Upper Gastrointestinal Bleeding Nursing Care Plan

Nursing Diagnosis 1: Fluid Volume Deficit

Fluid Volume Deficit related to Upper GI bleeding (UGIB): hemorrhage proximal to the ligament of Treitz; hematemesis, coffee-ground emesis, or melena as evidenced by Active hematemesis (bright red or coffee-ground); Melena or hematochezia documented; Tachycardia (HR > 110 bpm); Hypotension (SBP < 90 mmHg) or orthostatic changes; Decreased urine output (< 0.5 mL/kg/hr).

Interventions

• Monitor vital signs at intervals matched to clinical acuity and facility protocol (commonly q15 minutes during active bleed, advancing to q1h once stable); include orthostatics when safe and ordered.
• Establish and maintain two large-bore (16–18 g) peripheral IVs per facility protocol; coordinate central access with the provider team for failed peripheral attempts or persistent instability.
• Monitor and report serial Hgb, BUN, Cr, lactate, and coagulation studies per provider order (commonly q4–6h).
• Measure and document all emesis and stool output; describe character (bright red, coffee-ground, melena, hematochezia).
• Maintain strict hourly I&O; calculate net balance and trend with vital-sign changes per facility protocol.
• Maintain continuous cardiac telemetry and continuous pulse oximetry per facility protocol.
• Administer ordered IV crystalloid (NS or LR) per provider direction until blood products are available; reassess perfusion after each bolus.
• Verify type & cross is current and coordinate with blood bank to keep 2–4 units PRBC available bedside per provider order and facility protocol.
• Administer ordered blood products using two-RN/bedside verification per facility policy; transfuse PRBC over 2–4 hours, or rapidly via MTP when ordered for unstable patients.
• Administer ordered IV pantoprazole bolus and infusion (non-variceal) and/or octreotide bolus and infusion (suspected variceal) per provider order and facility protocol.
• Maintain NPO status per provider order; coordinate readiness for emergent endoscopy (consent support, NPO confirmation, baseline labs, blood available) per facility protocol.
• Support activation of the massive transfusion protocol (MTP) per facility protocol when criteria are met (commonly ≥ 4 U PRBC in 1 hour or ≥ 10 U in 24 hours) per provider order.
• Explain to the patient and family the rationale for IV access, NPO status, blood transfusions, and emergent endoscopy in plain language.
• Educate the patient post-stabilization on triggers to avoid (NSAIDs, alcohol, certain anticoagulants) and signs of rebleeding to report.
• Notify the provider for SBP < 90, HR > 120, UOP < 30 mL/hr x 2 hours, new hematemesis, or Hgb drop > 2 g/dL between draws.
• Coordinate with GI, anesthesia, ICU, and blood bank for emergent endoscopy and possible MTP activation per facility protocol.
• For refractory variceal bleeding despite ordered octreotide and endoscopic band ligation, coordinate with the provider team to prepare for balloon tamponade (Sengstaken-Blakemore or Minnesota tube) as a temporizing bridge and for emergent TIPS evaluation per facility protocol.

Outcome: MAP and perfusion indicators are monitored and reported within ordered parameters; HR trend is documented and reported within ordered parameters; Urine output is monitored and reported per facility protocol.

Nursing Diagnosis 2: Impaired Cardiovascular System

Cardiovascular Alteration related to Upper GI bleeding (UGIB): hemorrhage proximal to the ligament of Treitz; hematemesis, coffee-ground emesis, or melena as evidenced by Estimated volume loss ≥ 30% (ATLS Class III pattern); Sustained tachycardia and narrowed pulse pressure; Cool, mottled extremities with delayed capillary refill; Elevated lactate > 2 mmol/L; Troponin elevation that may reflect demand ischemia.

Interventions

• Maintain continuous cardiac telemetry per facility protocol; document any new arrhythmias or ST-segment changes.
• Assess peripheral perfusion (skin temperature, color, capillary refill, peripheral pulses) at intervals matched to clinical acuity (commonly every 1–2 hours).
• Trend serial lactate and central venous oxygen saturation when available and ordered.
• Monitor for signs of cardiogenic compromise: chest pain, dyspnea, new S₃, JVD, pulmonary crackles.
• Recheck troponin and ECG per provider order with significant Hgb drop, sustained tachycardia, or new chest pain.
• Administer ordered vasopressor support (commonly norepinephrine first-line) per provider direction and facility protocol to support MAP within ordered parameters.
• Coordinate central line placement per facility protocol when sustained vasopressor support is anticipated or peripheral access is inadequate.
• Administer ordered blood products using restrictive thresholds per provider order (commonly Hgb < 7 g/dL; cirrhosis target 7–8 g/dL).
• During acute hypotensive episodes while ordered volume resuscitation is underway, position the patient supine per facility protocol when clinically appropriate.
• Cluster nursing care to allow rest periods between assessments and interventions when clinical state allows.
• Explain to the patient and family the rationale for ICU-level monitoring, vasopressors, and frequent labs in plain language.
• Educate the patient post-stabilization on cardiac risk factors and the importance of cardiology follow-up after UGIB-associated troponin rise, when ordered.
• Findings such as persistent SBP < 90, MAP < 65 despite ordered resuscitation, new mottling, or decreased LOC should prompt urgent reassessment, provider notification, and rapid-response activation per facility protocol.
• Coordinate cardiology consultation per provider order for new ischemic ECG changes, sustained troponin elevation, or new heart-failure signs.

