GI 911: Rapid Response to Acute Abdomen - National Center of

29 Pages·2012·1.58 MB·English

GI 911: Rapid Response to
Acute Abdomen
Course # 128
Contact Hours: 20
Authors: Shelda L.K. Hudson, RN, BSN, PHN
Cheryl Duksta, RN, ADN, M.Ed.
Course Material valid through 08/2015
Copyright © 2012
W.S. Keefer
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© National Center of Continuing Education GI 911 Page 1
TABLE OF CONTENTS
About the Authors .............................................3 Figure 10: A Closer Look at Blood Products,
Purpose and Goals ............................................3 Colloids, and Crystalloids ...............................13
Instructional Objectives ....................................3 Figure 11: Massive Transfusions:
Introduction .......................................................3 Recognizing the Hazards ................................14
Assessing the Abdominal Quadrants ...............3 Bleeding Esophageal Varices .........................15
Inspecting the Abdomen ...................................3 Acute Pancreatitis ...........................................16
Figure 1: Nine Abdominal Regions ..................4 Appendicitis .....................................................16
Auscultating Bowel Sounds ..............................4 Figure 12: Reviewing Esophageal Tubes .......17
Percussing the Abdomen ..................................4 Acute Mesenteric Ischemia ............................18
Figure 2: Percussing the Abdomen ..................5 Abdominal Aortic Aneurysm (AAA) ...............18
Palpating the Abdomen ....................................5 Case Study: AAA Rupture ..............................19
Assessment of the Acute Abdomen ..................5 Abdominal Trauma .........................................19
The Patient's Description of Pain ....................5 Assessment ......................................................19
Figure 3: Estimating the Size of the Liver ......6 Diagnostic Tests ..............................................21
Key Observations ..............................................6 Intervention .....................................................22
Withholding Pain Medications .........................6 Evaluation .......................................................22
Figure 4: Some Causes of Acute Abdominal Pain ...7 Case Study: Abdominal Trauma ....................22
When Minutes Count ........................................7 Figure 13: Diagnostic Peritoneal Lavage ......23
The Causes of Acute Abdomen .........................7 Conclusion .......................................................23
Gastrointestinal Bleeding .................................7 Inside Tract Resource List ..............................23
Figure 5: Key Assessment Signs ......................8 Figure 14: Procedures Used to Diagnose
Figure 6: Evaluating Orthostatic Vital Signs .9 Abdominal Trauma .........................................24
Figure 7: Estimating Blood Loss ....................10 Skills Assessment ...........................................25
Figure 8: The Four Stages of Figure 15: Guide to Abdominal Trauma ........26
Hemorrhage .....................................................11 References and Suggested Readings ..............28
Figure 9: Lab Values That Signal a
GI Bleed ...........................................................12
Page 2 GI 911 © National Center of Continuing Education
About the Authors Instructional This course will show you how to put
the pieces of the puzzle together and
Objectives
Shelda L. Hudson, RN, BSN, PHN learn how to detect ominous trends to
completed her Baccalaureate Degree decrease your patient’s risk of compli-
At the completion of this course you
in Nursing and public health certificate cations. Using this information you will
will be able to:
at Azusa Pacific University. She is the be able to recognize injuries that may
1. Identify the nine regions of the
Nurse Supervisor of the Instructional be life-threatening and take action in a
abdomen and the underlying organs
Systems Development section of the Na- timely fashion to prevent deterioration
and structures.
tional Center of Continuing Education, while maintaining the safety of your
2. List the standard assessment sequence
Inc. In this capacity, she is responsible patient. The nurse's first response to a
to examine the abdomen.
for directing the activities of this depart- GI emergency is an assessment of the
3. Explain how to inspect, auscultate,
ment; selecting qualified, credentialed abdomen.
percuss, and palpate the abdomen.
authors for the courses offered by the
4. Describe two eponymous signs
National Center; and advising staff of Assessing the
associated with injury to specific
required course design and criteria. Ms.
organs. Abdominal
Hudson has more than 20 years of ex-
5. Differentiate the various four causes
tensive experience in publishing courses Quadrants
of acute abdominal pain.
in continuing education for healthcare
6. Identify common causes of bleeding Your assessment should include all
professionals with the National Center.
