Medical-surgical Nursing Demystified

(Sean Pound) #1

CHAPTER 7 Gastrointestinal System^305



  • Diaphoresis (sweating)

  • Nausea


INTERPRETING TEST RESULTS



  • Positive fecal occult blood.

  • Hemoglobin drops.

  • Hematocrit drops.

  • Anemia (iron deficiency) with chronic slow bleed.

  • Nasogastric aspirate positive with upper GI bleed.

  • Anoscopy, sigmoidoscopy, or colonoscopy may show site of lower GI bleed.

  • Arteriography may show site of bleed.

  • Bleeding scan may show site of bleed with radioisotope-tagged RBCs.


TREATMENT



  • Maintain IV access.

  • Administer isotonic fluids like normal saline.

  • Monitor serial hemoglobin and hematocrit levels.

  • Type and cross match for 3 to 6 units depending on amount of blood loss.

  • Transfuse packed RBCs, type-specific when possible (type O negative when
    type-specific unavailable—no time to get results back from lab yet).

  • May need to administer albumin or fresh frozen plasma, depending on amount
    of units transfused and comorbidities such as cirrhosis or clotting disorders.

  • Endoscopic procedures to treat ulcer topically, with injectable or laser treatment.

  • Esophageal varices may be treated by tamponade with Blakemore-Sengstaken
    tube.

  • Surgery indicated when bleeding uncontrolled.


NURSING DIAGNOSES



  • Deficient fluid volume

  • Decreased cardiac output

  • Anxiety

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