Lesson Objective for Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed

Gastrointestinal (GI) bleeding is like a plumbing problem in the body’s digestive system. Imagine the GI tract as a series of pipes (esophagus, stomach, small and large intestines, ending at the rectum) that food travels through. GI bleeding happens when there’s a leak in these pipes, causing blood to escape into the digestive system. This can be due to various reasons, such as a tear, inflammation, or ulcers, much like how pipes can get damaged or corroded.

Upon completion of this care plan, nursing students will be able to:

• Recognize and prioritize signs and symptoms indicative of gastrointestinal bleeding, employing effective clinical assessment skills.
• Perform a comprehensive nursing assessment, including a detailed patient history, physical examination, and monitoring of vital signs, to identify the underlying cause and severity of the GI bleed.
• Differentiate between upper and lower GI bleeds, understanding the unique clinical presentations and potential causes associated with each.
• Collaborate with the healthcare team in the timely implementation of diagnostic tests, such as endoscopy or imaging studies, to identify the source and extent of the bleeding.
• Develop and implement individualized nursing interventions aimed at stabilizing the patient, controlling bleeding, and preventing complications.
• Provide patient and family education regarding the nature of GI bleeding, treatment modalities, and strategies for preventing recurrence.
• Evaluate the effectiveness of interventions through ongoing assessment, monitoring of laboratory values, and responsiveness to treatment.

Pathophysiology for Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed

Gastrointestinal (GI) bleeding, also known as gastrointestinal hemorrhage, refers to the loss of blood from the digestive tract, which includes the esophagus, stomach, small intestine, and large intestine. The pathophysiology of GI bleeding can vary based on the location and underlying cause. Here’s a general overview:

• Upper GI Bleeding:
  • Location: Originating proximal to the ligament of Treitz, including the esophagus, stomach, and duodenum.
  • Common Causes:
    • Peptic ulcers: Erosions or breaks in the lining of the stomach or duodenum.
    • Gastritis: Inflammation of the stomach lining.
    • Esophageal varices: Dilated blood vessels in the esophagus are often associated with liver cirrhosis.
    • Mallory-Weiss tears: Tears in the mucosal lining of the lower esophagus due to severe vomiting.
  • Pathophysiology: Bleeding can occur from ulcerations, erosions, or rupture of varices, leading to the release of blood into the GI tract.
• Lower GI Bleeding:
  • Location: Originating distal to the ligament of Treitz, including the small intestine, colon, and rectum.
  • Common Causes:
    • Diverticulosis: Small pouches (diverticula) in the walls of the colon that can bleed.
    • Colonic polyps: Abnormal growths in the colon that may bleed.
    • Inflammatory bowel disease (IBD): Conditions like Crohn’s disease or ulcerative colitis.
    • Colorectal cancer: Malignancies in the colon or rectum.
  • Pathophysiology: Bleeding may result from inflammation, ulceration, or tumor-related vascular disruption in the lower GI tract.
• Clinical Manifestations:
  • Upper GI Bleeding:
    • Hematemesis (vomiting of blood) or coffee-ground emesis.
    • Melena (black, tarry stools) due to digestion of blood in the stomach.
    • Hematochezia (bright red or maroon-colored stools) in severe cases.
  • Lower GI Bleeding:
    • Hematochezia is more common, indicating fresh blood in the stool.
    • Abdominal pain, cramping, or discomfort.
    • Signs of anemia, such as fatigue and pallor.
• Complications:
  • Hypovolemic Shock: Rapid and significant blood loss can lead to decreased blood volume and shock.
  • Anemia: Chronic or recurrent bleeding may result in iron-deficiency anemia.
  • Perforation: In severe cases, ulcerations or erosions can lead to perforation of the GI wall.
• Diagnostic Evaluations:
  • Upper GI Bleeding: Esophagogastroduodenoscopy (EGD), angiography, or capsule endoscopy.
  • Lower GI Bleeding: Colonoscopy, sigmoidoscopy, or radionuclide imaging.

Etiology for Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed

Upper GI Bleeding:

• Peptic Ulcers:
  • Erosions or breaks in the lining of the stomach or duodenum, are often caused by Helicobacter pylori infection, nonsteroidal anti-inflammatory drugs (NSAIDs), or stress-related mucosal damage.
• Gastritis:
  • Inflammation of the stomach lining, frequently triggered by infection (H. pylori), alcohol abuse, or long-term use of NSAIDs.
• Esophageal Varices:
  • Dilated blood vessels in the esophagus, are usually associated with liver cirrhosis, leading to increased pressure in the portal vein.
• Mallory-Weiss Tears:
  • Tears in the mucosal lining of the lower esophagus, are often caused by severe vomiting or retching.
• Esophagitis:
  • Inflammation of the esophagus can result from acid reflux (gastroesophageal reflux disease or GERD) or infections.
• Arteriovenous Malformations (AVMs):
  • Abnormal connections between arteries and veins in the GI tract may be congenital or acquired.