in GI emergencies. regions of the abdomen. The abdomen is
Cheryl Duksta, RN, ADN, M.Ed., is
7. Interpret various diagnostic studies commonly divided into four quadrants,
currently a critical care nurse in an inter-
used to confirm GI bleeding. with the umbilicus as the center point.
mediate care unit in Austin, Texas. She is
8. Compare pharmacological therapies Sometimes the abdomen is divided into
an active member of the American Asso-
in the treatment of GI bleeding. nine regions (see Figure 1).
ciation of Critical-Care Nurses (AACN)
9. Summarize the complications of
To examine the abdomen, use the
Greater Austin chapter. A master's pre-
acute pancreatitis, appendicitis, and
four standard assessment techniques
pared teacher and former public school
acute mesenteric ischemia.
of inspection, percussion, palpation,
teacher, Ms. Duksta frequently serves as
10. Describe the symptoms associated
and auscultation but not in the normal
a continuing education facilitator. She
with abdominal aortic aneurysm
sequence. Instead, inspect the abdo-
has 15 years of experience in educa-
rupture.
men first, then auscultate, percuss, and,
tion and medical publishing, including
11. Compare and contrast penetrating and
finally, palpate. Because percussion and
writer and editor at the National Center
blunt trauma.
palpation can affect bowel motility, in-
of Continuing Education, Inc.
12. Identify the procedures used to
creasing the frequency of bowel sounds,
diagnose abdominal trauma.
Purpose and Goals perform those actions after inspection
13. Determine the treatment goals for
and auscultation.
patients with abdominal trauma.
Gastrointestinal (GI) emergencies 14. Describe the procedure for peritoneal Inspecting the
can occur in a variety of situations. lavage.
Abdomen
The goal of this course is to educate
Introduction
healthcare professionals regarding
How you position yourself during
assessment of the abdomen, treatment
When patients suffer GI trauma, as- assessment of the abdomen can affect
methods, and care planning for patients
sessment doesn’t end in the emergency your observations. Standing at the foot
with emergencies of the GI tract.
department. Complications can develop of the bed for part of your inspection and
suddenly after patients are transferred then sitting to the patient’s side offer two
to other units of the hospital. Determin- vantage points that complement each
ing the cause of a GI emergency can be other. For instance, sitting will allow you
puzzling. The signs and symptoms can to better view the abdominal contour and
be subtle and are often obscured by other any visible peristalsis. When you stand,
life-threatening conditions or by drug you are at a better angle to evaluate
or alcohol use. The nature or extent of abdominal symmetry.
the injury cannot be determined by any To begin your inspection of the abdo-
single test. To see the whole picture, the men ask the patient to void and then lie
patient’s history, physical examination, supine with arms at each side. To help
lab reports, and test results must be relax the abdominal muscles, place a
evaluated. small pillow under the patient's head
(or raise the head of the bed a little) and
ask the patient to slightly flex his or her
knees. At the same time, encourage the
patient to take slow, deep breaths. Then
© National Center of Continuing Education GI 911 Page 3
Report any abnormal bowel sounds,
Nine Abdominal Regions
particularly when they are accompanied
The nine regions of the abdo-
by other signs and symptoms. Certain ab-
men are:
((11)) (2) (3) normal sounds indicate a life-threatening
1. right hypochondriac situation. For example, a patient who
2. epigastric has hyperactive, high-pitched, tinkling
bowel sounds that coincide with ab-
3. left hypochondriac
(4) (5) (6) 4. right lumbar dominal cramping may have an intestinal
obstruction.
5. umbilical
6. left lumbar Percussing the
7. right inguinal Abdomen
8. hypogastric
(7) (8) (9) By percussing the abdomen, you
9. left inguinal
can gain information about a patient's
During assessment, the most
abdominal structures. Three types of
frequently used regions are
percussion sounds help to determine
the epigastric, umbilical, the location of abdominal organs and
Figure 1 and hypogastric. structures. Dull percussion sounds,
which are heard when percussing over
shine a flashlight across the patient’s auscultate first, as long as you proceed
dense abdominal organs, are short and
abdomen. You can place the light either systematically, in a clockwise fashion,
high pitched. Dull sounds are heard over
at the foot of the bed or to the right of and listen to all four quadrants. Many
the liver in the RUQ, over the spleen just
the patient’s abdomen. Any changes in examiners like to follow the path of the
behind the left midaxillary line at the
abdominal contour will cast a shadow. large bowel: right lower quadrant (RLQ)
10th rib, and over a distended bladder.
