FINALS 1 - Care of The Patient With An Acute Gastrointestinal Bleed or Pancreatitis

Critical Care Nursing
Jason Anthony I. Alberto, RN

Student – MAN major in Adult Health Nursing
UP Manila
Lecturer, MS Nursing III
Pamantasan ng Lungsod ng Pasig
Care of the Patient with

an Acute Gastrointestinal
Bleed or Pancreatitis
Copyright © 2018 Pearson Education, Inc. All Rights Reserved

Learning Outcomes
13.1 Compare and contrast risk factors, clinical m
anifestations, and collaborative management of the person
with upper and lower gastrointestinal bleeding.
13.2 Explain why pancreatitis may develop and differentiate
between the manifestations of mild and severe pancreatitis.
13.3 Describe collaborative management and nursing
responsibilities when caring for the patient with severe
pancreatitis.

Introduction
• Gastrointestinal (GI) bleeding is a common, costly, and
potentially life-threatening medical condition.
• Upper gastrointestinal (UGI) bleeding
– Originates proximal to the ligament of Treitz
– Classified as variceal or nonvariceal
• Lower gastrointestinal (LGI) bleeding
– Refers to bleeding originating distal to the ligament of Treitz
– Differentiated into bleeding from the small bowel or mid-GI
bleeding, and bleeding from the colon, or lower GI bleeding

Learning Outcome 13.1
Compare and contrast risk factors, clinical

manifestations, and collaborative management of the
person with upper and lower gastrointestinal bleeding.

Anatomy and Physiology Review (1 of 5)
• GI tract begins at the oral cavity and ends at the anus.
• Major functions of the GI tract include:
– Ingestion
– Mechanical processing
– Digestion
– Secretion
– Absorption
– Excretion

• The Gastrointestinal Tract
– Structures include:
▪ Esophagus
▪ Stomach
▪ Small intestine
▪ Ileocecal valve
▪ Large intestine

– Esophagus
▪ Hollow muscular tube
▪ Carries solids and liquids from pharynx to stomach
– Stomach
▪ J-shaped organ
▪ Functions include storage of food; mechanical
breakdown of food; production of gastric secretions

– Small intestine
▪ Tubular structure
▪ Responsible for most of the important digestive and
absorptive functions
▪ Duodenum
▪ Jejunum
▪ Ileum
– Ileocecal valve
▪ Marks the transition between the small and the large
intestines

– Large intestine
▪ Tubular structure
▪ Cecum/ascending colon
▪ Transverse colon
▪ Descending colon
▪ Sigmoid colon
▪ Rectum

Figure 13-1 Organs of the Alimentary Canal
and Related Accessory Organs

Visual Map 13-1 Overview of
Gastrointestinal Bleeding

The Patient With Gastrointestinal Bleeding
(1 of 30)
• GI bleeding is a common reason for a patient to be

admitted to an intensive care unit (ICU).
• 74-100% of critically ill patients develop stress-related GI
mucosal erosions within 24 hours of admission.
– Can lead to serious GI bleeding in 0.6 to 4% of
patients.

(2 of 30)
• Predisposing Factors and Causes of Gastrointestinal

Hemorrhage
– Most common is peptic ulcer disease.
▪ Approximately 31% to 67% of nonvariceal UGI
bleeds
– Diverticular bleeding accounts for 20% to 65% of acute
LGI bleeds.

(3 of 30)
– Peptic Ulcer Disease

▪ Typically refers to ulcers in the stomach and the first part
of the duodenum
▪ Major risk factors for peptic ulcer disease are:
– Age
– Heliobacter pylori
– Nonsteroidal anti-inflammatory drugs
– Stress-related mucosal damage (including stress
ulcers)
– Gastric acid and pepsin co-contributors
– Alcohol and smoking are contributing factors as well.

