-
3. Increased
rotten odor). volume 2. Assess vital signs, or impending GI 20%).
fluid
● Brisk upper GI within particularly blood pressure bleeding, such as volume
bleeding (UGIB) normal level. Hypovolemia due to blood in vomitus or Recurrence of
within
manifests as limits. GI bleeding may lower stools, pallor, cool Upper
normal
hematochezia (red blood pressure levels and skin, and Gastrointestinal
limits.
or maroon stools); Planning for put the patient at risk for lightheadedness; (GI) Bleeding
the redder the health hypotensive episodes that include instructions (UGIB) is common.
stool, the more restoration and lead to shock. The to notify the Readmission rate
rapid the transit, alterations and physician should
maintenance was 14.6%. age
which suggests a fluctuations in blood any such signs
1. Fluid older than 60 years
large upper tract pressure may be used for occur
volume is an independent
hemorrhage. rough estimate of blood
replacement marker for a poor
● Past medical loss; BPless than 90
with outcome in UGIB,
history relevant to mmHg may reflect a 25%
crystalloid ● Encourage with the mortality
potential bleeding volume loss.
solutions compliance with rate ranging from
sources (e.g., initially, 12% to 25% in this
3. Assess the client's abstinence if
varices, portal followed by group of patients.
physiological response to alcohol use causes
hypertension, colloids and hemorrhage like changes bleeding and refer
alcohol abuse, blood FDAR
in mentation, weakness, to support groups
tobacco abuse, component CHARTING
apprehension, diaphoresis, such as Alcoholic
ulcers, H.pylori, therapy Date and Time:
restlessness, and anxiety.
 diverticulitis, Worsening in Anonymous. 09/02/2020
hemorrhoids, symptomatology may be 7:00 am to 3: 00 pm
inflammatory due to continuous
bowel disease) hemorrhage or inadequate Received patient on
● Preoperative
● Contributory or fluid replacement. bed, awake and
teaching, as
confounding responsive.
4. Measure central venous indicated.
medications (non-
steroidal anti- pressure if indicated and F: Fluid Volume
available. It reflects blood Deficit related to
inflammatory
volume in the body and ● Educate the patient blood volume loss
drugs,
cardiac response to (or guardian) on secondary to GI
anticoagulants,
bleeding; It may reflect how to fill out a bleeding as
antiplatelet
how effective fluid fluid balance. To evidenced by
agents, bismuth,
replacement therapy is. help the patient or hematemesis,
iron).
● Patients may have the guardian take hematochezia, and
5. Commence a fluid balance lightheadedness.
a history of ownership of the
chart, monitoring the input
dyspepsia patient’s care,
and output of the patient. D: (7:00 a.m.)
encouraging them
Include episodes of Patient reported
Objective Data: to drink more fluids
vomiting, gastric passage of black
as needed, or
Physical Assessment suctioning, and other stool and vomiting
gastric losses in the I/O report any changes
▪ BP < 90 mm Hg of blood. There is
charting. To monitor a to the nursing team.
▪ HR > 100 manifestation of
patient's fluid volume
beats/min facial grimacing,
accurately. It gives the
▪ RR: tachycardia guarding behavior,
basis for fluid ● The patient was
▪ Temperature: restlessness and
replacement. advised to evade
Elevated irritability. Pain
milk because it scale of 8/10.
6. Maintain the client on occasionally
Abdominal (signature).
NPO as ordered by the
● Maybe tender increases gastric
physician. That is in order A: (8:00 a.m.)
with guarding acid secretion.
to prevent further gastric
● Bowel sounds Assessed patient’s
distress.
hyperactive or vital sign - BP, RR,
absent HR, and
7. Monitor laboratory ● The patient was
Temperature.
findings like hemoglobin, taught with a list of
Cardiovascular (signature).
hematocrit, BUN and irritating foods and
● Rapid pulse creatinine. It assists in drugs to avoid like > (10:00 a.m.)
● Capillary refill > knowing how much blood coffee, tea, Administered IV
3 sec. replacement is needed; caffeine, spicy fluid resuscitation,
BUN greater than 40 with foods, rough foods, and assisted in
Skin normal creatinine level citric acid juices, whole blood
● Pale, diaphoretic reflects a major bleeding. hot foods as they transfusion as
● Cool, clammy can increase acid in prescribed by
● Jaundice ✔ Psychosocial the stomach. physician
1. Encourage use of (Signature)
Diagnostic cognitive behavioral
studies/procedures relaxation (e.g., music > (11:00 a.m.)
therapy, guided imagery). ● The patient was Monitored patient
● ECG Changes
Relaxation techniques, instructed to eat for any transfusion
● BUN/creatinine
desensitization, and small, frequent reaction and
ratio > 30
guided imagery can help meals, to chew food recorded intake and
● hemoglobin level
patients cope, increase well, and to eat output. (signature)
< 8.0 g/dL
their sense of control, slowly to avoid
and allay anxiety. distress on the GI > (2:00 p.m.)
tract. The patient Assessed the
2. Provide information and was instructed to patient’s mentation
explanation regarding drink water with and anxiety level to
care before care is given. meals to aid in know the worsening
Providing information digestion. of condition.
prepares the patient and (signature).
family for understanding R: (3:00 p.m).
the situation and possible ● The patient was Patient reported
outcomes. advised to evade decreased
use of aspirin lightheadedness and
having medications was able to sleep
like ibuprofen and and rest. Pain scale
✔ Spiritual other nonsteroidal of 7/10.
anti-inflammatory
1. Respect the patient's medicines as this Nurse on duty:
beliefs. Promotes trust and interferes with your Patricia Vasquez,
connectedness. blood's clotting RN (Signature)
2. Be physically present and action. _____
available to help clients Clinical Instructor:
determine religious and Cheska Salvador
 ● The patient was (Signature) _____
spiritual choices. Studies taught to design a Student Nurse:
show that a client's faith and diet high in vitamin Cheska B. Vasquez
trust in nurses produces a K to promote (Signature)
positive effect on client and proper blood Endorsed Patient
family. spiritual care clotting. (Signature) _____
interventions promote a sense
of well-being.
Date and Time:
▪ Interdependent ● The patient was 09/02/2020
✔ Pharmacological advised to evade 3:00 p.m. to 11: 00
therapeutics coughing, sneezing, pm
1. Start intravenous therapy lifting, straining
as prescribed. during defecation, F: Fluid Volume
Electrolytes may need to or vomiting to rest Deficit related to
be replaced the GI and avoid blood volume loss
intravenously. recurrent bleeding. secondary to GI
Encourage oral fluid bleeding as
intake of at least 2000 evidenced by
mL per day if not hematemesis,
contraindicated. To hematochezia, and
replenish the fluids and lightheadedness.
electrolytes lost from
vomiting or other gastric D: (3:00 p.m.)
losses, and to promote Received patient on
better blood circulation semi-fowlers, awake
around the body. and responsive.
(signature)
2. Administer blood
transfusion as prescribed. A: (3:00 p.m.)
To increase the Referred patient to
hemoglobin level and dietician for
treat anemia and nutritional support.
hypovolemia related to (signature)
GI bleeding. > (6:00 p.m.)
Administered
3. Insert NGT as indicated Ranitidine (Zantac)
 by the physician. It is an 150 mg orally and
avenue for removing Tums 500 mg orally
gastric secretions, blood, as ordered.
andclots; reduces (Signature).
vomiting and facilitates
endoscopy, if applied. > (9:00 p.m.)
Monitored patient’s
4. Perform gastric lavage response to
with cold saline solution medication and
until the aspirate is assessed vital signs.
pinkish in color or if it is (Signature).
clear. It prevents further > (11:00 p.m.)
bleeding by local placed the patient on
vasoconstriction. NPO as ordered.
(Signature).
5. Administer medications
like H2 receptors R: Patient reported
antagonists, antiulcer decreased pain as
agents, antacids, Vitamin evidenced by pain
K, antiemetic, and anti scale of 6/10.
infective. These Patient appears
medications are essential rested and with little
in treating clients with abdominal guarding.
acute GI hemorrhage;
they have their own Nurse on duty:
specific actions Patricia Vasquez,
regarding this condition. RN (Signature)
_____
✔ Complementary and
Clinical Instructor:
alternative therapies
Cheska Salvador
1. Acupuncture:
(Signature) _____
Acupuncture helps to
reestablish energy Student Nurse:
balance and proper blood Cheska B. Vasquez
flow in the (Signature)
gastrointestinal system.
The needles help Endorsed Patient
 stimulate gastrointestinal (Signature) _____
muscle contraction that
regulates the production
of gastric acid and allow Date and Time:
the stomach and spleen to 09/03/2020
lessen the stress and
pressure in the 11:00 p.m. to 7: 00
gastrointestinal system to a.m.
help relax and relieve
other digestive F: Fluid Volume
symptoms. Deficit related to
blood volume loss
2. Herbal Therapy: secondary to GI
Rhubarb contains several bleeding as
chemicals which might evidenced by
help improve movement hematemesis,
of the intestines. Some hematochezia, and
chemicals in rhubarb lightheadedness.
might reduce swelling. In
D: (11:00 p.m.)
some people with
Received patient
bleeding in the stomach
lying on bed, asleep
or intestines, a tube
and with no visible
covered in a drug called
discomfort.
norepinephrine is placed
(signature)
down the throat to stop
the bleeding. Using a A: (3: 00 a.m.)
tube covered in rhubarb Assessed patient
powder seems to work vital signs and
better than monitored response
norepinephrine. to medication and
transfusion.
✔ Nutritional and diet (signature).
therapy
1. Anticipate the use of > (6:00 a.m.)
parenteral nutrition if the Performed Gastric
patient is to remain on lavage with cold
nothing-by-mouth status saline solution as
 for several days or weeks. ordered by the
Assess abdomen for physician.
bowel sounds. Expect to (Signature).
resume enteral or oral
feedings after the > (7:00 a.m.)
patient’s bowel function Monitored patient’s
has returned and there’s response to
no further evidence of procedure and
bleeding documented vital
signs.
2. Resume intake with clear/ R: (8:00 a.m.)
bland fluids or as Patients reported
indicated by the decreased passage
physician; avoid giving of blood tinged stool
dark colored foods. and vomitus,
Foods easily digested decreased
reduce the risk for added lightheadedness and
irritation; to take note of the patient appears
possible rebleeding. rested, calm and
with less abdominal
guarding. Pain scale
✔ Surgical intervention rated at 5/10.
1. Prepare the patient for (signature).
endoscopic repair or
surgery. Emergency Nurse on duty:
surgery typically entails Patricia Vasquez,
oversewing the bleeding RN (Signature)
vessel in the stomach or _____
duodenum (usually
preoperatively identified Clinical Instructor:
by endoscopy). Cheska Salvador
(Signature) _____
2. Electrocoagulation or
Student Nurse:
injection of a sclerolant
Cheska B. Vasquez
or epinephrine by way of
(Signature)
endoscopy may be the
treatment of choice to Endorsed Patient
 stop the site from (Signature) _____
bleeding. Instilling
topical thrombin to clot
blood at the bleeding site
may also be done.