Next, sit at the patient’s side so that to right upper quadrant (RUQ) to left
Percussing over an air-filled structure
your eyes are level with the patient's upper quadrant (LUQ) and finally to left
produces long, low-pitched, tympanic
abdomen. Inspect the patient’s skin lower quadrant (LLQ).
percussion sounds. These sounds occur
for pigmentation changes, superficial To begin, warm the diaphragm of the
over most of the abdomen because the
veins, lesions, rashes, striae, and scars. stethoscope with your hands. A cold
stomach and bowel contain gas.
Observe the size and shape of the abdo- diaphragm can cause abdominal tense-
A flat percussion sound is almost si-
men. Note whether it is concave, flat, ness. Place the warmed diaphragm on the
lent, very short, and high pitched. This
rounded, or distended and whether it abdomen, in one of the quadrants. Hold
sound occurs when you percuss over
appears symmetrical. Look for visible the diaphragm lightly in place and listen
muscle. Expect to hear flat percussion
masses, pulsations, and peristalsis. Then for bowel sounds. Note the quality and
sounds over the epigastric area.
assess the abdominal musculature and frequency of the sounds.
To percuss an abdomen, begin by per-
the condition of the umbilicus. Sometimes you may hear bowel
forming light percussion over the entire
Tell the patient to take a deep breath sounds that are almost continuous. These
abdomen, following the same sequence
and hold it. This will force the diaphragm hyperactive sounds indicate increased
you used to auscultate. Note areas of
downward, increase intraabdominal bowel motility, which may occur in
dullness, tympany, and flatness, as well
pressure, and reduce the size of the ab- patients with gastroenteritis or early
as any tenderness (see Figure 2).
dominal cavity. In many cases, you will intestinal obstruction. A prolonged gur-
Percussion is used to estimate the
be able to see hepatic and splenic masses gling sound, known as borborygmi, may
size of the liver. Start percussing on the
more easily when a patient holds his or result from increased motility and can be
right midclavicular line about two fin-
her breath. accompanied by diarrhea.
gerbreadths below the nipple. Because
Instruct the patient to raise his or her Sluggish bowel sounds (three or fewer
this area is over lung tissue, a resonant
head to further assess the abdominal per minute) indicate decreased motility.
percussion sound will be heard. As you
musculature. With the patient in this You might hear such decreased sounds
move down the midclavicular line, the
position, superficial abdominal wall in a patient with a late-stage bowel ob-
sound becomes dull, indicating the upper
masses, hernias, and muscle separations struction, paralytic ileus, or peritonitis.
border of the liver. Usually, a change in
should be more apparent. After a com- If you don’t hear bowel sounds in one
sound from resonance to dullness oc-
plete inspection, move on to auscultation quadrant, on to the next quadrant, take
curs somewhere between the fifth and
of bowel sounds. your time, and listen carefully. Bowel
the seventh intercostal spaces. Mark the
sounds are described as absent if they are
location using a water-soluble marker
Auscultating Bowel
not heard for at least 5 minutes. Common
(see Figure 3).
Sounds causes of absent bowel sounds include
To find the liver’s lower border, start
complete obstruction, paralytic ileus,
percussing on the right midclavicular
When auscultating for bowel sounds, peritonitis, and gangrene.
line about three fingerbreadths below the
it doesn’t matter which quadrant you
Page 4 GI 911 © National Center of Continuing Education
area and then quickly remove them. If
Right Upper Quadrant Left Upper Quadrant the patient feels severe pain after you
remove your fingers, the patient has
rebound tenderness, a classic sign of
peritoneal irritation. Remember, this
maneuver can be extremely painful, so
perform it at the end of the examination.
Note: If at any time you suspect appen-
dicitis or abdominal aortic aneurysm,
avoid deep palpation of the abdomen.
Assessment of the
Acute Abdomen
Acute abdomen is medical shorthand
for acute abdominal pain, usually ac-
companied by vomiting, constipation,
and changes in genitourinary function.
