Bleeding duodenal ulcer is the most frequent cause of massive upper gastrointestinal (GI) hemorrhage, but bleeding may also occur because of gastric ulcers, gastritis, and esophageal varices. Severe vomiting can precipitate gastric bleeding as a result of a tear in the mucosa at the gastroesophageal junction (Mallory-Weiss syndrome). Stress ulcers are often associated with severe burns, major trauma/surgery, or severe systemic disease. Esophagitis, esophageal/gastric carcinoma, hiatal hernia, hemophilia, leukemia, and disseminated intravascular coagulation (DIC) are less common causes of upper GI bleeding. Note: Eighty percent to 90% of ulcer patients are now found to have Helicobactor pylori as an underlying cause. Because this organism is easily treated with anti-infectives, complications such as perforation and GI bleeding have dropped dramatically.
CARE SETTING
Generally, a patient with severe, active bleeding is admitted directly to the critical care unit (CCU); however, a patient may develop GI bleeding on the medical-surgical unit or be admitted there for evaluation/treatment of subacute bleeding.
RELATED CONCERNS
Cirrhosis of the liver
Fluid and electrolyte imbalances, see Nursing Care Plan CD-ROM
Psychosocial aspects of care
Renal failure: acute
Subtotal gastrectomy/gastric resection, see Nursing Care Plan CD-ROM
Patient Assessment Database
ACTIVITY/REST
May report: Weakness, fatigue
May exhibit: Tachycardia, tachypnea/hyperventilation (response to activity)
CIRCULATION
May report: Palpitations
Dizziness with position change
May exhibit: Hypotension (including postural)
Tachycardia, dysrhythmias (hypovolemia/hypoxemia)
Weak/thready peripheral pulse
Capillary refill slow/delayed (vasoconstriction)
Skin color: pallor, cyanosis (depending on the amount of blood loss)
Skin/mucous membrane moisture: Diaphoresis (reflecting shock state, acute pain, psychological response)
EGO INTEGRITY
May report: Acute or chronic stress factors (financial, relationships, job-related)
Feelings of helplessness
May exhibit: Signs of anxiety, e.g., restlessness, pallor, diaphoresis, narrowed focus, trembling,
quivering voice
ELIMINATION
May report: Change in usual bowel patterns/characteristics of stool
May exhibit: Abdominal tenderness, distension
Bowel sounds often hyperactive during bleeding, hypoactive after bleeding subsides
Character of stool: Diarrhea; dark bloody, tarry, or occasionally bright red stools; frothy, foul-smelling (steatorrhea); constipation may occur (changes in diet, antacid use)
Urine output may be decreased, concentrated
FOOD/FLUID
May report: Anorexia, nausea, vomiting (protracted vomiting suggests pyloric outlet obstruction
associated with duodenal ulcer)
Problems with swallowing; belching, hiccups
Heartburn, indigestion, burping with sour taste
Bloating/distension, flatulence
Food intolerances, e.g., spicy food, chocolate; special diet for preexisting ulcer disease
Weight loss
May exhibit: Vomitus: coffee-ground or bright red, with or without clots
Mucous membranes dry, decreased mucus production, poor skin turgor (chronic bleeding)
Urine specific gravity may be elevated
NEUROSENSORY
May report: Fainting, dizziness/lightheadedness, weakness
Mental status: Level of consciousness (LOC) may be altered, ranging from slight
drowsiness, disorientation/confusion, to stupor and coma (depending on
circulating volume/oxygenation)
PAIN/DISCOMFORT
May report: Pain described as sharp, dull, burning, gnawing; sudden, excruciating (can accompany perforation)
Vague sensation of discomfort/distress following large meals and relieved by food (acute
gastritis)
Left to midepigastric pain and/or pain radiating to back, often accompanied by vomiting
after eating and relieved by antacids (gastric ulcer)
Localized right to midepigastric pain, gnawing, burning, occurring about 2–3 hr after
meals when stomach is empty, and relieved by food or antacids (duodenal
ulcers)
Midepigastric pain and burning with regurgitation (chronic gastroesophageal reflux disease
[GERD])
Absence of pain (esophageal varices or gastritis)
Precipitating factors may be foods (e.g., milk, chocolate, caffeine), smoking, alcohol, certain drugs (salicylates, reserpine, antibiotics, ibuprofen), psychological stressors
May exhibit: Facial grimacing, guarding of affected area, pallor, diaphoresis, narrowed focus
SAFETY
May report: Drug allergies/sensitivities, e.g., acetylsalicylic acid (ASA)
May exhibit: Temperature elevation
Spider angiomas, palmar erythema (reflecting cirrhosis/portal hypertension)
TEACHING/LEARNING
May report: Recent use of prescription/over-the-counter (OTC) drugs containing ASA,
alcohol/recreational drugs, steroids, or nonsteroidal anti-inflammatory drugs (NSAIDs) (leading cause of drug-induced GI bleeding)
Current complaint may reveal admission for related (e.g., anemia) or unrelated (e.g., head
trauma) diagnosis, intestinal flu, or severe vomiting episode; long-standing health problems, e.g., cirrhosis, alcoholism, hepatitis, eating disorders
History of previous hospitalizations for GI bleeding or related GI problems, e.g.,
peptic/gastric ulcer, gastritis, gastric surgery, irradiation of gastric area
Discharge plan
DRG projected mean length of inpatient stay: 5.3 days
May require changes in therapeutic/medication regimen.
