1

UPPER
GASTROINTESTINAL
BLEEDING
 •Overview of the
CONTENTS Health Problems
•Profile of the Patient
•Case Definition
•Anatomy and
Physiology
•Pathophysiology
•Signs and Symptoms
https://www.youtube.
CONTENTS
•Medical-Surgical
Management
•Diagnostic Studies
•Nursing Care Plan
(NCP)
•Drug study
•Discharge Planning
OBJECTIVE
S
 GENERAL OBJECTIVE

This case presentation seeks to provide

depth knowledge regarding to a patient
with diagnosis of Upper Gastrointestinal
Bleeding (UGIB) in order to provide
information and awareness to the people
about the topic, and to provide effective
 SPECIFIC OBJECTIVES
a) To introduce and provide deeper understanding about the topic.
b) To determine the its risk factors and different etiology.
c) To understand the disease process and to explain its clinical manifestation.
d) To recognize each possible diagnostic procedure available.
e) To understand the role of each drug therapy in managing the patient’s condition.
f) To render appropriate nursing care and health teaching to the patient and family.
g) To explain importance of the medical and surgical management in treating the
condition.
OVERVIEW OF THE
HEALTH PROBLEM
Gastrointestinal bleeding is a
potentially life-threatening
abdominal emergency that remains
a common cause of hospitalization.

Upper GI bleeding (UGIB) is

defined as bleeding derived from a
source proximal to of the ligament
of Treitz (the esophagus, stomach,
or duodenum)
 In the United States,

350,000
hospital admissions annually.
 In the United Kingdom,

70,000
hospital admissions each year, with the
majority of cases non-variceal in origin.
 In a nationwide
study from Spain

UGIB was 6x
more common
than LGIB
Changing trends in peptic ulcer prevalence in a tertiary care
setting in the Philippines: A seven-year study by Wong et. al

January 1996 to December 2002

University of Santo Tomas Hospital

In the Philippines,
Peptic ulcer prevalence decreased significantly
over a seven-year period.

35.87% in 1996 to
18.80% in 2002

Although the prevalence of peptic

ulcer bleeding remained stable.
 Changing trends in peptic ulcer prevalence in a tertiary care
setting in the Philippines: A seven-year study
by Wong et. al

There was no significant difference in the

incidence of bleeding between Gastric
Ulcer and Duodenal Ulcer.

The prevalence of bleeding secondary to

PUD remained stable during the 7-year
period.

No relationship was established between

the presence of bleeding and H. pylori
infection.
https://sci-hub.se/https://pubmed.ncbi.nlm.nih.gov/15836714/
 SEX
UGIB is twice as common in men than in women.
 AGE DEATH
Increases in prevalence with Mortality rates from UGIB are
age 60 yrs old and above. 6%-10% overall.
 16

PATIENT’S
PROFILE
Profile
Name: Patient X
Age: 37 years old
Sex: Male
Nationality: Filipino
Civil Status: Single

Religion: Roman Catholic

Address: Sta. Rosa, Nueva Ecija
Admission
Date: March 22, 2021
Time: 1:20 pm
Attending Physician: Dr. Lagoc
Diagnosis: UGIB to consider Anemia
Chief Complaint:
Blood in the vomit, black tarry stool
and epigastric pain that radiates in
the back.
 
Health History
Present Health History
2 weeks PTA: presence of epigastric pain
that radiates in the back.

1 day PTA: epigastric pain and 1 episode of

passage of black stool.

Few hours PTA: epigastric pain, 1 episode of

passage of black stool and
accompanied with vomiting
of fresh blood.
Health History
Past Health History
3 years ago: Anastomosis of Intestines at
Laguna Provincial Hospital Sta.
Cruz, Laguna.
• Allergies Ingestants, Injectants, Inhalants
and Contactants – none.
• Habits are smoking and consumption of
alcoholic beverages.
Health History
Family Health History
•Father : History of Hypertension
Died due to stroke.
• Grandmother: History of Diabetes.
.
Health Status
Nutrition-Metabolic Pattern
Diet as tolerated except dark colored food

Elimination Pattern
Have episode of black stool and normal
urination

Sleeping Pattern
Normal sleeping pattern

Cognitive-Perception Pattern
No problem in visual, vision and sensory
perception.
Health Status
Activity-Exercise Patterns
Decrease self-care ability as evidence by the
patient requires assistance or supervision from
another person.