Right Lower Quadrant Left Lower Quadrant The word acute usually means a condi-
tion is brewing rapidly. For this reason,
Percussing the Abdomen you may equate an acute abdomen with
a surgical abdomen. The two terms
When percussing your patient's abdomen, move your hands
are not interchangeable; surgery is not
clockwise, starting from the right upper quadrant unless
always a foregone conclusion, although
your patient is experiencing pain. If he is, identify in which
a diagnostic laparoscopy and possibly
quadrant the pain is occurring and percuss that quadrant
an exploratory laparotomy may be per-
last. Remember when tapping, to quickly move your right
formed in many cases. As a general rule,
finger away so you don't damp vibration.
surgery is more likely when acute pain
Figure 2
lasts more than 6 hours. Because elderly
level of the umbilicus and move upward. acute cholecystitis, pelvic inflammatory patients present more frequently than
When the sound changes from tympany disease, and ruptured ectopic pregnancy. younger patients with operable diagno-
to dullness, you have reached the lower Voluntary guarding, on the other hand, ses, surgery is more likely for patients
border of the liver. Mark that location. can result because the patient is anxious. older than 60 years.
Now, measure the distance between To help a patient feel more relaxed, have Finding the underlying cause of an
the upper and lower borders. The nor- the patient take deep breaths through the acute abdomen is not an easy matter
mal liver span on the midclavicular line nose and then exhale through the mouth. because the pain may result from a
is 6–12 cm, depending on the person's After you have used light palpation number of causes, including intestinal
age. Measuring the liver may help you in all quadrants, examine each quadrant obstruction or perforation, vascular
identify underlying disease. A patient with deep palpation. Assess for deep ten- abnormalities, bacterial and viral infec-
with hepatitis, for instance, may have an derness and masses. If you find a mass, tions, inflammation, metabolic disorders,
enlarged, tender liver, whereas someone note its size, shape, consistency, texture, and poisoning (see Figure 4). No one test
with cirrhosis may have a small, hard motility, and location. If you detect ten- will clinch a particular diagnosis.
liver. derness, note its location and whether the Interestingly, for many patients with
tenderness is diffuse or localized. Also, acute abdominal pain their diagnosis
Palpating the record if guarding occurs. changes during their hospitalization.
Abdomen To palpate the liver, place your finger- For example, a patient admitted with a
tips below the pen mark indicating the diagnosis of “rule out pancreatitis” may
After percussing, use light palpation to lower border. As you gently push in and later be diagnosed with a common bile
relax the patient. Again, follow the se- up, ask the patient to take a deep breath. duct obstruction.
quence you established during ausculta- When the patient inhales, the edge of the
The Patient's
tion. With your finger pads, press gently liver should descend to meet your fin-
into the abdomen about 1 cm. Evaluate gertips. Normally, it should feel smooth, Description of Pain
muscle tone and check for distention, firm, and sharp. A cirrhotic liver feels
tenderness, and gross abnormalities. hard. If the liver feels hard and nodular, The quality of the pain associated with
If you detect tenderness, assess for however, a malignancy may be present. an acute abdomen may range from vague
guarding (or muscle rigidity). Involun- If you detect tenderness, check for to diffuse to immobilizing. Because
tary guarding may be associated with rebound tenderness. Push your finger many abdominal organs share the same
conditions such as acute appendicitis, pads gently but deeply into the tender nerve pathways, the source of the pain
© National Center of Continuing Education GI 911 Page 5
Key Observations discoloration in the flanks, a positive
Figure 3
Grey Turner's sign is present.
Keen observations skills are vital in
Cullen’s sign. Look for a bluish
assessing the acute abdomen. Watch
discoloration of the skin around the
your patient's behavior closely. You may
umbilicus, sometimes associated with
notice some key diagnostic clues. For
intraperitoneal hemorrhage, especially
example, if your patient is tachypneic
following rupture of the fallopian tube
but not using his or her abdomen to
in ectopic pregnancy. Cullen's sign may
breathe, the patient may have peritoneal
also indicate acute hemorrhagic pancre-
irritation. The patient with this condition
atitis (see Figure 5).
will often try to immobilize the abdomen
Rovsing’s sign. This sign is based on
and diaphragm to avoid pain. A patient
the concept that changes in intraluminal
with acute pancreatitis, on the other
pressure are transmitted through the
hand, may lean forward in an effort to
large intestine when the ileocecal valve
relieve pain.
