Something you’ll see pretty regularly if you work on a medical unit or emergency room is the gastrointestinal bleed. GI bleeds come in many forms…the slow steady bleed that sneaks up on the patient and they don’t even know they’re sick until they’re hemoglobin drops so low that they can’t catch their breath or stand up unassisted. Then there’s the coffee-ground emesis type of bleed, the bright red “oh-my-gosh-what-is-that-in-the-commode” type of bleed and the oh-so-scary upper GI bleed from a fragile esophagus. But before we get into all that, let’s start with the basics.
Upper vs lower GI bleeds
You will often hear GI bleeds referred to by their location of origin…upper or lower. When we talk about upper GI bleeds, we are talking about bleeds that originate above the duodenum; lower GI bleeds are below the duodenum (and if you forgot, the duodenum is the first segment of the small intestine).
Coffee, tar or frank?
The blood from your patient’s GI bleed will typically present in one of three forms:
Coffee-ground emesis: this is the result of partially-digested or clotted blood (ewwwww) in the upper GI tract. Typically if the blood looks like coffee grounds, this means it’s been in there for a bit so there’s a chance the bleeding is not likely happening right now.
Black, tarry stools (also known as “melena”): if your patient has black tarry stools, this means that bleeding is taking place in the esophagus, stomach or the upper part of the small intestine. Melena has a distinctive odor that you will never, ever, ever forget.
Frank bleeding: bright red blood (also called “frank bleeding”) is a sign that bleeding is occurring RIGHT NOW and can be from the upper or lower GI tract. In the lower GI tract, this could be due to diverticulosis, anal fissures, hemorrhoids, inflammatory bowel disease or even cancer. When there’s bright, frank blood passing through the anus it’s called “hematochezia.” In the upper GI tract it’s typically because of a baaaad ulcer or problems in the esophagus…tears, varices, cancer or severe esophagitis.
Whatcha gonna do about it?
I always say that nursing is all about seeing problems and fixing them…so how do you intervene when your patient has a GI bleed?
- Serial H/H (typically q 4 or q 6 hours)
- Monitor PLTs, INR, PTT
- Watch for signs of bleeding
- Monitor BP and check for orthostatic hypotension
- Perform occult blood test on stool
- Assess abdominal pain
- Ensure two IVs in place for blood administration, fluids, antibiotics (if needed), electrolyte replacement, protonix gtt, etc…
- Make sure pt’s type & screen is current; transfuse as necessary
- Prep patient for endoscopy (either EGD or colonoscopy)
- Prep patient for interventional radiology if problem can’t be treated by traditional endoscopy
- Anticipate patient being NPO initially, then clears, then advance as tolerated
- Administer medications such as protonix, antifungals and antibiotics as needed
- Replace fluids and electrolytes
- Anticipate many many trips to the bedside commode (or many many clean-up projects). Blood in the GI tract is very irritating, which leads to increased gastric motility.
When GI bleeds go bad
If the bleed is bad enough then your patient can bleed out right in front of you. To me, the scariest GI bleeds are from Mallory-Weiss tears or esophageal varices. These esophageal hemorrhages are devastating and often very rapidly fatal. Have suction ready at the bedside at all times and be extra watchful for any increase in bloody emesis.
Patients can bleed out via the rectum as well, so ANY increase in bleeding, significant drop in hemoglobin or blood pressure should be immediately investigated and reported!
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Looking for even more information about the gastrointestinal system? Check out Med Surg Starter Pack study guides!
Be safe out there!