Outcome: MAP and perfusion indicators are monitored and reported within ordered parameters; Capillary refill and peripheral perfusion are documented and reported; Lactate trend is documented and reported to the provider team.

Nursing Diagnosis 3: Impaired Nutritional Status

Aspiration Risk related to Upper GI bleeding (UGIB): hemorrhage proximal to the ligament of Treitz; hematemesis, coffee-ground emesis, or melena as evidenced by Active hematemesis with potential for airway compromise; Altered level of consciousness from hypovolemia or sedation; Pre-procedure NPO may not always be feasible in emergent endoscopy; Decreased gag reflex during procedural sedation; Supine positioning during resuscitation.

Interventions

• Assess level of consciousness, gag reflex, and cough strength at intervals matched to clinical acuity (commonly every 1–2 hours during active bleed).
• Monitor SpO₂ continuously and auscultate breath sounds per facility protocol and after any vomiting episode.
• Observe for signs of aspiration: new cough, focal crackles, increased work of breathing, fever, or desaturation.
• Assess for hepatic encephalopathy in cirrhotic patients (asterixis, confusion, somnolence).
• Position the patient with head of bed elevated 30–45° during active hematemesis when hemodynamically tolerated and per facility protocol.
• Maintain suction setup (Yankauer catheter, wall suction) ready at the bedside at all times per facility protocol.
• Maintain NPO status per provider order until endoscopy is completed and a diet is ordered.
• For altered LOC or pre-procedure sedation, support lateral positioning with HOB elevated when clinically feasible per facility protocol.
• Coordinate anesthesia presence and airway readiness for high-risk endoscopy (active hematemesis, altered LOC, suspected variceal) per facility protocol.
• Place NG/OG tube only per provider order; coordinate with the provider before insertion in suspected esophageal varices.
• When the patient is alert, instruct to turn the head to the side and call for suction if feeling nauseated or about to vomit.
• Educate the family on the rationale for HOB elevation, NPO status, and bedside suction.
• Notify the provider for new desaturation, witnessed aspiration event, or new focal crackles.
• Coordinate anesthesia consultation per provider order for airway protection in patients with altered LOC, ongoing massive hematemesis, or planned emergent endoscopy.

Outcome: Airway patency is monitored and supported per facility protocol; SpO₂ is maintained within ordered parameters; Breath sounds are auscultated and changes reported.

Nursing Diagnosis 4: Impaired Urinary System Function

Anxiety related to Upper GI bleeding (UGIB): hemorrhage proximal to the ligament of Treitz; hematemesis, coffee-ground emesis, or melena as evidenced by Witnessing own hematemesis or large-volume melena; Verbalized fear of dying or worsening; Rapid escalation of care (multiple IVs, blood products, ICU transfer); Unfamiliar procedures (endoscopy, central line, transfusion); Sympathetic activation: tachycardia, restlessness, hypervigilance.

Interventions

• Assess anxiety level using a 0–10 scale at the start of every shift and PRN; identify patient-specific triggers.
• Observe for physical signs of anxiety: tachycardia disproportionate to clinical state, restlessness, hand-wringing.
• Differentiate anxiety-driven tachycardia from hypovolemic tachycardia by reassessing perfusion, Hgb trend, and response to ordered resuscitation.
• Provide a calm, reassuring presence; speak clearly and at a measured pace.
• Explain each procedure and finding in patient-friendly terms before performing it (IV insertion, transfusion, endoscopy prep).
• Facilitate a support person at the bedside when clinically feasible and per facility policy.
• Cluster nursing cares to allow protected rest periods when hemodynamically stable and per facility protocol.
• Limit non-essential stimuli at night (overhead lights, loud conversations, unnecessary alarms) per facility protocol.
• Teach diaphragmatic breathing and grounding techniques the patient can use independently.
• Educate the patient and family on what monitor alarms mean and what is and is not clinically concerning.
• Provide post-discharge education on what to expect at home, signs of rebleeding, and the follow-up plan.
• Coordinate with chaplaincy, social work, or psych services if anxiety persists or worsens despite non-pharmacologic measures.
• Notify the provider for severe or persistent anxiety unresponsive to non-pharmacologic measures.