is competent. Apply pressure to the pa-
Perform the iliopsoas test and the
tient’s left lower quadrant for 5 seconds,
oburator muscle test and observe your
trapping air within the large bowel. This
patient's response:
increases the pressure within the cecum
Iliopsoas test. With the patient lying and produces pain in the right lower
Estimating the Size of the Liver supine in bed, place one hand on the pa- quadrant if the appendix is inflamed.
tient's right hip and the other just below
To estimate the size of the liver, To complete your assessment, observe
the right knee. Now ask the patient to
follow the percussion pattern shown the patient as you test for shifting dull-
raise the leg against your resistance. If
ness. This test can detect changes in the
here. First, percuss upward and then
this maneuver is painful for the patient,
abdomen’s contour when the patient
downward on the right midclavicular
inflammation of the iliopsoas muscle
moves from the supine to the lateral
line. By noting in each sequence when
in the groin may be present, which is
position. These changes occur if there
dullness begins, you can approximate strongly suggestive of appendicitis.
is free fluid in the abdomen, such as
the lower and upper borders of the
Obturator muscle test. With the pa- with ascites.
liver. Normally, the distance between
tient lying supine, flex the hip and knee
To detect shifting dullness, percuss the
these borders, or the liver size, is
at right angles and rotate the leg both
abdomen with the patient lying supine.
2-3/8" to 4-3/4" (6 to 12 cm) at the internally and externally. A positive test
Start percussing along the midline of the
midclavicular line. elicits hypogastric pain and may indicate
abdomen, then move outward toward the
a pelvic mass or appendicitis.
flanks. Use a water-soluble pen to mark
can be hard to track down. For example, In addition to indicative patient be- all areas of dull percussion with a B (to
the pain produced by gallstones, ulcers, haviors, you may observe the following indicate that the patient was on his or
and esophagitis is very similar. eponymous medical signs: her back). Dullness is usually heard over
For these reasons, you must listen Murphy’s sign. Ask the patient to take abdominal fluid or masses.
carefully to your patient’s description a deep breath while you palpate the right Now have the patient roll to the side.
of the quality, location, duration, sever- subcostal area, below the hepatic margin. If free fluid is present in the abdomen, it
ity, and pattern of pain. Ask the patient As the patient’s diaphragm descends will move to the dependent side. Percuss
if the pain occurs with an activity, such during inspiration, the gallbladder, if the abdomen again, marking dull areas
as eating, or if it’s associated with a par- distended, will touch your fingers. This with RS (right side) or LS (left side). To
ticular body position. Remember that the contact will induce pain in the patient ensure consistent assessments among
absence of pain is not necessarily a good with cholecystitis. The patient may stop nurses, all nurses should use the same
sign. If the patient’s pain has subsided, it inhaling to guard against the pain. Mur- technique for marking shifting dullness.
may indicate that the affected tissue has phy’s sign is also known as the "sign of
become necrotic, which means it can no inspiratory arrest." Withholding Pain
longer send pain messages to the brain. Kehr's sign. A positive Kehr's sign is Medications
Be especially alert for changes in the a classic situation of referred pain. The
nature of the patient’s pain. For example, patient will complain of pain in the left In the past, nurses were discouraged
a patient may complain of sharp pain in shoulder, which is caused by irritation of from administering analgesics, anti-
the right lower quadrant, the classic sign the diaphragm due to bleeding. This sign spasmodics, smooth muscle relaxants,
of appendicitis, and then suddenly com- indicates a ruptured spleen. and anticholinergics before a medical
plain of generalized pain throughout the Grey Turner’s sign. This sign is indica- examination because these medications
entire abdomen. In this case, the patient's tive of blood collecting in the abdomen were thought to mask the patient’s pain
appendix may have ruptured—a medical from retroperitoneal hemorrhage. To during physical exam, making it diffi-
emergency requiring surgery. identify Grey Turner's, assess the pa- cult to accurately diagnose a condition,
tient's back. If the patient has a bluish which might delay surgery. This cardinal
rule is no longer followed in many cases.
