Chapter 42 #2 - Upper GI Bleeding

Collaborative Care: GI Bleed, Drugs

-Drug therapy used in acute phase GI Bleed to 1. ↓ bleeding 2.↓ HCl acid secretion 3. Neutralize HCl acid that is present

Emergency Assessment & Management in GI Bleed (Contd)

-Abdominal exam: Acute abdomen/peritonitis Sudden, severe abdominal pain Absent/diminished bowel sounds Tense, rigid abdomen REBOUND TENDERNESS!

Drug Therapy that DECREASE HCl SECRETION (cont.)

-Acid reducers -Histamine-2 receptor blockers (H2Rs) -Inhibit action of histamine at H2 receptors -Decrease HCl acid secretion -Cimetidine (Tagamet) -Ranitidine (Zantac) -Famotidine (Pepcid)

2. Drug Therapy that DECREASE HCl SECRETION

-Acid reducers- Acidic environment can alter platelet function & clot stabilization -Proton pump inhibitors (PPIs) -Inhibits gastric acid pump -Pantoprazole (Protonix) -Esomeprazole (Nexium) -No proven ability to control active bleeding -Part of standard treatment protocols

Emergency Treatment of Shock in GI Bleed

-Assess ABCs, administer O2 ( sat). VITALS! -Establish large bore IV access x2 (#16, #18g) IV- Aggressive, rapid fluid resuscitation Lactated Ringers (LR) or Normal Saline (NS) -Stat labs (upcoming) -Blood/ blood products, colloids -Medications -NPO, NG tube to suction (remove clots) -Foley (UOP best measure of perfusion) -Accurate I/O, CVP 0EMERGENT ENDOSCOPY (endotherapy) -Surgery

Origin of Bleeding

-Bleeding from arterial source is profuse; blood is bright red. -Bright red means it is fresh, acute, happening NOW -MAY BE LIFE THREATENING

Common Causes of Bleeding: ESOPHAGEAL ORIGIN

-Chronic esophagitis- GERD, mucosa-irritating drugs, alcohol, cigarettes -Mallory-Weiss tear- Tear in mucosa near esophagogastric junction -Esophageal varices (next) *Esophageal Varices are extremely dilated sub-mucosas veins in lower 1/3 of esophagus that are extremely prone to bleeding

Nursing Diagnoses: GI Bleed

-Deficient fluid volume r/t bleeding a/e/b hypotension, tachy., clammy skin, thirst -Decreased cardiac output -Ineffective tissue perfusion -Anxiety -Risk for aspiration r/t dec. LOC and gastric distension

Common Causes of UGI Bleeding

-Esophageal origin (most common) -Stomach and duodenal origin (most common) -Drug-induced origin -Systemic disease origin .*The most common sites are the esophagus, stomach, and duodenum.

Health Promotion: GI Bleed

-Identify patient populations at risk History chronic gastritis or PUD Major bleeding episode is likely to reoccur Cirrhosis -Patient education Disease process and drug therapy Testing vomitus/stools for occult blood Potential adverse effects related to GI bleeding GI bleed: This is no joke!

Patient Teaching: GI Bleed

-If aspirin prescribed, enteric-coated tablets substituted for regular tablets Take with meals or snacks Take only prescribed medications -Avoid gastric irritants- (Alcohol, smoking, stress)

1. Drug Therapy to DECREASE BLEEDING

-Injection therapy to site of bleeding -Given during endoscopy to cause acute hemostasis -Epinephrine -Produces tissue edema → pressure on bleeding source and bleeding -Drug therapy that ↓blood flow to GI organs -Somatostatin or octreotide (Sandostatin) IV drip -When endoscopy not available -Reduces blood flow to area! -Vasoconstriction, bleeding -Used with upper GI bleeding

Acute Intervention: Upper GI Bleed

-Maintain IV/fluids -I/O-hourly -CVP line or PA readings every 1 to 2 hours (next) Normal CVP is 3-8 mm/Hg or 0-5 mm/H20 Low=Hypovolemia, ?bleeding High= Watch for fluid overload esp. in elderly -Assess stools for blood -Monitor labs Hgb and Hct q. 4-6 hours BUN Oxygen

