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MANAGEMENT OF A PATIENT WITH A GI BLEED

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MANAGEMENT OF A PATIENT WITH A GI BLEED ACUTE GI BLEEDING Many patients requiring care in the ICU have upper GI bleeding. They may have underlying comorbidities that ... – PowerPoint PPT presentation

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Title: MANAGEMENT OF A PATIENT WITH A GI BLEED


1
MANAGEMENT OF A PATIENT WITH A GI BLEED
2
ACUTE GI BLEEDING
  • Many patients requiring care in the ICU have
    upper GI bleeding. They may have underlying
    comorbidities that contribute to the risk of
    upper GI bleeding, such as
  • Recent major surgery
  • History of a MI
  • Renal failure
  • History of chronic liver damage secondary to
    alcohol abuse or hepatitis
  • History of radiation therapy
  • Chronic pain condition, such as arthritis, where
    NSAIDS have been taken in large amounts
  • Taking excessive amounts of Goody powders or BC
    powders

3
CAUSES OF UPPER GI BLEED
  • Peptic ulcer disease
  • Rupture of esophageal varices
  • Esophagitis
  • Mallory-Weiss tear
  • Erosive gastritis
  • Arteriovenous malformations

4
CAUSES OF LOWER GI BLEED
  • Diverticulitis
  • Polyps
  • Hemorrhoids
  • Neoplasm
  • Angiodysplasias
  • Crohns disease
  • Ulcerative colitis
  • Colitis

5
WHAT HAPPENS???
  • Because the arterial blood supply near the
    stomach and esophgus is extensive, bleeding can
    lead to a rapid loss of large amounts of blood,
    leading to hypovolemia and shock.

6
MORE HAPPENING
  • Loss of circulating blood volume leads to a
    decreased venous return.
  • Cardiac output and blood pressure decrease,
    causing poor tissue perfusion. The body
    compensates by shifting interstitial fluid to the
    intravascular space.
  • The sympathetic nervous system is stimulated,
    resulting in vasoconstriction and increased heart
    rate.
  • The renin-angiotensin-aldosterone system is
    activated, leading to fluid retention and
    increasing blood pressure.
  • If blood loss continues, CO decreases, leading to
    cellular hypoxia. This leading to all organs
    failing due to hypoperfusion.

7
SIGNS AND SYMPTOMS
  • Cool, clammy skin
  • Pallor
  • Restlessness
  • Apprehension
  • Tachycardia
  • Diaphoresis
  • Hypotension
  • Syncope

8
WHAT TEST TELL
  • EGD reveals the source of esophageal or gastric
    bleeding.
  • 12 lead EKG may reveal cardiac ischemia secondary
    to hypoperfusion.
  • Abdominal X-ray may indicate air under the
    diaphragm, suggesting ulcer perforation.
  • Angiography may aid in visualizing the bleeding
    site and may also be used to embolize a bleeding
    vessel.
  • Coagulation studies (PT,PTT, INR) may be
    prolonged, especially if the patient has liver
    disease.
  • Mesenteric angiography can help locate the site
    of the bleeding.
  • CBC reveals the amount of blood loss, changes
    may not be seen for 4 to 6 hours.
  • ABG can indicate metabolic acidosis from
    hemorrhage and possible hypoxemia.

9
HOW ITS TREATED
  • Fluid volume replacement with crystalloid
    solutions initially, followed by colloids and
    blood component therapy
  • Respiratory support
  • Gastric intubation with gastric lavage (unless
    the patient has esophageal varices) and gastric
    pH monitoring
  • Drug therapy, such as antacids, H2-receptor
    antagonist, and proton pump inhibitors (Protonix
    drip)
  • Endoscopic or surgical repair of bleeding sites

10
WHAT YOU NEED TO DO
  • Type and crossmatch at least 2 units of PRBC
  • Start at least two large bore IV sites (at least
    20G or 18G preferred). You may have to get
    supplies for possible central line placement if
    needed.
  • Assess the patient for blood loss and begin fluid
    replacement therapy as ordered, initially
    delivering crystalloid solutions, such as normal
    saline or lactated Ringers, followed by blood
    component products.
  • Ensure the patient has a patent airway. Monitor
    cardiac and respiratory status and assess LOC agt
    least every 15 minutes until he stabilizes and
    then every 2-4 hours or more often. If in a
    critical area assess every 15-30 min. Assist
    with insertion of hemodynamic monitoring devices,
    and assess hemodynamic parameters.
  • Administer supplemental oxygen as ordered.
    Monitor O2 saturation levels.
  • Keep the HOB raised at least 30 degrees to
    minimize the risk of aspiration.
  • Monitor the patients skin color and capillary
    refill for signs of hypovolemic shock.
  • Obtain H/H levels often (Q6-12Hours) and
    administer blood products as ordered.
  • Monitor intake and output closely, including all
    losses from GI tract. Check for occult blood.

11
  • Assist with insert and NG tube and perform lavage
    using room temperature saline to clear blood and
    clots from the stomach.
  • Assess the patients abdomen for bowel sounds and
    gastric pH, as ordered. Expect to resume enternal
    or oral feedings after bowel function returns and
    theres no evidence of further bleeding.
  • Patient may need FMS for skin protection.
  • Provide appropriate emotional support to the
    patient.
  • Prepare the patient for endoscopic repair or
    surgery.
  • Obtain informed consent once the MD has spoken to
    patient or family
  • Fill out time out and SBAR forms if needed

12
  • Critical Care Nursing made Incredibly Easy
  • 2nd edition. Wolters/Lippincott Williams and
    Wilkins. 464-467.
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