Page 6 GI 911 © National Center of Continuing Education
Recent studies show that analgesics do
Some Causes of Acute Abdominal Pain not compromise assessment but instead
can enhance an assessment because they
relax the patient and relieve anxiety,
Right Upper Quadrant Left Upper Quadrant allowing for a more thorough exam.
In addition, physicians rely on lab and
radiologic studies for diagnosis in addi-
tion to observation. Therefore, patient
comfort during the physical exam is
allowed and encouraged.
Choice of analgesic depends on the
patient's age, symptoms, and possible
diagnosis, but morphine and fentanyl are
frequently prescribed. Any opiate anal-
gesic can cause spasm of the sphincter
of Oddi, but fentanyl is less likely than
morphine to induce spasm and is more
often the recommended analgesic for
relief of acute abdomen.
When Minutes Count
Assessment of the patient with an
acute abdomen is an active process,
requiring constant, curious attention. A
stable patient may rapidly deteriorate.
Because of the time-critical nature of
these injuries, effective communication
is paramount. Reassess patients regularly
Right Lower Quadrant Left Lower Quadrant
and after a patient reports a change in
symptoms and notify a physician of any
RIGHT UPPER QUADRANT LEFT UPPER QUADRANT
changes that may signal a compromise
Duodenal ulcer Ruptured spleen in the patient's condition.
Hepatitis Gastric ulcer
The Causes of Acute
Hepatomegaly Aortic aneurysm
Abdomen
Pneumonia Perforated colon
Pneumonia Many conditions can cause acute
RIGHT LOWER QUADRANT
abdomen. This course focuses on the
Appendicitis LEFT LOWER QUADRANT
causes classified as GI emergencies,
Salpingitis Sigmoid diverticulitis when quick thinking and early responses
Ovarian cyst Salpingitis are necessary to prevent loss of life. The
following sections describe the signs
Ruptured ectopic pregnancy Ovarian cyst
and symptoms of these conditions, their
Renal/ureteral stone Ruptured ectopic pregnancy
treatment, and the related nursing care.
Strangulated hernia Renal/ureteral stone
Meckel’s diverticulitis Strangulated hernia Gastrointestinal
Regional ileitis Perforated colon Bleeding
Perforated cecum Regional ileitis
GI bleeding most commonly comes
Ulcerative colitis from the upper GI tract (above the
PERIUMBILICAL
ligament of Treitz, at the duodenojejunal
Intestinal obstruction junction): mouth, esophagus, stomach,
Acute pancreatitis or duodenum. Common causes of upper
GI bleeding include abdominal trauma,
Early appendicitis
gastritis (a rare cause of massive bleed-
Mesenteric thrombosis
ing), peptic ulcer (a common cause of
Aortic aneurysm massive bleeding), and esophageal vari-
Diverticulitis Figure 4 ces (bleeding associated with significant
© National Center of Continuing Education GI 911 Page 7
Key Assessment Signs
Bluish discoloration
around the umbilicus
(Cullen’s sign) or flank
(Grey-Turner’s sign)
indicates abdominal
bleeding. With
Cullen’s sign, suspect
peritoneal bleeding
from ruptured ectopic
pregnancy or acute
pancreatitis. Grey-
Turner’s sign may
reflect retroperitoneal
bleeding from the
pancreas, duodenum,
kidneys, vena cava,
or aorta.
