UGI Bleed

cdunbar4's version from 2016-10-21 01:22

Color, consistency, oriface

Question Answer
severity depends onwhether venous, capillary or arterial
most serious loss of blood is characterized bya sudden onset, insidious occult bleeding
Could be a result of: ulcer, cancer, gastritis...
A massive upper GI hemorrhage is a loss of >1500mL of blood or 25% of intravascular blood volume
The longer the passage of blood through the intestines, the _________ the stool color due to the breakdown of ______________ & the release of ______.darker; hemoglobin; iron
"Clinically important bleeding" is defined as:overt bleeding complicated by one of the following w/in 24hrs after onset of bleeding: spontaneous ↓ of sBP >20mmHg; ↑ 20bpm or ↓ in Hgb level of > 2g/dL
"occult bleeding" presence of guaiac-positive stools or nasogastric aspirates
hematemesis can look likecan be profuse and bright red or coffee-ground color
Arterial bleeds indicatesprofuse & bright red which indicates blood hasn't been in contact with stomach acid secretions
Coffee-ground emesis indicatescontact with gastric secretions and has been in stomach for awhile
Melana indicatesUpper GI source: blood has been in intestines for a long period of time

Origins and Causes

Question Answer
esophageal origin caused byvarices from ETOH; chronic esophagitis; bleeding from a tear in mucosa of esophagogastric junction
stomach and duodenal origins mostly caused bypeptic ulcers which can penetrate into arteries
Stress ulcers (physiologic)may occur after severe burn, trauma or major surgery; erodes more superficial blood vessels than a peptic ulcer
gastritisingestion of drugs or ETOH; reflux of bile from SI
Gastric carcinomasteady blood loss grows & ulcerates through mucosa & blood vessels;
hematemesis and melena are commonly associated withgastric carcinoma
Aspirin, NSAIDs and corticosteroids effect on stomachirritates and disrupts gastric mucosal barrier
Systemic diseases that interfere with normal blood clotting:leukemia, hemophilia or thrombocytopenia

ER mgmt

Question Answer
Mortality rate6-10%
Percentage of people who spontaneously stop bleeding80-85%
You are in the ER, priority?immediate physical exam that focuses on hemorrhagic shock and hypovolemia
Specific ER interventions, first?BP, rate & character of pulse, peripheral perfusion w cap refill
Specific ER interventions, second?VS Q15 to 30 minutes; s/s of shock evaluated & quick treatment as soon as possible
Specific ER interventions, third?abdominal exam and bowel sounds; COMPLETE hx of events leading to bleeding episode
Lab studies to be done after initial assessment in ERCBC, BUN, electrolytes, blood glucose, PTT, liver, enzymes, ABGs; type & cross-match for blood transfusions
other labwork to be done in ERvomitus, urine & stools tested for occult blood, UA for SG (hydration)
What type of IV fluid do you think would be used initially?Isotonic lactated Ringer's
Type of blood used to replace?whole blood, pack RBCs and fresh frozen plasma
Other nursing implementations in ERO2 delivery by nasal cannula or face mask; CVP line to monitor fluid volume status; Foley (indirect measure of CO)


Question Answer
Fiberoptic panendoscopythe test that accurately id's the bleeding source: gastroscopy or endoscopy
angiography*only when fiberoptics don't work: catheter placed in the left gastric or superior mesenteric artery and advanced until site of bleeding is discovered
Barium contrast studiesxrays
Endoscopic therapy (diagnostic & curative)thermal heat probe; electrocoagulation probe; laser
Surgical therapysite of hemorrhage decides the type of operation; most people who hemorrhage have a high percentage of a massive one in 5 years.

Drug Therapy

Question Answer
During acute phase, drugs are used to↓ bleeding, ↓ HCl secretion, and neutralize HCl acid that is present
Epinephrine is used during endoscopy and is effective foracute hemostasis; it produces tissue edema & ultimately, pressure on the source of bleeding.
PPI's and H2 receptor blockers-idines and -azoles to decrease or inhibit acid secretion
vasopressin is used for what type of UGI bleed?esophageal varices: causes vasoconstriction; ↓ pressure in the portal circulation and arrests bleeding
antacidsduodenal, gastric ulcers; acute gastritis; neutralizes acid and maintains gastric pH above 5.5, ↑pH inhibits activation of pepsinogen

Assessment and Health Promotion

Question Answer
Nursing assessmentLOC, VS, appearance of neck veins, skin color and temperature, cap refill, abdominal distention, guarding, peristalsis, ↑ thirst
Overall planhave no further GI bleed; have the cause of the bleed identified & treated; experience a return to a normal hemodynamic state, minimal or no sx of pain or anxiety
Patient with a history of chronic gastritis or peptic ulcer disease is at _____-______.high-risk
Patient who has had one major _______ _______ is likely to have anotherbleeding episode
Patient must be instructed to avoid _____________ _________irritating foods
Patient must be instructed to prevent or ↓ _____-inducing situations and take only prescribed meds.stress
Patient should be instructed on how to test for ______ ________ in stools or ______.occult blood; vomit
If patient absolutely can't avoid ulcerogenic drugs, what is the next best option?enteric-coated tablets or use of an antacid along with prescribed med

Acute Nursing Intervention

Question Answer
I/O: UO should be at least how many ml/kg/hr to indicate adequate renal perfusion?0.5ml/kg/hr
Urine specific gravity measured, why?hydration
Initially HCT levels will appear falsely high or low
BUN level is generally elevated or decreased (why)?elevated; since blood proteins are subjected to bacterial breakdown in GI tract
Nutrition-oralonce oral starts, watch for n/v and blood
Nutrition-what do feedings initially consist of clear fluids or milk; given hourly until tolerance is determined
Nutrition-if no signs of discomfort with clear liquids and milk....bland foods can be introduced
Antacids-BOLOpreparations containing calcium or aluminum may result in constipation wheras those with magnesuim cause diarrhea
DT'sdelirium tremors: patient in whom hemorrhage was the result of chronic alcohol abuse requires close observation d/t w/drawal

Other UGI topics

Question Answer
Food poisoningnon-specific term: n/v, diarrhea, abd cramping; bacteria (raw foods); teach prevention; usually just let it run it's course
Esophageal diverticulasaclike outpouchings of 1 or more layers of esophagus: no specific tx, limit diet
esophageal stricturesmost commonly caused by GERD
achalasiaperistalsis of lower 2/3 of esophagus is absent which causes obstruction of esophagus near diaphragm, food and fluid accumulates in lower esophagus
esophageal varicesdilated veins occurring in lower portion of esophagus as a result of portal hypertension: common complication of liver cirrhosis

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