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https://www.scribd.com/doc/62262158/UGIB-NCP
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Upper Gastrointestinal/ Esophageal


Bleeding
1.

Deficient fluid volume (isotonic)

2.

Risk for ineffective tissue perfusion

3.

Fear or anxiety (specify level)

4.

Acute or chronic pain

5.

Knowledge deficient (learning need) regarding condition,


prognosis, treatment regimen, self-care, and discharge
needs

Upper gastrointestinal bleeding is characterized by the sudden


onset of bleeding from the GI tract at a site (or sites) proximal to the
ligament of Treitz. Most upper GI bleeds are a direct result of peptic ulcer
erosion, stress related- mucosal disease, that may evidence as
superficial erosive gastric lesion to frank ulcerations, erosive gastritis
(secondary to use or abuse of NSAIDs, oral corticosteroids, or alcohol)
or esophageal varices (secondary to hepatic failure). In addition to these,
Mallory-Weiss tears can cause gastroesophageal bleeding as a result of
severe retching and vomiting, but the bleeding tends to be less severe

than in other types. Hospitalized critically ill patients are at heightened


risk for stress related mucosal disease, particularly if they are intubated
and mechanically ventilated and/or evidencing coagulopathies.
Signs and Symptoms

Melena and hematemesis

Pain

Hypovolemic shock

Physical Examination
Vital signs

BP < 90 mm Hg

HR > 100 beats/min

RR: tachycardia

Temperature: maybe elevated

Other

Hematemesis

Melena

Bloody stool with fetid odor

Coffee ground gastric aspirate

Skin

Pale, diaphoretic

Cool, clammy

Jaundice

Cardiovascular

Weak, thready pulse

Capillary refill > 3 sec

Abdominal

Maybe tender with guarding

Bowel sounds hyperactive or absent

Acute Care Patient Management


Nursing Diagnosis: Deficient fluid volume related to blood loss from
hemorrhage.
Outcome Criteria

Patient alert and oriented

Skin, pink, warm, and dry

CVP 2 to 6 mm Hg

PAS 15 TO 30 mm Hg

PAD 5 to 15 mm Hg

BP 90 to 120 mm Hg

MAP 70 to 105 mm Hg

HR 60 to 100 beats/min

Urine output 30 ml/hr

Patient Monitoring
1.

Obtain pulmonary artery pressure, central venous pressure


and blood pressure every 15 minutes during acute episodes
to evaluate fluid needs and the patients response to
therapy.

2.

Monitor fluid volume status. Measure intake and output


hourly to evaluate renal perfusion.

3.

Measure blood loss if possible.

4.

Continuously monitor ECG for dysrythmias and myocardial


ischemia.

Patient Assessment

1.

Assess patient for increases restlessness, apprehension or


altered consciousness, which may indicate decreased
cerebral perfusion.

2.

Assess hydration status.

3.

Be alert for recurrence of bleedings.

Diagnostic Assessment
1.

Review Hgb and Hct levels to determine the effectiveness


of treatment or worsening of the patients condition.

2.

Review clotting factors and serum calcium levels if


multiple transfusions have been give.

3.

Review serial BUN levels.

4.

Review serial ABGs to evaluate oxygenation and acid-base


status.

5.

Review the result of endoscopic evaluation.

Patient Management
1.

Maintain a patent airway. Administer supplemental oxygen


as ordered.

2.

Administer colloids as ordered to restore intravascular


volume.

3.

Type and crossmatch for anticipated blood products.

4.

Evacuate stomach contents with nasogastric tube and


initiate lavages with room temperature water or saline to
clear blood clots from the stomach.

5.

Continue to monitor the patient closely once stabilized.

6.

Vitamin K or fresh-frozen plasma (FFP) may be ordered to


correct coagulation deficiencies.

7.

Explain all procedures and tests to the patient to help


alleviate anxiety and decreased tissue oxygen demands.