Figure 5
portal hypertension), which can result GI bleeding may also occur from the ● Colonic angiodysplasia—arterio-
from liver disease. lower GI tract (below the ligament of venous malformations, typically in the
The following conditions are less com- Treitz). Common causes of lower GI ascending colon and usually occurring in
mon causes of upper GI bleeding: bleeding include diverticulosis (most elderly patients with a history of aortic
● Mallory-Weiss syndrome—a muco- common), inflammatory bowel disease valvular disease or previous GI bleeding
sal lining tear just below the esophago- (rarely causes massive bleeding), and ● Bleeding diverticula—small pouches
gastric junction, which usually occurs hemorrhoids (usually cause mild, local that branch out from the intestinal wall
after violent or forceful vomiting bleeding). The following conditions that can become inflamed (diverticulitis)
● Boerhaave’s syndrome—esophageal are less common causes of lower GI and perforate, causing massive bleeding
bleeding:
perforation from esophageal dilation ● Rectal trauma—rectal perforations
(expect a history of vomiting blood after ● Intussusception—telescoping of a that frequently cause acute rectal hem-
a large meal bowel segment into its communicating orrhage
proximal segment; usually associated
● Osler-Weber-Rendu disease (he- ● Anal disorders—conditions of the
with the passage of currant jelly–like
reditary hemorrhagic telangiectasia)— anus that typically cause less dramatic
stools; usually occurs in children young-
chronic GI bleeding from dilated su- blood loss
er than 2 years of age
perficial capillaries and veins in the GI If you suspect your patient has a GI
mucosa bleed, perform a rapid assessment to
Page 8 GI 911 © National Center of Continuing Education
gauge the urgency of the situation. First, stools, also known as pseudomelena,
determine whether the patient is stable may indicate lower GI bleeding from Figure 6
or unstable. Pale, clammy skin; nervous- a condition that diminishes intestinal
Evaluating
ness, restlessness, and anxiety; slowed motility, such as obstructive cancer. (Re-
Orthostatic Vital
capillary refill time; and altered mental member that certain medicines, supple-
status are a few symptoms that may ac- ments, and foods can cause maroon or Signs
company an unstable GI bleed. black stools, including iron and bismuth
Obtain a set of vital signs. Acute, sig- preparations as well as spinach, beets, A change in your patient’s blood
nificant blood loss is often accompanied and licorice.) Suspicious stool should be pressure or pulse rate that accompa-
by increased heart rate and hypotension. sent to the lab for a guaiac test. If a pa- nies changes in body position may in-
Also, check for orthostatic or postural tient presents with symptoms of GI bleed dicate hypovolemia, a common result
changes in blood pressure and pulse, but has brown stools plan to have stool of acute GI bleeding. To measure or-
which help indicate the degree of acute collected for a guaiac test because brown thostatic vital signs, take the patient's
blood loss. For example, a drop in stools also can test positive, indicating blood pressure and pulse rate first
systolic blood pressure 20 mmHg and slight, intermittent, or chronic bleeding. while the patient is supine, then while
an increased heart rate of 20 beats per (See Figures 7 & 8 for symptoms of mild the patient is sitting, and last while
minute when a patient moves from su- to severe blood loss.) the patient is standing (wait at least 1
minute after each position change to
pine to standing reflect a blood volume Complications of GI bleeding may
obtain vital signs). Record your find-
loss of approximately 20%. The greater include anemia from blood loss; hy-
ings in the following manner:
the positional change in blood pressure povolemic shock from severe volume
and pulse, the greater the volume loss. depletion; exsanguination from rapid,
Supine: Blood pressure: 120/80, pulse: 86
(See Figure 6 for instructions on how massive intravascular blood loss; myo-
Sitting: Blood pressure: 110/70, pulse: 96
to obtain and document orthostatic vital cardial or cerebral infarction from acute Standing: Blood pressure: 80/40, pulse: 126
signs.) hemoglobin depletion; disseminated
If the patient is not in shock or exsan- intravascular coagulation (DIC) from Consider a decrease in systolic pres-
guinating, quickly determine the site of shock and clotting factor loss; peritonitis sure of 20 mmHg or more, or a pulse
the bleed (if it’s not evident): and sepsis from bowel rupture; and aspi- rate increase of 10 beats per minute
ration from massive upper GI bleeding.
● Upper GI bleed. Symptoms include or more, as positive for hypovolemia
hematemesis or melena. Hemateme- Keep in mind that for life-threatening and possible impending hypovolemic
sis—blood in vomitus or gastric aspi- bleeding, you may need to intervene as shock. Dizziness, light-headedness,
rate—may be bright red (indicating fresh you perform your assessment. or vision disturbances (e.g., blurred
bleeding) or the color of coffee grounds As your patient’s condition permits, vision) that occur when your patient
(indicating older blood decomposed by gather pertinent medical history and ob- changes position may also indicate
gastric hydrochloric acid). Hematemesis tain data about their symptoms. Most pa- orthostatic hypotension.
almost always reflects upper GI bleed- tients with GI bleeding report weakness,
ing. All vomitus and gastric aspirate easy fatigue, and abdominal discomfort.