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Esophagogastroduodenoscopy (EGD): Key diagnostic test for upper and lower GI bleeding, done to visualize site of bleeding/ degree of tissue ulceration/injury.
Gastrointestinal nuclear scan: Radionuclide uptake at sites of bleeding identifies site (not cause) of bleeding. Test is considered to be more sensitive than EGD, upper GI studies with barium, or angiography in detecting sites of lower GI bleeding or persistent bleeding anywhere in GI tract.
Helicobacter pylori breath test: Patient drinks a carbon-enriched urea solution. If H. pylori is present, it breaks down the compound and releases CO2. H. pylori can also be detected by blood or tissue tests with blood test now being the most common.
Barium swallow with x-ray: Done after bleeding has ceased for differential diagnosis of cause/site of lesion, presence of structural defects such as strictures.
Gastric aspirate analysis: May be done in suspected peptic ulcer disease as indicated by low to normal pH and/or presence of blood; also in suspected gastric cancer (abnormal acidity, blood and/or abnormal cells on cytological examination).
Gastric cultures: Determine presence of H. pylori (Gram-negative urease-producing bacteria), currently accepted as organism responsible for 90% of duodenal and 70%–80% of gastric ulcers.
Angiography: GI vasculature may be reviewed if endoscopy is inconclusive or impractical. Demonstrates collateral circulation and possibly bleeding site.
Stools: Testing for blood will be positive.
Complete blood count (CBC), hemoglobin (Hb)/hematocrit (Hct): Decreased levels occur 6–24 hr after acute bleeding begins. Red blood cells (RBCs) and platelets may also be decreased. White blood cell (WBC) count may be elevated, reflecting body’s response to injury.
Prothrombin time (PT) and activated partial thromboplastin time (aPTT); coagulation profile: Prolonged in active bleeding. May indicate need for replacement of coagulation factors (fresh frozen plasma [FFP]). Increased platelets with decreased clotting times may be the body’s attempt to restore hemostasis. Severe abnormalities may reveal coagulopathy, e.g., DIC, as cause of bleeding.
Blood urea nitrogen (BUN): Elevated within 24–48 hr as blood proteins are broken down in the GI tract and kidney filtration is decreased.
Creatinine (Cr): Usually not elevated if renal perfusion is maintained.
Ammonia: May be elevated when severe liver dysfunction disrupts the metabolism and proper excretion of urea or when massive whole blood transfusions have been given.
Arterial blood gases (ABGs): May reveal initial respiratory alkalosis (compensating for diminished blood flow through lungs). Later, metabolic acidosis develops in response to sluggish liver flow/accumulation of metabolic waste products.
Sodium: May be elevated as a hormonal compensation to conserve body fluid.
Potassium: May initially be depleted because of massive gastric emptying/vomiting or bloody diarrhea. Elevated potassium levels may occur after multiple transfusions of stored blood or with acute renal impairment.
Serum gastrin analysis: Elevated level suggests Zollinger-Ellison syndrome or possible presence of multiple poorly healed ulcers. Normal or low in type B gastritis.
Serum amylase: Elevated with posterior penetration of duodenal ulcer.
Pepsinogen level: Increased by duodenal ulcer; low level suggestive of gastritis.
Serum parietal cell antibodies: Presence suggestive of chronic gastritis.