Functional Level Code

Self-care Ability 0 Full self-care
II = Feeding I Requires use of equipment or device
II= Toileting II Requires assistance or supervision
II= Dressing from another person
II= Bathing Requires assistance or supervision
III
II= Bed Mobility from another person and equipment
II= Grooming or device
  IV Dependent and does not participate
Physical Assessment
Vital Signs
Temperature: 38.3° C
Pulse Rate: 110 bpm
Respiratory rate: 22 cpm
Blood pressure: 100/70 mmHg

Integumentary
Skin: pale in skin
Nails: pale nail bed with
poor capillary refill
Hair : Normal
Physical Assessment
HEENT
All normal except eyes.
Eyes: Pale conjunctiva

Abdomen
Pain in the epigastric region.
Graded as 7/10.

Musculo-Skeletal/Extremities
STRENGTH: weak muscle strength
ROM: limited
Physical Assessment

Neurologic and
Neck/Lymph Nodes
Normal findings.
 Hematology
MALE
Decrease due to
HEMOGLOBIN 73 g/dl 130-180
bleeding
g/dl

MALE Decrease due to

HEMATOCRIT 0.22 g/dl 0.40-0.54 bleeding
g/dl

5-10x Increase due to

TOTAL WBC 12.4
10^9/L inflammation

Blood Type: A+
 28

CASE
DEFINITION
 Upper gastrointestinal bleeding (UGIB)
a) Common medical condition with
various etiologies and presentations.
b) It is defined as blood loss originating
proximal to the ligament of Treitz.
c) The most common manifestation of
UGIB is melena or hematemesis.
a) A condition in which you lack enough
healthy red blood cells to carry
adequate oxygen to your body's tissues. ANEMIA
b) Having anemia can make you feel tired
and weak.

c) Upper GI bleeding  causes anemia due

to blood loss.
d) If hemorrhage is profuse, it is usually
detected before evidence of iron
deficiency anemia occurs, because
hematochezia or melena causes the
patient to seek medical attention.
ANATOMY
AND
PHYSIOLOGY
The Upper Gastrointestinal
tract is generally considered
to be:
• Mouth
• esophagus
• Stomach
• First part of the small
intestine (Duodenum).
 MOUTH
a) The oral cavity or mouth is responsible for the
intake of food.

b) The mastication refers to the mechanical

breakdown of food by chewing and chopping
actions of the teeth.

c) An enzyme called amylase breaks down starches

(complex carbohydrates) into sugars, which your
body can more easily absorb.
 ESOPHAGUS
a) The esophagus is a muscular tube of approximately 25cm in length
and 2cm in diameter, from pharynx to the stomach after passing
through an opening in the diaphragm

b) Primarily function is transport medium between mouth and

stomach.

c) The esophageal peristalsis consists of sequential contraction of

the circular muscles of the muscularis propria, that push the bolus
down to stomach.
 STOMACH

The stomach is a J shaped expanded bag.

It is divided into four main regions (Cardia,
Fundus, Body and Pylorus) and has two
borders called the greater and lesser
curvatures.

The functions of the stomach include:

a) Storage of ingested food.
b) Mechanical breakdown of food by churning
and mixing motions.
c) Chemical digestion by acids and enzymes.
 DUODENUM

a) The duodenum is the first part of the intestine.

b) It's largely responsible for the continuous

breaking-down process and receives secretions
from the liver (bile) and pancreas (pancreatic
juice containing digestive enzymes).
 Structure of Gastrointestinal Tract

a)Mucosa
b)Submucosa
c)Muscularis externa
d)Serosa
Lesions less than 5 mm in diameter are
termed erosions.
Lesions greater than 5 mm in diameter are
termed ulcers.
PATHOPHYSIOLO
GY
 Precipitating Factors: Conversion of Further mucosal
Alcohol and Smoking pepsinogen to erosion and Epigastric
pepsin destruction of Pain
blood vessels
Increase Hydrochloric acid
production Back diffusion of ulceration
acid into gastric
mucosa

Irritation of the lining of the Bleeding/hemorrhage

stomach or duodenum.
Decrease function
of mucosal cells, Black tarry stool Tachycardia
decrease quality of Vomiting with Tachypnea
Damage mucosal barrier mucus and loss of presence of
tight junction blood
between cells.
Inflammatory process
Pallor, poor Decrease Oxygen carrying capacity
capillary refill as manifested by decrease
Elevated WBC Elevated
and weakness hemoglobin and hematocrit level
temperature
SIGNS AND
SYMPTOMS
SIGNS AND 1. Black tarry stool.

SYMPTOMS 2. Vomiting with blood.