Outcome: Patient verbalizes decreased anxiety on a 0–10 scale; Patient demonstrates at least one coping strategy; HR is consistent with clinical state and is monitored and reported.

Nursing Diagnosis 5: Knowledge Deficit

Knowledge Deficit related to Upper GI bleeding (UGIB): hemorrhage proximal to the ligament of Treitz; hematemesis, coffee-ground emesis, or melena as evidenced by Prolonged NPO status pre- and post-endoscopy; Blood loss with associated iron-deficiency anemia; Increased metabolic demand from acute illness; Cirrhosis with baseline protein-calorie malnutrition; Nausea or anorexia post-endoscopy.

Interventions

• Assess for signs of rebleeding (new hematemesis, melena, drop in Hgb, tachycardia) before advancing diet per provider order.
• Monitor weight, intake, and tolerance of prescribed diet each shift.
• Monitor for iron-deficiency anemia (Hgb, ferritin, transferrin saturation) per provider order post-bleed.
• Administer ordered diet advancement per provider order (commonly clear liquids → full liquids → soft → regular as tolerated).
• Administer ordered iron replacement (oral or IV) per provider direction and facility protocol.
• Coordinate dietitian consultation per provider order for cirrhotic patients or those with significant baseline malnutrition.
• Support small, frequent meals and avoidance of GI irritants (alcohol, NSAIDs, spicy foods) during recovery per provider direction.
• Educate the patient on avoidance of NSAIDs, aspirin (unless cardio-protective and approved by the provider), alcohol, and tobacco.
• Teach the patient about H. pylori eradication therapy when prescribed and the importance of completing the full course.
• Educate on a diet adapted to comorbidities (e.g., low sodium for cirrhosis) per provider and dietitian guidance.
• Teach rebleeding warning signs (new hematemesis, black or tarry stools, dizziness, weakness, palpitations) and when to seek emergency care.
• Notify the provider for poor PO intake > 48 hours, signs of rebleed, or inability to advance diet.
• Coordinate outpatient GI follow-up per provider order for repeat endoscopy and H. pylori testing as indicated.

Outcome: Patient verbalizes understanding of the diet-advancement plan; Patient verbalizes understanding of medications, including any H. pylori regimen when prescribed; Patient verbalizes rebleeding warning signs and when to seek care.

Upper GI bleeding (UGIB) is hemorrhage originating proximal to the ligament of Treitz, from the esophagus, stomach, or duodenum. Non-variceal sources account for 80–90% of cases: peptic ulcer disease (PUD, often H. pylori- or NSAID-related), gastritis/erosions, Mallory-Weiss tears, malignancy, AV malformations, and Dieulafoy lesions. Variceal sources (10–20%) arise from esophageal or gastric varices secondary to portal hypertension in cirrhosis and carry roughly 20–30% mortality with a ~30% rebleeding rate at 6 weeks. Clinical presentation: hematemesis (bright red or coffee-ground) may reflect active or recent bleeding; melena (black tarry stool) may reflect digested blood from an upper source via oxidized hemoglobin; hematochezia from an upper source can imply brisk bleeding with rapid intestinal transit. Hemodynamic severity can be described using the ATLS Class I–IV volume-loss classification (Class III ≥ 30% loss is typically symptomatic). The Glasgow-Blatchford Score (GBS) stratifies pre-endoscopy risk (0 may support outpatient management at provider discretion), and the Rockall score estimates post-endoscopy mortality. The AIMS65 score may also be used by the provider team for inpatient mortality risk stratification. Management is guided by the ACG 2021 UGIB Guideline and ASGE 2024 endoscopic-management guidance.

• IV access: 2 large-bore 16–18g; coordinate central access per facility protocol if unstable
• MTP threshold: 4U PRBC/1h or 10U/24h (1:1:1 PRBC:FFP:plt) per facility protocol
• Hgb transfusion: Provider-team threshold; commonly < 7 g/dL; cirrhosis target 7–8
• Endoscopy: ≤ 24h non-variceal (after resus); ≤ 12h variceal/unstable per facility protocol
• Octreotide gtt: 50 mcg bolus + 50 mcg/h commonly started empirically in cirrhotic UGIB per provider order
• TXA: Not indicated in UGIB (HALT-IT 2020: no benefit, ↑ VTE)

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