Lower GI Bleeding:

• Diverticulosis:
  • Presence of small pouches (diverticula) in the walls of the colon, which can bleed when inflamed or injured.
• Colonic Polyps:
  • Abnormal growths in the colon, particularly adenomatous polyps, may bleed and, if left untreated, can lead to colorectal cancer.
• Inflammatory Bowel Disease (IBD):
  • Conditions such as Crohn’s disease or ulcerative colitis can cause inflammation, ulceration, and bleeding in the colon.
• Colorectal Cancer:
  • Malignancies in the colon or rectum can cause bleeding, especially in advanced stages.
• Angiodysplasia:
  • Abnormalities in the blood vessels of the colon, which may result in bleeding.
• Ischemic Colitis:
  • Reduced blood flow to the colon, is often associated with conditions like atherosclerosis or thromboembolism.
• Anal Fissures:
  • Tears or cracks in the lining of the anus, are typically caused by trauma during bowel movements or underlying conditions.
• Hemorrhoids:
  • Swollen and inflamed blood vessels in the rectum and anus, which can cause bleeding, especially during bowel movements.
• Meckel’s Diverticulum:
  • A congenital pouch in the small intestine may contain gastric tissue and can be a source of bleeding.
• Infectious Colitis:
  • Infections in the colon, such as bacterial or parasitic infections, can lead to inflammation and bleeding.

General Factors:

• Coagulopathies:
  • Disorders affecting blood clotting, such as hemophilia or liver disease, can contribute to bleeding.
• Anticoagulant Medications:
  • The use of anticoagulants (blood-thinning medications) increases the risk of bleeding.
• Thrombocytopenia:
  • Low platelet count, either due to conditions like immune thrombocytopenia or medication-induced.
• Trauma:
  • Physical injury or trauma to the GI tract, which may result from accidents or medical procedures.

Desired Outcome for Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed

• Identification and Resolution of Underlying Cause:
  • Short-Term Goal: Prompt identification of the cause of GI bleeding through diagnostic assessments.
• Stabilization of Vital Signs:
  • Short-Term Goal: Maintenance of stable vital signs, including blood pressure, heart rate, and respiratory rate.
• Control of Acute Bleeding:
  • Short-Term Goal: Successful control of acute bleeding episodes.
• Prevention of Hemodynamic Compromise:
  • Short-Term Goal: Prevention of hypovolemic shock and hemodynamic compromise.
• Correction of Coagulopathies:
  • Short-Term Goal: Correction of any coagulopathies contributing to bleeding.
• Normalization of Hemoglobin Levels:
  • Intermediate-Term Goal: Restoration of normal hemoglobin levels and correction of anemia.
• Prevention of Recurrent Bleeding:
  • Intermediate-Term Goal: Implementation of strategies to prevent recurrent episodes of GI bleeding.

GI Bleed Nursing Care Plan

Nursing Assessment for Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed

• Patient History:

• • Obtain a detailed medical history, including any previous episodes of GI bleeding, chronic medical conditions, and current medications.
  • Ask patient about anti-coagulant, aspirin and NSAID use.
  • Inquire about family history of GI disorders or bleeding disorders.
  • Explore the onset and duration of the current episode of GI bleeding.

• Current Symptoms:

• • Document the patient’s symptoms, including the presence of hematemesis (vomiting of blood), melena (black, tarry stools), hematochezia (bright red or maroon-colored stools), and abdominal pain or discomfort.
  • Assess the quantity and frequency of bleeding episodes.

• Vital Signs:

• • Monitor vital signs, including blood pressure, heart rate, respiratory rate, and temperature.
  • Assess for signs of hypovolemia, such as orthostatic changes or tachycardia.

• Physical Examination:

• • Conduct a comprehensive physical examination, focusing on the abdomen, to assess for tenderness, distension, or masses.
  • Evaluate the patient’s skin color and mucous membranes for signs of pallor or jaundice.
  • Inspect the perianal area for external signs of bleeding.

• Assessment of Fluid Balance:

• • Evaluate fluid balance by assessing skin turgor, mucous membrane moisture, and urine output.
  • Monitor for signs of dehydration, such as dry mucous membranes or decreased urine output.

• Laboratory Investigations:

• • Review laboratory results, including complete blood count (CBC) to assess for anemia and coagulation studies (PT, INR, and aPTT) to identify potential coagulopathies.
  • Monitor liver function tests and assess for evidence of hepatic dysfunction if liver disease is suspected.