3. Epigastric pain (7/10) radiates in the back.
4. Feeling tired/weakness.
5. Pallor.
6. Tachycardia.
7. Tachypnea.
8. Elevated temperature.
9. Pale nail bed with poor capillary refill.
10. Decrease Hemoglobin and Hematocrit.
11. Elevated White Blood Cells due to presence of
inflammation.
MEDICAL-SURGICAL
MANAGEMENT
 Medical-Surgical Management

Blood transfusions generally

should be administered to
patients with upper
gastrointestinal bleeding who
have a hemoglobin level of 7
g per dL (70 g per L) or less.
 Medical-Surgical Management

Early upper endoscopy (within

24 hours of presentation) is
recommended in most patients
with upper gastrointestinal
bleeding.
 Medical-Surgical Management

Patients with low-risk peptic ulcer bleeding

based on clinical and endoscopic criteria can
be discharged on the same day as
endoscopy.

Most patients with high-risk peptic ulcer

bleeding and stigmata of recent hemorrhage
based on clinical and endoscopic criteria
should remain hospitalized for at least 72
hours.
 Medical-Surgical Management

Routine second-look endoscopy

is not recommended in patients
with upper gastrointestinal
bleeding who are not considered
to be at high risk of rebleeding.
 47

LABORATORY &
DIAGNOSTIC
STUDIES
Blood tests Nasogastric lavage

Stool tests Colonoscopy

Upper endoscopy Abdominal CT scan

Capsule endoscopy Flexible sigmoidoscopy

 Laparoscopy Laparotomy

Balloon-assisted enteroscopy
NURSING
CARE PLAN
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Fluid volume Short Term: Independent Short Term:

“Nung nasuka ako may deficit related to After 4 hours of 1. Assess vital signs, particularly blood pressure After 4 hours of nursing
dugo na kasama at nung blood volume loss nursing level. interventions, the
dumumi din ako may itim secondary to GI interventions, the 2. Commence a fluid balance chart, monitoring patient report
yung dumi ko” as bleeding as patient will report the I/O of the patient. Include vomiting, understanding of
verbalized by the patient. evidenced by understanding of gastric suctioning and other gastric losses in causative factors for
hematemesis and causative factors for the I/O charting fluid volume deficit.
Objective: melena. fluid volume deficit. 3. Educate the patient or guardian on how to  
  fill out a fluid balance. Long Term:
(Inspection) Long Term: Dependent After 3 days of nursing
Skin: Pale in color, After 3 days of 4. Administer blood transfusion as prescribed. interventions, the
smooth, no nursing 5. Start intravenous therapy as prescribed. patient will maintain
abnormalities interventions, the Electrolytes may need to be replaced fluid volume at
Nails: Pale in bed with patient will maintain intravenously. Encourage oral fluid intake of functional level as
poor capillary refill fluid volume at at least 2L per day if not contraindicated. evidenced by well
functional level.   Collaborative hydrated, intake is equal
6. Consult Dietician or nutritional team, as as output, and normal
indicated. capillary refill.
7. Establish a nutritional plan that meets
individual needs incorporating specific food
restrictions and special dietary needs.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: Activity After 8 hours of Independent: After 8 hours of nursing

“Nanghihina ako at intolerance nursing intervention 1.Encourage deep breathing technique and intervention the patient was
medyo nahihirapan related to the patient will be administer oxygen as prescribed. able to:
gumalaw” as able to:
verbalized by the Imbalance 2.Verbalization of feelings regarding limitations. Perform physical activity
Performs physical
patient. between oxygen activity 3.Aid in gradual increase of activities to tolerance as independently or with
supply and independently or the patient’s strength progress. devices as needed.
Objective: demand as with assistive 4.Gradually progress patient activity with the Improve self-care.
  manifested by devices as needed. following:
Self-care Ability decrease level of Improve self-care.  Range-of-motion (ROM) exercises in bed
II = Feeding hemoglobin and
II= Toileting hematocrit.  Deep-breathing exercises three or more times
II= Dressing daily.
II= Bathing  
II= Bed Mobility  Sitting up in a chair 30 minutes three times daily.
II= Grooming  Walking in room 1 to 2 minutes TID.
 
(II- Requires 5. Allow time for the patient to have undisturbed
assistance or rest.
supervision from 6. Document response to activity.
another person) Dependent:
  1. Give blood components (commonly packed
RBCs) via intravenous catheter as prescribed.
Collaborative:
1.Dietitician advise consumption of food rich in iron
and folate, also food rich in Vitamin C.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective:   Short Term Independent Short Term