Acute Intervention: Upper GI Bleed

-NG tube maintenance Watch for blood, record in I/O, ✓patency -Nutrition Initially NPO! Observe for nausea/vomiting ✓Recurrence of bleeding Feedings initially include clear liquids! Gradual introduction of food as tolerated -Clearfull soft -Examples

Take Home Concepts

-No food in a bleeding abdomen, NG? -If NPO for any reason, need IV to prevent dehydration Watch for fluid overload -ASSESSMENT ! Know symptoms of shock/hypovolemia Know symptoms of acute abdomen -Acute GI bleeding needs STAT intervention -UOP is good indicator of volume status/perfusion -I/O, CVP w/ any volume problem to monitor status -ASA, NSAIDs, steroids, EtOH cause GI Bleeding -Give PRBC and FFP for symptomatic bleeding -PPI and H2R blockers HCl

Evaluation: Upper GI Bleed

-No further GI bleeding -Normal fluid volume/ normal hemodynamic state -Absence of/tolerable levels of pain -Understand potential etiologic factors -Lifestyle modifications

Emergency Assessment & Management

-Once immediate emergency interventions have started -What caused this??? Complete history of events leading to bleeding episode. -Previous bleeding episodes -Weight loss -Other illnesses (liver disease, cirrhosis) -Medication use -Blood transfusion an option? -Religious preferences regarding blood product use

Etiology & Patho: UGI Bleed

-Serious loss of blood from UPPER GI tract -Severity depends on bleeding origin Arterial Venous Capillary -Often sudden onset -Massive: may lose 1500 ml of blood (25%) -Obvious/Occult bleeding

Collaborative Care

80% to 85% w/ massive hemorrhage spontaneously stop bleeding Cause must be identified Treatment must be initiated immediately *A complete history of events leading to the bleeding episode is deferred until emergency care has been initiated.

Other Diagnostic Studies

Angiography To diagnose when endoscopy cannot be done Invasive procedure Catheter placed into left gastric or superior mesenteric artery until site of bleeding found Surgical repair Lab Serum (H/H) Vomitus/stools (occult blood) UA (urinalysis) for specific gravity

When teaching a patient with a history of upper GI bleeding to check the stools for blood, the nurse informs the patient that: 1. If vomiting of bright red blood occurs, stools will not be black and sticky. 2. Blood is never obvious in stools and must be detected by fecal occult blood testing. 3. Acute bleeding in the upper GI tract will result in bright red blood in the stools. 4. Stools that are black and tarry occur with prolonged bleeding from the stomach or small intestine.

Answer: 4 Rationale: Melena (Black, tarry stools) indicates slow bleeding from an upper GI source. The longer the passage of blood through the intestines, the darker the stool color, because of the breakdown of hemoglobin and the release of iron.

Drug Therapy for GI Bleeding

Antacids Bleeding Source: Duodenal ulcer, gastritis Drug Action: Neutralizes Acid H2 Receptors (Tagamet, Pepcid, Zantac) Bleeding Source: Duodenal Ulcer, Gastritis (inc. hemorrhagic) Drug Action: Inhibits histamine receptors > decreased Hcl PPI (Prevacid, Protonix) Bleeding Source: Duodenal Ulcer, Gastritis (Inc. Hemorrhagic) Drug Action: Decreases gastric acid pump Sandostatin Bleeding Source: UGI bleed, esoph. varies Drug Action: Vasoconstriction, arrests bleeding Epinepherine Bleeding Source: ulcerative bleeds Drug Action: Tissue edema puts pressure on bleeder

Emergency Assessment & Management 2

Blood replacement -PRBCs, and fresh frozen plasma (FFP). Goal: replacement of lost volume AND clotting factors in massive hemorrhage H&H provide guide for further treatment Transfusions are not reflected in H&H until 2-3 hours after 1 u PRBC should = 1 gm in Hgb. -Initial Hct may not reflect blood loss until 4-6 hrs after bleed

What is Central Venous Pressure?

Central venous pressure (CVP) is the blood pressure in the venae cavae, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart.