Figure 13-2 Peptic Ulcer Disease
(St Bartholomew’s Hospital/Science Source)

(4 of 30)
• Predisposing Factors and Causes of Gastrointestinal

Hemorrhage
– Diverticular Disease
▪ Results from weak points on the intestinal wall that
herniate to form a saclike projection called
diverticula
– Most often found in the descending and sigmoid
colon
– Bleeding results from rupture of submucosal arterial
vessels at the neck or the dome of the diverticulum.
▪ Clinical presentation is usually acute, painless
passage of bright red blood.
Figure 13-3 Diverticular Disease
(Gastrolab/Science Source)

(5 of 30)
• Manifestations of Gastrointestinal Bleeding

– Most common manifestations of GI bleeding are:
▪ Hematemesis.
▪ Melena.
▪ Hematochezia.
– Hematemesis
▪ Vomiting of blood that is either bright red or has a
coffee ground appearance:
▪ Suggests UGIB

(7 of 30)
• Manifestations of Gastrointestinal Bleeding

– Melena
▪ Passage of black tarry colored stool with a very
characteristic foul odor
▪ Usually suggests an UGI bleed
– Hematochezia
▪ Passage of bright red or maroon blood in the stool
▪ Suggests a LGI bleed
– Can originate from UGI tract

Visual Map 13-2 Assessment of
Gastrointestinal Bleeding

(8 of 30)
• Collaborative Care
– Patients should be asked about prior episodes of UGI
bleeding.
– Immediate management is directed by hemodynamics
and may involve resuscitation and stabilization of vital
signs.
– Goals are to:
▪ Identify the source
▪ Stop the bleeding
▪ Prevent recurrent bleeding
▪ Prevent and treat complications
(9 of 30)
– Assessment of Fluid Volume Status

▪ Evaluate the extent of blood loss by immediately
assessing the patient’s hemodynamic status.
▪ Calculation of blood loss relative to the amount of
measured melena or hematochezia is difficult and
inaccurate related to being mixed with stool.
– Patients with less than 30% blood loss are more
difficult to recognize.

(10 of 30)
– Nurse assesses hemodynamic status by looking for

signs and symptoms of hypovolemia and poor tissue
perfusion.
▪ Hypotension
▪ Narrowed pulse pressure
▪ Orthostatic hypotension
▪ Tachycardia
▪ ECG changes

(11 of 30)
▪ Chest Pain
▪ Capillary refill
▪ Dry mucous membranes
▪ Decreased urine output
▪ Mental status changes

(12 of 30)
– Laboratory Studies
▪ Hemoglobin
▪ Platelets
▪ Electrolytes
▪ Blood urea nitrogen (BUN)/creatinine
▪ Prothrombin time (PT)
▪ Cardiac enzymes
▪ Liver function tests
▪ Type and cross-match

(13 of 30)
• Nursing Actions
– Goals of resuscitation are to:
▪ Restore intravascular volume
▪ Maintain cardiac output
▪ Restore blood cells
▪ Prevent complications of red blood cell loss

(14 of 30)
– Interventions for Restoration of Normovolemia

▪ Patient should have two large-bore intravenous
catheters placed immediately.
▪ Total fluid deficit cannot be accurately predicted.
– Fluid resuscitation should remain at a rapid rate
as long as the BP remains low.

(15 of 30)
– Blood Transfusions
▪ Packed Red Blood Cells
▪ Platelets/Fresh Frozen Plasma (FF
P)/Cryoprecipitate (Factor VIII)
▪ Patient Positioning
▪ Gathering of Additional Assessment Data

Visual Map 13-3 Collaborative Management
of GI Bleeding

(16 of 30)
• Nasogastric Tube Placement

– Placement is controversial.
▪ Traditionally, NGT insertion and lavage have been
utilized to confirm GI bleeding and distinguish upper
from lower bleeding.
– Use for hemodynamically unstable patients
– Can help validate UGI bleed
▪ Does not provide information about the specific
cause of the bleeding

(17 of 30)
• Erythromycin Administration
– Can be beneficial because erythromycin promotes gastric
emptying
• Acid Suppression: Proton Pump Inhibitors
– Proton pump inhibitors (PPIs) cross the parietal cell membrane.
▪ Resulting in irreversible inhibition of gastric secretion of
hydrochloric acid by the proton pump
– pH of 6.0-6.5 is recommended.
– Evidence has shown that high-dose PPIs administered
intravenously in patients with high-risk ulcers receiving therapeutic
endoscopy results in a decrease in hospital length of stay,
rebleeding rate, and need for blood transfusions.

(18 of 30)
• Bowel Preparation
– Recommended prior to a colonoscopy
– Cleansed colon allows for a safer procedure and better
chance at visualization.

