GI bleed Nursing Diagnosis & Care Plan


The words gastrointestinal bleeding surrounded by healthcare-related vector images

Contents: 

Gastrointestinal bleeding can be a symptom of many disorders of the GI tract. Bleeding can often arise from the upper GI tract or the lower part of the GI tract. Since many variables are considered, a systematic approach is necessary to make an accurate diagnosis and promote appropriate treatment. 

Causes: 

Bleeding can be the symptom of many gastric conditions originating from the upper GI or lower GI tract. 

Upper GI conditions: These conditions usually comprise conditions from the mouth to the duodenum. 

  • Esophagitis: inflammation of the esophagus 
  • Gastritis: inflammation of the stomach lining 
  • Peptic ulcer disease: mucosal lesion of the stomach not protected from stomach acid 
  • Barrett’s esophagus: change in cells lining the esophagus due to constant irritation (i.e., GERD) 
  • Esophageal varices: Dilated veins of the esophagus that are at risk for rupturing; results from portal hypertension 
  • Mallory-Weiss Syndrome: tearing of the esophagus due to straining 
  • Erosion/ Erosive gastritis 
  • Tumors/ Cancer 

Lower GI conditions: Conditions from the distal small intestine and the entire large intestine.

  • Diverticulosis: outpouching of the colon wall 
  • Vascular ectasia: weak stomach vessels prone to rupture 
  • Ischemic colitis: reduced blood flow to parts of the intestine
  • Infectious colitis: inflammation 
  • Inflammatory bowel disease (IBS): inflammation 
  • Hemorrhoid: swollen veins in the lower rectum 
  • Aortoenteric fistula (AEF): a connection between aorta and intestine 

Signs and Symptoms 

  • Black and tarry stools
  • Hematochezia (maroon blood with stool) 
  • Melena (bloody stool) 
  • Hematemesis (bloody vomit)  
  • Vomit with a coffee ground appearance 
  • Abdominal pain 
  • Lightheadedness 
  • Shortness of breath 
  • Weakness 
  • Orthostatic blood pressure/ postural hypotension
  • Signs of blood loss/shock
    • Hypotension
    • Tachycardia 
    • Low urine output 
    • Fainting/unconsciousness 

Diagnosis: 

  • Upper endoscopy – insertion of a scope with a camera attached down the esophagus to visualize abnormalities that could cause bleeding 
  • Colonoscopy – insertion of a scope into the large intestine to visualize abnormalities 
  • CT angiography – detection of a slow rate of GI bleed 
  • Standard angiography – insertion of a catheter through the groin to visualize the lumen of vessels and organs of the body
  • Laboratory studies 

Treatment: 

  • Fluid resuscitation 
  • Blood transfusion 
  • Procedures 
    • Endoscopy 
    • Barium studies 
    • Angiography 

Nursing Diagnosis for GI bleed 

Deficient Fluid Volume r/t blood loss secondary to gastrointestinal bleed 

Fatigue r/t decreased ability to transport oxygen secondary to low blood volume 

Deficient Knowledge r/t first time of gastrointestinal bleeding 

Acute Pain r/t compromised stomach lining secondary to gastrointestinal pathology

Nursing Care Plans for GI bleed 

Deficient Fluid Volume r/t blood loss secondary to gastrointestinal bleed 

Expected Outcome: The patient will maintain adequate fluid volume as evidenced by stable hemoglobin and hematocrit, stable blood pressure, absence of orthostasis, and intact skin turgor and mucous membranes. 

Assess the characteristics of hematemesis, melena, or rectal bleeding.  Note 

Color 
Amount 
Consistency

This information may help determine the origin and site of the bleeding. For example, the source of the bleeding may originate from the upper GI or lower GI regions. 

Consider essential risk factors when obtaining a health history. 

Past medical history
Patients may have had GI conditions such as a previous GI bleed, gastric ulcers, H. pylori, diverticulitis, hemorrhoids, or IBS. 