NURSING PRIORITIES
1. Control hemorrhage.
2. Achieve/maintain hemodynamic stability.
3. Promote stress reduction.
4. Provide information about disease process/prognosis, treatment needs, and potential complications.
DISCHARGE GOALS
1. Hemorrhage curtailed.
2. Hemodynamically stable.
3. Anxiety/fear reduced to manageable level.
4. Disease process/prognosis, therapeutic regimen, and potential complications understood
5. Plan in place to meet needs after discharge.
CARE SETTING
Generally, a patient with severe, active bleeding is admitted directly to the critical care unit (CCU); however, a patient may develop GI bleeding on the medical-surgical unit or be admitted there for evaluation/treatment of subacute bleeding.
RELATED CONCERNS
Cirrhosis of the liver
Fluid and electrolyte imbalances, see Nursing Care Plan CD-ROM
Psychosocial aspects of care
Renal failure: acute
Subtotal gastrectomy/gastric resection, see Nursing Care Plan CD-ROM
Patient Assessment Database
ACTIVITY/REST
May report: Weakness, fatigue
May exhibit: Tachycardia, tachypnea/hyperventilation (response to activity)
CIRCULATION
May report: Palpitations
Dizziness with position change
May exhibit: Hypotension (including postural)
Tachycardia, dysrhythmias (hypovolemia/hypoxemia)
Weak/thready peripheral pulse
Capillary refill slow/delayed (vasoconstriction)
Skin color: pallor, cyanosis (depending on the amount of blood loss)
Skin/mucous membrane moisture: Diaphoresis (reflecting shock state, acute pain, psychological response)
EGO INTEGRITY
May report: Acute or chronic stress factors (financial, relationships, job-related)
Feelings of helplessness
May exhibit: Signs of anxiety, e.g., restlessness, pallor, diaphoresis, narrowed focus, trembling,
quivering voice
ELIMINATION
May report: Change in usual bowel patterns/characteristics of stool
May exhibit: Abdominal tenderness, distension
Bowel sounds often hyperactive during bleeding, hypoactive after bleeding subsides
Character of stool: Diarrhea; dark bloody, tarry, or occasionally bright red stools; frothy, foul-smelling (steatorrhea); constipation may occur (changes in diet, antacid use)
Urine output may be decreased, concentrated
FOOD/FLUID
May report: Anorexia, nausea, vomiting (protracted vomiting suggests pyloric outlet obstruction
associated with duodenal ulcer)
Problems with swallowing; belching, hiccups
Heartburn, indigestion, burping with sour taste
Bloating/distension, flatulence
Food intolerances, e.g., spicy food, chocolate; special diet for preexisting ulcer disease
Weight loss
May exhibit: Vomitus: coffee-ground or bright red, with or without clots
Mucous membranes dry, decreased mucus production, poor skin turgor (chronic bleeding)
Urine specific gravity may be elevated
NEUROSENSORY
May report: Fainting, dizziness/lightheadedness, weakness
Mental status: Level of consciousness (LOC) may be altered, ranging from slight
drowsiness, disorientation/confusion, to stupor and coma (depending on
circulating volume/oxygenation)
PAIN/DISCOMFORT
May report: Pain described as sharp, dull, burning, gnawing; sudden, excruciating (can accompany perforation)
Vague sensation of discomfort/distress following large meals and relieved by food (acute
gastritis)
Left to midepigastric pain and/or pain radiating to back, often accompanied by vomiting
after eating and relieved by antacids (gastric ulcer)
Localized right to midepigastric pain, gnawing, burning, occurring about 2–3 hr after
meals when stomach is empty, and relieved by food or antacids (duodenal
ulcers)
Midepigastric pain and burning with regurgitation (chronic gastroesophageal reflux disease
[GERD])
Absence of pain (esophageal varices or gastritis)
Precipitating factors may be foods (e.g., milk, chocolate, caffeine), smoking, alcohol, certain drugs (salicylates, reserpine, antibiotics, ibuprofen), psychological stressors
May exhibit: Facial grimacing, guarding of affected area, pallor, diaphoresis, narrowed focus
SAFETY
May report: Drug allergies/sensitivities, e.g., acetylsalicylic acid (ASA)
May exhibit: Temperature elevation
Spider angiomas, palmar erythema (reflecting cirrhosis/portal hypertension)
TEACHING/LEARNING
May report: Recent use of prescription/over-the-counter (OTC) drugs containing ASA,
alcohol/recreational drugs, steroids, or nonsteroidal anti-inflammatory drugs (NSAIDs) (leading cause of drug-induced GI bleeding)
Current complaint may reveal admission for related (e.g., anemia) or unrelated (e.g., head
trauma) diagnosis, intestinal flu, or severe vomiting episode; long-standing health problems, e.g., cirrhosis, alcoholism, hepatitis, eating disorders
History of previous hospitalizations for GI bleeding or related GI problems, e.g.,
peptic/gastric ulcer, gastritis, gastric surgery, irradiation of gastric area
Discharge plan
DRG projected mean length of inpatient stay: 5.3 days
May require changes in therapeutic/medication regimen.