(19 of 30)
– Endoscopy
▪ Procedure that uses a flexible fiber-optic endoscope
to directly visualize the inside of a hollow organ or
cavity
▪ Purpose
– Diagnose site of bleeding
– Assess risk of re-bleeding
– Perform interventions to stop bleeding

(20 of 30)
▪ Upper Gastrointestinal Endoscopy

– EGD (esophagogastroduodenoscopy)
• Involves oral intubation with a flexible
endoscope to visualize the esophagus,
stomach, and proximal duodenum.
▪ Colonoscopy
– Insertion of endoscope into anus to examine
colon or large intestine from the rectum to the
ileocecal valve

(21 of 30)
▪ Sigmoidoscopy
– Inspection and visualization of only the rectal-
sigmoid area of the colon

(22 of 30)
– Categories of Therapeutic Interventions

▪ Injection Therapy
– Agents may sclerose (harden), vasoconstrict, or
cause a tamponade effect.
– Most commonly used agent is epinephrine.
▪ Thermal Coagulation
▪ Mechanical Techniques
– Endoclips (hemoclips)

(23 of 30)
▪ New Endoscopic Technologies

– Application/injection of tissue adhesive or fibrin
glue
– Over the scope clips
– Endoscopic suturing
– Radio frequency ablation
– Cryotherapy
– Endoscopic ultrasound-guided angiotherapy

(24 of 30)
• Nursing Care
– Maintain safety.
– Provide nutrition.
– Enhance comfort.
– Provide patient and family centered care.
– Monitor for potential complications

(25 of 30)
• Other Diagnostic Tests

– If colonoscopy cannot be performed or does not yield a
bleeding site, other diagnostic options can assist.
▪ Angiography
▪ Radionuclide imaging
▪ Helical computer tomography scan

(26 of 30)
• Surgical Consult
– Most definitive
– May be the final option for some bleeding lesions
– Surgery has a high morbidity and mortality.
▪ Generally reserved for patients whose bleeding is
not controlled by endoscopic treatment
– Depending on the acuity of the patient, every effort
should be made to accurately localize the bleeding site
prior to surgery to avoid increased mortality and
morbidity.

(27 of 30)
• Identification and Prevention of Recurrent Bleeding

– Certain patients with an initial severe bleed are at high
risk for re-bleeding.
– Risks include:
▪ Older age
▪ Comorbid disease states
▪ Hemodynamic instability
▪ Coagulopathy/anticoagulants
▪ Endoscopic diagnosis/stigmata

(28 of 30)
– Collaborative Care
▪ Acid Suppression: Proton Pump Inhibitors
▪ Elimination of Precipitating Factors
– NSAIDs should be discontinued.
– Aspirin plus a PPI is recommended for
preventing ulcer reoccurrence and re-bleeding.
– All patients presenting with a UGI bleed should
be tested for Helicobacter pylori.

(29 of 30)
– Nursing Care
▪ Maintaining Safety
▪ Providing Nutrition
▪ Enhancing Comfort
▪ Fostering Patient and Family-Centered Care

(30 of 30)
• Prevention of Complications
– Acute GI bleeding needs to be systematically assessed and treated.
– Vigilant assessment, interventions, and evaluation of the patient’s
response to the interventions are critical.
– Monitor for evidence of:
▪ Myocardial ischemia/infarction
▪ Cerebral ischemia/thrombosis
▪ Respiratory insufficiency/failure
▪ Acute renal injury
▪ Hepatic failure
▪ Disseminated intravascular coagulation
▪ Sepsis
▪ Multisystem organ failure (MSOF)

Explain why pancreatitis may develop and differentiate

between the manifestations of mild and severe
pancreatitis.

Pancreatitis (1 of 6)
• Acute Pancreatitis
– Sudden nonbacterial inflammatory process of the
pancreas
▪ Occurs from the activation of digestive enzymes
found inside the acinar cells that compromise the
pancreatic gland, nearby tissues, and other organs
– Clinical course ranges from a mild interstitial self-
limiting illness to a severe life-threatening disorder.
– Gallstone disease and excessive alcohol use are the
most common causes.

– Pancreatic necrosis and the presence, timing, and
duration of organ failure influence morbidity and
mortality.
– Risk of death doubles when patients have both infected
necrosis and persistent organ failure.

Visual Map 13-4 Overview of Acute
Pancreatitis

• Anatomy and Physiology Review
– Pancreas
▪ Elongated, lobulated gland
▪ Lies behind the stomach in the retroperitoneal
space
▪ Extends from the duodenum to the spleen
▪ Divided into three segments:
– Head
– Body
– Tail

Figure 13-4 The Pancreas
The gross anatomy of the pancreas. The head of the pancreas is tucked into a C-shaped
curve of the duodenum that begins at the pylorus of the stomach.