Medications
Medicines such as NSAIDs, steroids, platelet inhibitors, and anticoagulants could increase the risk of developing a GI bleed. In addition, iron supplements may change the stool color into a dark tint and obscure the clinical picture. 

Social history
Heavy alcohol use and smoking are risk factors for GI bleed. Excessive and chronic alcohol use may contribute to compromised GI mucosa and liver damage, increasing bleeding risk. In addition, smoking may cause peptic ulcers and severely slows the healing process of these ulcers.

Comorbidities 
Conditions such as renal disease, cancer, and cirrhosis are considered risk factors for GI bleed. 

Detailed assessment and documentation may help identify the cause of the development of a GI bleed. In addition,  the history and physical may give more clues to narrow down the etiology of gastrointestinal bleeding. For example, a history of liver disease may increase the risk for bleeding due to portal hypertension and varices. 

Ask about recent gastrointestinal procedures. 

Recent procedures such as colonoscopy, abdominal or pelvic radiation, or surgery may cause GI bleeding. 

Monitor vital signs frequently. Note the presence of orthostasis. 

GI bleed can cause symptoms of low blood pressure or orthostatic blood pressure due to low blood volume. This may cause tachycardia as a compensatory mechanism to maintain an adequate cardiac output. Orthostatic hypotension can occur with low blood pressure. It happens when gravity draws blood into the legs with position changes from supine to sitting or standing. A 20mmHg point drop in systolic pressure and a 10mmHg drop in diastolic pressure is considered positive orthostasis.

Assess the patient’s fluid status.

The patient may appear dehydrated with dry mucous membranes, sunken eyes, decreased skin turgor, and significant weight loss. These findings might be due to low blood volume and the inability of fluid and food intake from gastric irritation. 

Monitor the patient’s urine output. 

Adequate urine output (at least 30ml per hour) indicates sufficient renal perfusion. 

Obtain laboratory studies. 

CBC 
Decreased hemoglobin and hematocrit, and platelet count may indicate blood loss. 

BMP 
BMP is helpful to monitor for azotemia and a BUN to creatinine ratio. A BUN to creatinine ratio higher than 30:1 correlates with an upper GI bleed.

Liver Panel (LFTs)
This reveals any liver dysfunction which may be the cause of bleeding. 

Coagulation factors (INR, PT, PTT) 
Coagulopathy may make it more challenging to stop instances of bleeding.

Watching a trend of these studies helps identify the worsening of an individual’s condition and whether treatment is effective. 

Administer vascular volume resuscitation with either isotonic crystalloid solutions or blood products as ordered. 

Volume repletion will help treat hypovolemia and therefore help stabilize low blood pressure and postural hypotension. 

Anticipate the use of a vasopressin drip as ordered. 

Vasopressin can be used to treat upper GI bleeding. The drug causes vasoconstriction and therefore reduces mesenteric blood flow, decreasing bleeding. 

Fatigue r/t decreased ability to transport oxygen secondary to deficient blood volume 

Expected Outcome: The patient will demonstrate reduced fatigue as evidenced by a stable hematocrit and hemoglobin as well as the decreased need for daily activities and verbalization of increased energy levels.

Monitor the patient’s vital signs. 

Individuals with low blood volume may present with low blood pressure or even orthostasis, an increased heart rate due to decreased vascular volume, and shortness of breath due to oxygen depletion. Because hemoglobin aids in oxygen transport, oxygen delivery to the body tissues may be compromised if hemoglobin levels are low.

Assess the patient’s energy level and ability to care for self. 

Baseline assessment serves as a starting point for treatment. If support requirements increase tremendously during the hospital stay, the patient’s condition may be worsening or become more critical.

Anticipate standing orders by the physician for fluid and blood transfusions. 

Standing orders entail tasks to complete if specific threshold values are not met or reached. For example, the physician may place a standing order to transfuse one unit of blood if the hemoglobin level falls beneath a certain number. This concept accelerates treatment and helps avoid unnecessary delays in care. 

Deficient Knowledge r/t first time of gastrointestinal bleeding 

Expected Outcome: The patient will verbalize an improved understanding of gastrointestinal pathology and treatment methods. 