Diagnostic Studies

Endoscopy*** Primary tool for diagnosing and TERMINATING source of bleeding Endoscopic hemostasis therapy Goal: To coagulate/thrombose bleeding artery

Esophageal Varices

Extremely dilated sub-mucosal veins in lower 1/3 of esophagus that are EXTREMELY PRONE TO BLEEDING, 2° cirrhosis

Emergency Assessment & Management: Acute GI Bleed

Immediate physical examination to identify: 1.) SIGNS AND SYMPTOMS OF SHOCK Drop in blood flow throughout the body O2 & nutrients delivered to vital organscell death Tachycardia, weak pulse, hypotension, cool extremities w/ capillary refill >3 sec. VS every 15 to 30 minutes (HR,BP, RR indicates shock)******** 2.) Risk/actual perforation, peritonitis Rigid abdomen, no bowel sounds Surgery, antibiotics

Nursing Management: GI bleed

Nursing assessment -History, meds, EtOH, smoking, symptoms -Assess LOC, agitation, restless (shock) or DTs -Skin: pale, cool, clammy -Resp: rapid, shallow respirations Watch for fluid volume overload w/ rapid IV infusion CV: ECG ✓ VS Every 15 to 30 minutes, orthostatic HR and BP, clammy skin indicate shock ✓Capillary refill ✓Neck veins (distended? flat?) **Subjective and objective data that should be obtained from the patient or significant others are presented in Table 42-15. **When obtaining vital signs, consider the patient's age and physical condition.

Nursing Management: GI bleed 2

Nursing assessment GI: -✓Abdominal distention, guarding, visible peristalsis -Red or coffee ground vomitus? -Tense, rigid abdomen= peritonitis -Bowel sounds (absent, hypo.,hyper.) -Black, tarry stools (OLD BLOOD) Urine output, specific gravity -30 ml/hr UOP is minimum (0.5 ml/kg/hr) -Normal specific gravity (SG) is 1.005 to 1.025 > 1.025 indicate concentrated urine; blood volume is probably low.

Types of UGI Bleeding: Obvious vs. Occult

Obvious bleeding Hematemesis (Bloody vomitus) -Appears fresh: bright red blood -Coffee ground Blood has been in the stomach long enough to have been changed by gastric secretions. Bloody or mahogany colored stools Melena (foul smelling) Black, tarry stools Digestion of blood in GI tract Black appearance—may also be due to iron

Occult Bleeding

Occult bleeding -Small amounts of blood in gastric secretions, vomitus, or stools -Undetectable by appearance -Detectable by guaiac test

Ambulatory & Home Care: Upper GI Bleed

Patient teaching -How to avoid future bleeding episodes -Consequences of noncompliance w/ diet & drug therapy -No smoking or alcohol -Emphasis that no drugs other than those prescribed should be taken -Need for long-term follow-up care -Instruction if an acute hemorrhage occurs

Common Causes of Bleeding: Stomach, Duodenal, Drug, Systemic, Origin

Peptic ulcer disease (40%) Related to H. pylori or drug use Drugs ASA, NSAIDs (Advil), Steroids Stress-related mucosal disease AKA physiologic stress ulcers Severe burns or trauma, or after major surgery Less common causes Polyps, vascular lesions, hemorrhagic gastritis & gastric cancer, coagulopathies *Approximately 25% of persons on chronic nonsteroidal antiinflammatory drugs (NSAIDs e.g., ibuprofen [Advil]) will develop ulcer disease, and of these, 2% to 4% will bleed. Even low-dose aspirin is associated with risk for GI bleeding. Many OTC preparations contain aspirin. A careful history of all commonly used drugs is necessary whenever upper GI bleeding is suspected. **Less common causes of upper GI bleeding include Polyps, vascular lesions, hemorrhagic gastritis & gastric cancer (Steady blood loss as CA grows and ulcerates through the mucosa and blood vessels located in its path.)

Planning: GI Bleed

Planning: Overall goals -No further GI bleeding -Identify and treat bleeding -Return to normal hemodynamic state -Minimal or no symptoms of pain or anxiety

Emergency Assessment & Management

Serum Laboratory studies CBC: H/H! Type/cross-match for possible blood transfusions! Prothrombin time (PT) Liver enzymes BUN is with blood in gut (GI tract) Serum electrolytes/glucose ABGs (metabolic acidosis with shock)

Collaborative Care: GI Bleed, surgery

Surgical therapy -Indicated when bleeding continues -Site of bleeding identified determines choice of operation. -Mortality increases considerably in those over 60 years. *A high percentage of patients will have another massive hemorrhage within 5 years after the first bleeding episode.