• Anatomy and Physiology Review
– Cellular Systems of the Pancreas
▪ Exocrine cells
– Make up 98% to 99% of the pancreatic tissues
– Responsible for the production of pancreatic
juices and digestive enzymes
▪ Acini cells

– Major types of pancreatic enzymes are:
▪ Amylase
– Responsible for breaking down certain starches
▪ Lipase
– Responsible for breaking down certain complex
fats
▪ Proteases
– Responsible for breaking down proteins

– Pancreatic Ductal System
▪ Duct of Wirsung
– Main pancreatic duct
– Runs the whole length of the pancreas
▪ Papilla of Vater
▪ Sphincter of Oddi

The Patient with Pancreatitis (1 of 7)
• Predisposing Factors and Causes of Acute Pancreatitis
– Most common risk factors include gallstone disease
and excessive alcohol use.
– Other less common causes include:
▪ Infections
▪ Medications
▪ Toxins
▪ Developmental abnormalities
▪ Autoimmune disorders
▪ Mechanical obstruction of the ducts

– Other less common causes include:
▪ Hypertriglyceridemia
▪ Hypercalcemia
▪ Trauma
▪ Heredity
▪ Vascular abnormalities
▪ Idiopathic causes
– Determination of the cause is critical for decision
making and directing immediate interventions.

– Autodigestion
▪ Damaged acinar cells cause activation of
trypsinogen to trypsin.
▪ Trypsin activates enzymes that begin digestive
process in the pancreas.
▪ Results in inflammation and tissue damage
▪ Increased vascular permeability causing edema,
hemorrhage, and necrosis

• Determination of the Severity of Pancreatitis
– Accepted criteria for clinical diagnosis require the
presence of two out of three features:
▪ Characteristic epigastric or left upper quadrant pain
▪ Serum amylase and/or lipase greater than or equal
to three times the upper limit of normal.
– Establishing the severity and identifying those patients
likely to develop severe disease is critical to positive
patient outcomes.

• Determination of the Severity of Pancreatitis
– Mild
▪ Absence of organ failure and local or systemic
complications
▪ 85% of acute pancreatitis
▪ Inflammation without hemorrhage or necrosis
▪ Usually discharged within 3 to 5 days

– Moderately severe
▪ No organ failure or transient organ failure (< 48
hours) and/or local complications
▪ Frequently have extended length of stay
▪ May exacerbate comorbidities
▪ Have lower mortality rates than the severe form

– Severe
▪ 15% of acute pancreatitis
▪ Persistent organ failure (>48 hours) that may involve
one or multiple organs
▪ Most have pancreatic necrosis
▪ 30% mortality rate
▪ The most severe cases, pancreas becomes
hemorrhagic.

Describe collaborative management and nursing

responsibilities when caring for the patient with severe
pancreatitis.

Visual Map 13-5 Assessment and
Management of Acute Pancreatitis

Collaborative and Nursing Care of the
Patient with Severe Pancreatitis (1 of 11)
• Assessment and management focuses on:
– Correcting underlying cause
– Hemodynamic stability and fluid resuscitation
– Pain control
– Electrolyte balances
– Nutritional support
– Preventing and recognizing complications

• Assessment of Hypovolemia
– Nurse anticipates patient will experience severe
volume depletion.
– Signs and symptoms include:
▪ Poor skin turgor with dry mucous membranes
▪ Cool, clammy skin
▪ Flat jugular veins
▪ Hypotension or orthostatic hypotension with
dizziness
▪ Narrowed pulse pressure

– Signs and symptoms include:
▪ Tachycardia
▪ Decreased capillary refill
▪ Decreased urine output
▪ Mental status changes

– Severe necrotizing pancreatitis indicated by:
▪ Cullen’s sign
– Bluish discoloration around the umbilicus from
the escape of blood into the peritoneum
▪ Grey-Turner’s sign
– Bluish brown discoloration around the flanks
from blood in the retroperitoneal space

– Laboratory tests
▪ Hematocrit
▪ Leukocytes
▪ Serum electrolytes
▪ Blood urea nitrogen (BUN)
▪ Creatinine

– Laboratory tests
▪ Liver enzymes
▪ Calcium
▪ Glucose
▪ Abdominal ultrasound
▪ Abdominal imaging-CT scan and/or MRI

• Maintain Hemodynamic Stability and Normovolemia
– Invasive hemodynamic monitoring may be utilized to
determine fluid volume status.
– Treatment for hypovolemia involves:
▪ Aggressive fluid resuscitation
▪ Boluses of NSS, 1-2 liters followed by 250-500
mL/hr for 24-48 hours
▪ Blood transfusions
– Successful fluid resuscitation results in normalization of
vital signs & hemodynamics.