Assess the patient’s current knowledge about the cause and treatment for GI bleeding. 

This information can be used to devise a teaching plan. Getting the patient’s understanding allows for adjustments in the teaching plan so misinformation can be addressed and lacking information added. 

Educate about the effects of smoking, alcohol use, use of steroids, and NSAIDs. 

These substances are known to damage the stomach lining and may increase the risk of bleeding. 

Teach about the importance of maintaining the prescribed medication regimen. 

Treatment often extends well beyond the hospital stay. Sometimes the individual has to take medications for the rest of his or her life, even after procedures and treatment.
Offer resource information about smoking cessation and alcohol rehabilitation if indicated. 

Stopping these social habits may avoid further complications and cause fewer incidences of bleeding. 

Acute Pain r/t compromised stomach lining secondary to gastrointestinal pathology

Expected Outcome: The patient reports a satisfactory pain level of less than 3 on a scale from 0 to 10, as evidenced by increased comfort, such as reduced reporting of gastrointestinal discomfort. 

Assess the patient’s characteristics of pain. 

Precipitating or palliative 
Quality and quantity 
Region and radiation 
Severity Timing 

Detailed information about pain may help narrow down a more specific clinical picture about a particular GI pathology and assist with diagnosis and treatment. 

Perform an abdominal assessment. 

A comprehensive abdominal assessment is performed by examining all four quadrants beginning with the right upper quadrant and then systematically examining the remaining quadrants. The region that the individual reports pain in is examined last. All areas should undergo the four assessment techniques in the following order: inspection, auscultation, percussion, and palpation. Percussion is often only performed by advanced practice nurses.

Administer medication as ordered. 

Proton pump inhibitors (PPI) 
Proton pump inhibitors reduce the amount of acid secretion in the stomach and therefore slow down the bleeding. 

Reversal agents for anticoagulants 
Vitamin K and protamine are examples of antidotes to various anticoagulants. Not all anticoagulants have reversal agents, however. 

IV pain medication
PO pain medication may irritate the GI tract.

Pharmacological treatment comprises reduction of stomach acid secretion, management of bleeding, and pain control.

Teach non-pharmacological techniques to control pain. 

Techniques such as guided imagery, distraction, or heat and cold application may help alleviate pain.

Anticipate that the patient may be held NPO (nothing by mouth). 

NPO status promotes resting the gut and facilitates healing. 

Prepare the patient for procedures if indicated and ordered. 

Endoscopy
This procedure allows visualization of the digestive tract. 

Colonoscopy
This procedure provides visualization of the lower GI tract and allows for intervention if necessary. 

Barium swallow study 
This test may also be called a gastrointestinal series and uses x-ray imaging to visualize the upper GI tract. 

Barium enema 
This procedure allows the visualization of x-ray images of the colon.

Angiography 
This procedure allows for diagnosis and intervention. However, the bleeding rate has to exceed 0.5mL per minute to make a diagnosis. 

Often invasive procedures are necessary for diagnosis and treatment.

More Care Plans

Gastritis Nursing Diagnosis & Care Plan

Vomiting Nursing Diagnosis & Care Plan

Nausea Nursing Diagnosis & Care Plan

Acute Pain Care Plan

Deficient Fluid Volume Care Plan

Fatigue Care Plan

Risk for Bleeding Care Plan

References:

Topics, H., 2021. GI Bleed | Gastrointestinal Bleeding: MedlinePlus. [online] Medlineplus.gov. Available at: <https://medlineplus.gov/gastrointestinalbleeding.html> 

Ignatavicius, D., & Workman, M. (2016). Medical-surgical nursing (8th ed.). Elsevier.

Deglin, J., Vallerand, A. and Sanoski, C., 2014. Davis’s Drug Guide for Nurses (14th ed.). 14th ed. FA Davis Company.

Ghassemi, K. A., & Jensen, D. M. (2013). Lower GI bleeding: epidemiology and management. Current gastroenterology reports, 15(7), 333. https://doi.org/10.1007/s11894-013-0333-5

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