• Pain Assessment:

• • Evaluate the presence and characteristics of abdominal pain or discomfort.
  • Utilize a pain scale to assess the intensity of pain and its impact on the patient’s overall well-being.

• Assessment of Bleeding Severity:

• • Assess the severity of bleeding based on the quantity and color of blood in vomitus and stool.
  • Monitor for signs of shock, such as hypotension, tachycardia, and altered mental status.

• Diagnostic Tests:

• • Collaborate with healthcare providers to facilitate diagnostic tests, such as upper endoscopy, lower endoscopy, or imaging studies, to identify the source and extent of bleeding.

Nursing Interventions and Rationales for Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed

• Monitor Hemoglobin (HGB)

• HGB: Hemoglobin (Hbg), an iron-containing compound, is the main protein in Red Blood Cells (RBCs). It enables oxygen and carbon dioxide (CO2) to bind to RBCs for transport throughout the body.
• This is the most commonly looked-at lab value to assess the need for a blood transfusion. Every institution, Doctor, and person is different but as a general rule, a hemoglobin below 8 requires a blood transfusion.

• Monitor heart rate and blood pressure

• When the heart is low on fluids to fill it, it will start beating faster and your pressure gets lower. If the patient’s BP gets too low, they will start to shunt blood to their vital organs.
• If the patient becomes hypotensive, put them in reverse Trendelenburg, give them fluids, and get the physician.
• A patient’s heart can only beat fast for so long so monitor the heart rhythm while you work on getting the volume back into their cardiovascular system.

• Administer blood products

• This requires a blood match (Remember your ABO compatibility and Rh factor).
• When administering the blood, remember to have the blood product double-checked with another nurse. Vital signs every

• Administer pantoprazole (Protonix) 

• Give pantoprazole (Protonix), a proton pump inhibitor (PPI) that decreases the amount of acid in the GI lining. This reduces the ulceration which could be (and most likely is) causing the GI bleed.

• Potential surgical intervention to stop the bleeding
• If medications are not able to stop the bleeding, potential surgical intervention may be needed to stop the bleed. The nurse would prepare the patient for the procedure.

• 12 lead ECG
  Blood loss and hemodynamic changes can cause arrythmias, especially tachycardias.

• Assess for bleeding in stool GI bleed:

• The provider will place a gloved finger into the rectum and needs to have feces on it when it comes out. The feces is placed on a hemoccult card where a developing solution is married with the stool giving the provider insight of whether or not there is blood in the stool. If the card turns blue it is positive for blood.
• As a nurse, you will ask the patient if they have black/tarry stools (upper GI bleed) or bright red blood (lower GI bleed) in their stools.

• Fall precautions

• Control of Bleeding:
  • Expected Outcome: Resolution or significant reduction in the frequency and volume of GI bleeding.
  • Evaluation Criteria: Monitor ongoing bleeding through assessments of hematemesis, melena, or hematochezia. Review laboratory values for trends in hemoglobin and hematocrit levels
• Vital Signs Stability:
  • Expected Outcome: Maintenance of stable vital signs with no signs of hypovolemic shock.
  • Evaluation Criteria: Regularly assess blood pressure, heart rate, respiratory rate, and temperature. Evaluate for signs of orthostatic changes or tachycardia.
• Fluid and Electrolyte Balance:
  • Expected Outcome: Restoration of fluid and electrolyte balance.
  • Evaluation Criteria: Monitor urine output, assess skin turgor, and observe for signs of dehydration. Review laboratory values for electrolyte levels.
• Hemoglobin and Hematocrit Levels:
  • Expected Outcome: Improvement in hemoglobin levels and correction of anemia.
  • Evaluation Criteria: Compare current hemoglobin and hematocrit levels with baseline values. Adjust interventions as needed based on laboratory results.
• Coagulation Profile:
  • Expected Outcome: Correction of coagulopathies contributing to bleeding.
  • Evaluation Criteria: Review coagulation studies (PT, INR, aPTT) and adjust anticoagulant medications as prescribed. Monitor for signs of ongoing coagulopathy.
• Resolution of Underlying Cause:
  • Expected Outcome: Identification and resolution of the underlying cause of GI bleeding.
  • Evaluation Criteria: Collaborate with healthcare providers to interpret diagnostic test results and implement appropriate treatments. Ensure ongoing surveillance for recurrence.

References

• https://www.niddk.nih.gov/health-information/digestive-diseases/gastrointestinal-bleeding/symptoms-causes
• https://medlineplus.gov/gastrointestinalbleeding.html
• http://www.mayoclinic.org/diseases-conditions/gastrointestinal-bleeding/basics/definition/con-20035736