• Assessment and Management of Pain
– Patients frequently experience sudden severe onset of
pain.
– Adequate pain relief is a critical goal because the pain
is severe.
▪ Increases the patient’s anxiety level
▪ Unrelieved pain may indicate disease progression.
– IV administration of opiods and nonsteroidal anti-
inflammatory medications.
– Use morphine, dilaudid, or fentanyl.

• Nursing Actions
– Assess for signs of hypoxemia.
▪ Decreased oxygen saturation/pulse oximetry
– Less than 92%
▪ Increased or decreased respiratory rate
▪ Labored breathing, shortness of breath
▪ Abnormal lung sounds
– Crackles, wheezes, or decreased lung sounds
▪ Restlessness, anxiety, or decreased level of consciousness
▪ Cardiac dysrhythmias
▪ Respiratory insufficiency/failure necessitating intubation
ventilation

– Supplemental Oxygen
▪ Administered usually for the first 24 to 48 hours or
until there is no threat of hypoxemia.
▪ Progressive desaturation should be treated
aggressively as respiratory insufficiency/failure.
– Patient should be intubated and ventilated

– Assessment and Management of Infection
▪ Infection is a constant risk and significant cause of
late mortality.
▪ Treatment includes: fluid resuscitation, early enteral
feeding, antibiotics.
– Evidence-Based Interventions
– Debridement of Necrosis (Necrosectomy)/Surgery
▪ Surgical debridement of necrotic tissue.
▪ ERCP is used to remove obstruction and create a
passageway for ductile drainage.

Building Technology Skills (1 of 2)
• Endoscopic Retrograde Cholangiopancreatography (ERC
P)
– Invasive, endoscopic, and radiological procedure
– Involves oral intubation with a flexible fiber-optic
endoscope and advancing it into the duodenum to
directly view the ampulla/papilla of Vater
– Direct visualization of the ducts is accomplished by
injecting radiographic contrast medium and taking a
series of x-ray films.

Figure 13-5 MRCP Stone
(Lahey Clinic)

Building Technology Skills (2 of 2)
• Endoscopic Retrograde Cholangiopancreatography (ERC
P)
– Goals of a prompt ERCP are to:
▪ Remove the obstruction
▪ Create a passageway for sludge and other stones
▪ Improve pancreatitis
▪ Prevent cholangitis

FINALS 1 - Care of The Patient With An Acute Gastrointestinal Bleed or Pancreatitis

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Critical Care Nursing

Jason Anthony I. Alberto, RN

Care of the Patient with

Copyright © 2018 Pearson Education, Inc. All Rights Reserved

Copyright © 2018 Pearson Education, Inc. All Rights Reserved

Copyright © 2018 Pearson Education, Inc. All Rights Reserved

Compare and contrast risk factors, clinical

Copyright © 2018 Pearson Education, Inc. All Rights Reserved

Copyright © 2018 Pearson Education, Inc. All Rights Reserved

Copyright © 2018 Pearson Education, Inc. All Rights Reserved

Copyright © 2018 Pearson Education, Inc. All Rights Reserved

Copyright © 2018 Pearson Education, Inc. All Rights Reserved

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• GI bleeding is a common reason for a patient to be

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• Predisposing Factors and Causes of Gastrointestinal

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– Peptic Ulcer Disease

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(St Bartholomew’s Hospital/Science Source)

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• Predisposing Factors and Causes of Gastrointestinal

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• Manifestations of Gastrointestinal Bleeding

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• Manifestations of Gastrointestinal Bleeding

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– Assessment of Fluid Volume Status

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– Nurse assesses hemodynamic status by looking for

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– Interventions for Restoration of Normovolemia

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• Nasogastric Tube Placement

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▪ Upper Gastrointestinal Endoscopy

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– Categories of Therapeutic Interventions

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▪ New Endoscopic Technologies

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• Other Diagnostic Tests

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• Identification and Prevention of Recurrent Bleeding

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Explain why pancreatitis may develop and differentiate