should be tested to confirm the presence These symptoms may have been pres-
of blood. (Remember, however, that ent days, weeks, or months before the anti-inflammatory agents (NSAIDS), an-
traumatic insertion of a nasogastric, or patient seeks medical attention. Ask ticoagulants, steroids, and antacids. Also
NG, tube may cause the patient to swal- the patient about recent abdominal pain determine the patient's alcohol intake.
low blood, leading to a false-positive and tenderness (suggesting gastritis or a Perform a physical examination to
guaiac test.) Melena—liquid, tarry, foul- peptic ulcer); severe retching just before help uncover the cause of bleeding and
smelling black stools—usually reflects bleeding onset (suggesting Mallory- the patient’s response to it. Hematomas
upper GI bleeding. The result of blood Weiss syndrome); or a sudden fullness and petechiae suggest a blood disorder.
degradation, melena typically indicates in the throat followed by a gushing of Palmar erythema, spider angioma, jaun-
blood loss of at least 500 ml in a 24-hour blood (suggesting esophageal varices). dice, hepatomegaly, ascites, and caput
period. (Stools may also appear grossly Ask about recent dysphagia, heartburn, medusae may indicate liver disease.
bloody with a quick, massive blood loss, unexplained weight loss, hematemesis; Telangiectasia of the skin, lips, and buc-
reflecting short transit time through the and passage of black and tarry, maroon, cal mucosa suggest Osler-Weber-Rendu
bowel.) or bright red stools. Inquire about a his- disease. A pulsatile abdominal mass
● Lower GI bleed. Symptoms include tory of blood disorders; peptic ulcer; greater than 3 cm may mean an aortic
hematochezia or maroon or black stools. previous GI bleeding and its treatment; aneurysm. Hyperperistalsis usually
Hematochezia—bright red blood passed liver disease; gastric, abdominal, or indicates severe GI bleeding (intestinal
rectally—usually indicates lower GI vascular surgery; possible rectal trauma; blood acts as a potent laxative).
(primarily colonic) bleeding. Maroon or recent abdominal trauma. Determine Notify the physician immediately if
stools, formed from gross blood com- the use, frequency, and dosage of any you detect signs of shock: altered mental
bined with melena, usually indicate medications the patient is taking, particu- status; restlessness; increased anxiety;
bleeding distal to the duodenum. Black larly salicylate compounds, nonsteroidal
© National Center of Continuing Education GI 911 Page 9
Estimating Blood Loss
Blood Loss Estimated Physiologic
Signs and Symptoms
Severity Blood Loss Response
Mild blood loss <20% Mild to severe orthostatic Peripheral
Systolic blood hypotension; normal blood vasoconstriction
(<1,000 ml) vol-
pressure: pressure; cool, pale, diapho- and decreased per-
ume depletion
>90 mmHg. retic skin (patient feels cold); fusion to least vital
Pulse rate: <110 normal capillary refill time; peripheral organs
beats/minute collapsed neck veins; slight (skin, muscle, fat,
anxiety; concentrated, scanty bone). Increased
urine. circulating
catecholamines.
Moderate 20% to 40% Hypotension (as much as 50 Decreased
blood loss (1,000 to 2,000 mmHg systolic blood pressure perfusion to
Systolic blood ml) volume decrease); supine hypoten- kidneys, liver and
pressure: depletion sion; rapid, bounding pulse GI tract. Metabol-
at rest; pale mottled, cold, ic acidosis and
70 to 90 mmHg.
clammy skin; sluggish capil- hypoxemia.
Pulse rate: lary refill time (>2 seconds);
10 to 130 beats/ increased respirations; pa-
minute tient feels thirsty;
restlessness; increasing
anxiety; early mental status
changes; oliguria progressing
to anuria.
Severe blood loss >40% Severe supine hypotension Decreased
(<80 mm Hg, palpable to perfusion to heart
Systolic blood (>2,000 ml)
unobtainable); rapid, thready and brain. Se-
pressure: volume deple-
pulse (supine); cold, dusky, vere metabolic
tion
<70 mmHg.
gray skin; glassy eyes; pro- acidosis, respira-
Pulse rate: longed capillary refill time; tory acidosis, and
rapid, deep respirations; agi- hypoxemia.
>130 beats/min-
tation; confusion progressing
ute
to coma; anuria.
Figure 7
Page 10 GI 911 © National Center of Continuing Education