“Medyo mainit Hyperthermia After 1 hour of 1. Monitor vital signs. After 1 hour of appropriate
yung related to appropriate nursing 2. Perform tepid sponge bath. nursing intervention, the
pakiramdam bacterial intervention, the 3. Remove excess clothing and covers. patient's temperature
ko” as infection as patient's temperature 4. Promote well-ventilated area for the patient. decreased to 37.5° C.
verbalized by evidence by will decrease to 37.5° C. 5. Encourage ample fluid intake by mouth. (Goal Met)
the patient. temperature of   6. Promote bed rest.  
  38.3° C and pulse   7. Advice patient to fully follow the prescribed Long Term
Objective: rate of 110 bpm. Long Term days of taking of medication even though the After 24 hours of appropriate
Temp: 38.3° C After 24 hours of symptoms disappeared earlier. nursing intervention, the
PR: 110 bpm appropriate nursing Dependent patient's vital signs return to
RR: 22 cpm intervention, the 1. Administer Co-amoxiclav (Amoxicillin) as normal range with a
BP: 100/70 patient's vital signs will ordered. temperature of 36.5-37.5°C,
return to normal range Collaborative pulse rate of 60-100 bpm and
with a temperature of Medical Technologist: respiratory rate of 12-20 cpm.
36.5-37.5°C, pulse rate of 1. Monitoring hematologic result for what type of Also, able to verbalize the
60-100 bpm and bacteria causing the infection. rationale of following the
respiratory rate of 12-20 Dietician: prescribed days of taking of
cpm. Also, will able to 2. Advice patient to eat food rich in fiber, contains medication.
verbalize the rationale of probiotics and rich in Vitamin C. Also, eat fresh (Goal Met)
following the prescribed vegetables and fruits.
days of taking of
medication.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective:   Short Term Independent Short Term

“Sumasakit yung Acute pain related After 1 hour of appropriate 1. Note reports of pain, including After 1 hour of appropriate
sikmura na to chemical nursing intervention, the location, duration and intensity (0-10) nursing intervention, the
umaabot burning of gastric patient will verbalize the 2. Review factors that aggravate pain patient verbalized the relief
hanggang likod mucosa as relief from pain and rate it 3. Note nonverbal pain cues. from pain and rate it as 2/10
tapos sumasakit evidence by pain as 2/10 from 7/10, and sign 4. Provide small frequent and limit foods from 7/10, and sign of comfort
din pagkatapos immediately after of comfort in facial that create discomfort. in facial expression.
ko kumain” as eating. expression. 5. Advise patient to stop consumption of (Goal Met)
verbalized by the   alcohol and smoking.  
patient.     Long Term
  Long Term Dependent After 24 hours of appropriate
Objective: After 24 hours of 1. Administer acetaminophen (Tylenol) as nursing intervention, the
Pain Scale: 7/10 appropriate nursing ordered. patient able to maintain pain
Facial grimacing intervention, the patient   in low level and able to avoid
will able to maintain pain in Collaborative aggravating factors of pain.
low level and able to avoid Dietician: (Goal Met)
aggravating factors of pain. 6. Advice patient to avoid foods like citrus
fruits, fried foods, spicy foods and
beverages like coffee and carbonated
drinks.
7. Advice patient to eat high-fiber foods
like nuts and seeds, legumes, berries,
and green vegetables.
 
DRUG STUDY
DRUG STUDY
DRUG STUDY
DRUG STUDY
DRUG STUDY
DRUG STUDY
 62

DISCHARGE
PLANNING
 Discharge Planning
Next Visit/ Doctor’s appointment
 Remind pt. to have follow up care to his
healthcare provided as directed.
 Explain to patient the importance of visiting for
check-up and other tests if advised to do so.
 Inform patient to not take medicines that is not
effective and safe or not advise by his physician.
 Instruct the pt. and his family to seek care
immediately if any of the following symptoms
return; nausea, vomiting, or heartburn.
 Discharge Planning
Diet/Nutrition
• Explain to patient the proper diet he needs or a
special diet he has to follow.
• Encourage the pt. to continue eating what is advised
for him as it can prevent problems such as GI bleeding.
• Instruct the family that the pt. needs to follow the
prescribed diet he needs.
• Inform the pt. and his family about the food that
needs to be avoided which are spicy food and caffeine or
any food that can cause heartburn, nausea or diarrhea.
 Discharge Planning

Exercise
• Advice patient to rest as directed.
Promote proper exercise by simply
stretching hand and feet.
 Discharge Planning

Hygiene
• Provide health teachings for patient and
his family regarding proper hygiene and
hand washing.
• Instruct patient to have proper intake of
clean water and vitamins.
 Discharge Planning

Motivation
• Provide spiritual prayer for the family or
depending on the family’s religion.
• Advise patient and his family to do not
lose hope.
• Motivate the patient to improve his
condition and for faster healing
Prepared by:

JEFFREY R. GALANG Ed.D, MAN, RN

69