3. Resection and
anastomosis may be
necessary to treat some
causes of bleeding.

✔ Immunologic therapy

● none

References:

● Acupuncture and Gastrointestinal Conditions. (2021, May 5). Artemedica Miami Center for Acupuncture & Oriental Medicine.

https://www.changeyourhealth.com/acupuncture-and-gastrointestinal-conditions/

● Gastrointestinal GI Bleed Nursing Diagnosis Interventions and Care Plans. (2020, October 3). NurseStudy.net. https://nursestudy.net/gi-

bleed-care-plan-nclex-review/

● R.N, M. S. (n.d.). Acute Gastrointestinal Hemorrhage Nursing Care Plan: GI Bleed. Rnspeak.com. Retrieved September 2, 2021, from

https://rnspeak.com/acute-gastrointestinal-hemorrhage-nursing-care-plan/

● Rhubarb: Uses, Side Effects, Interactions, Dosage, and Warning. (2019). Webmd.com. https://www.webmd.com/vitamins/ai/ingredientmono-

214/rhubarb
● Tillisch, K. (2006). Complementary and alternative medicine for functional gastrointestinal disorders. Gut, 55(5), 593–596.

https://doi.org/10.1136/gut.2005.078089

● Upper Gastrointestinal Bleeding (UGIB) Treatment & Management: Approach Considerations, Proton-Pump Inhibitors, Therapeutic

Endoscopy. (2020). EMedicine. https://emedicine.medscape.com/article/187857-treatment#d1

● What is the role of surgery in the treatment of upper GI bleeding (UGIB)? (n.d.). Www.medscape.com. Retrieved September 2, 2021, from

https://www.medscape.com/answers/187857-193402/what-is-the-role-of-surgery-in-the-treatment-of-upper-gi-bleeding-ugib

● Upper Gastrointestinal Bleeding (UGIB): Practice Essentials, Background, Etiology. (2021). EMedicine.

https://emedicine.medscape.com/article/187857-overview

● What is the prognosis of lower gastrointestinal (GI) bleeding? (n.d.). Www.medscape.com. Retrieved September 3, 2021, from

https://www.medscape.com/answers/188478-36717/what-is-the-prognosis-of-lower-gastrointestinal-gi-bleeding