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Esophagogastroduodenoscopy (EGD): Key diagnostic test for upper and lower GI bleeding, done to visualize site of bleeding/ degree of tissue ulceration/injury.
Gastrointestinal nuclear scan: Radionuclide uptake at sites of bleeding identifies site (not cause) of bleeding. Test is considered to be more sensitive than EGD, upper GI studies with barium, or angiography in detecting sites of lower GI bleeding or persistent bleeding anywhere in GI tract.
Helicobacter pylori breath test: Patient drinks a carbon-enriched urea solution. If H. pylori is present, it breaks down the compound and releases CO2. H. pylori can also be detected by blood or tissue tests with blood test now being the most common.
Barium swallow with x-ray: Done after bleeding has ceased for differential diagnosis of cause/site of lesion, presence of structural defects such as strictures.
Gastric aspirate analysis: May be done in suspected peptic ulcer disease as indicated by low to normal pH and/or presence of blood; also in suspected gastric cancer (abnormal acidity, blood and/or abnormal cells on cytological examination).
Gastric cultures: Determine presence of H. pylori (Gram-negative urease-producing bacteria), currently accepted as organism responsible for 90% of duodenal and 70%–80% of gastric ulcers.
Angiography: GI vasculature may be reviewed if endoscopy is inconclusive or impractical. Demonstrates collateral circulation and possibly bleeding site.
Stools: Testing for blood will be positive.
Complete blood count (CBC), hemoglobin (Hb)/hematocrit (Hct): Decreased levels occur 6–24 hr after acute bleeding begins. Red blood cells (RBCs) and platelets may also be decreased. White blood cell (WBC) count may be elevated, reflecting body’s response to injury.
Prothrombin time (PT) and activated partial thromboplastin time (aPTT); coagulation profile: Prolonged in active bleeding. May indicate need for replacement of coagulation factors (fresh frozen plasma [FFP]). Increased platelets with decreased clotting times may be the body’s attempt to restore hemostasis. Severe abnormalities may reveal coagulopathy, e.g., DIC, as cause of bleeding.
Blood urea nitrogen (BUN): Elevated within 24–48 hr as blood proteins are broken down in the GI tract and kidney filtration is decreased.
Creatinine (Cr): Usually not elevated if renal perfusion is maintained.
Ammonia: May be elevated when severe liver dysfunction disrupts the metabolism and proper excretion of urea or when massive whole blood transfusions have been given.
Arterial blood gases (ABGs): May reveal initial respiratory alkalosis (compensating for diminished blood flow through lungs). Later, metabolic acidosis develops in response to sluggish liver flow/accumulation of metabolic waste products.
Sodium: May be elevated as a hormonal compensation to conserve body fluid.
Potassium: May initially be depleted because of massive gastric emptying/vomiting or bloody diarrhea. Elevated potassium levels may occur after multiple transfusions of stored blood or with acute renal impairment.
Serum gastrin analysis: Elevated level suggests Zollinger-Ellison syndrome or possible presence of multiple poorly healed ulcers. Normal or low in type B gastritis.
Serum amylase: Elevated with posterior penetration of duodenal ulcer.
Pepsinogen level: Increased by duodenal ulcer; low level suggestive of gastritis.
Serum parietal cell antibodies: Presence suggestive of chronic gastritis.
NURSING PRIORITIES
1. Control hemorrhage.
2. Achieve/maintain hemodynamic stability.
3. Promote stress reduction.
4. Provide information about disease process/prognosis, treatment needs, and potential complications.
DISCHARGE GOALS
1. Hemorrhage curtailed.
2. Hemodynamically stable.
3. Anxiety/fear reduced to manageable level.
4. Disease process/prognosis, therapeutic regimen, and potential complications understood
5. Plan in place to meet needs after discharge.
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