Recognising gastrointestinal bleeding
Gastrointestinal bleeding is graded by location and speed. Upper bleeding, above the ligament of Treitz, presents as haematemesis or coffee-ground emesis when blood has been partially digested, and as melaena — black, tarry, foul-smelling stool — when it passes through the intestine. Lower bleeding presents as bright red blood per rectum, though very brisk upper bleeding can also appear red.
The nursing significance is not the colour but the volume and the client's perfusion. Tachycardia, orthostatic hypotension, cool clammy skin, restlessness and a falling urine output indicate significant blood loss even before haemoglobin falls, because haemoglobin lags behind acute loss until haemodilution occurs.
Priorities are large-bore intravenous access, isotonic fluid, type and crossmatch, keeping the client nil by mouth, monitoring vital signs frequently and preparing for endoscopy. A common exam trap offers documentation or a repeat haemoglobin in six hours as options; when perfusion is threatened, neither is the priority.
- •Coffee-ground emesis and melaena indicate upper GI bleeding
- •Haemoglobin lags behind acute blood loss — trust the vital signs
- •Two large-bore IVs, isotonic fluid, type and crossmatch
- •Avoid NSAIDs and alcohol in teaching for peptic ulcer disease
Liver failure and hepatic encephalopathy
Cirrhosis matters on the exam because of what the liver stops doing. It stops making clotting factors, so bleeding risk rises. It stops making albumin, so oncotic pressure falls and ascites and oedema develop. It stops metabolising ammonia, so neurological function deteriorates. It stops handling portal blood flow normally, so oesophageal varices form.
Hepatic encephalopathy is graded by mental status change, from subtle personality alteration and sleep reversal through confusion and asterixis to coma. Lactulose is the mainstay: it acidifies the colon, traps ammonia as ammonium and speeds elimination. Titrate to two or three soft stools daily. If a client has too many stools, the risk is dehydration and hypokalaemia; if too few, ammonia rises again.
Oesophageal varices are the emergency that hides inside cirrhosis. Any client with known varices who vomits blood requires immediate escalation. Teaching emphasises avoiding straining, coughing forcefully, heavy lifting and alcohol, and reporting any vomiting of blood or black stools immediately.
| Lost function | Clinical result | Nursing focus |
|---|---|---|
| Clotting factor synthesis | Bruising, bleeding, prolonged INR | Bleeding precautions, monitor INR |
| Albumin synthesis | Ascites, peripheral oedema | Daily weight, abdominal girth, sodium restriction |
| Ammonia metabolism | Confusion, asterixis, encephalopathy | Lactulose titrated to 2–3 soft stools daily |
| Portal circulation | Varices, splenomegaly | Avoid straining; report haematemesis immediately |
| Bilirubin conjugation | Jaundice, pruritus | Skin care, cool baths, short nails |
Pancreatitis, cholecystitis and bowel disease
Acute pancreatitis presents with severe epigastric pain radiating to the back, often relieved slightly by leaning forward, with nausea, vomiting and elevated serum lipase and amylase. Nursing management is nil by mouth to rest the pancreas, intravenous fluids, pain control, and monitoring for hypocalcaemia and respiratory compromise. Grey Turner's and Cullen's signs indicate haemorrhagic pancreatitis and are urgent.
Cholecystitis produces right upper quadrant pain, often after a fatty meal, with nausea and a positive Murphy's sign. Post-cholecystectomy teaching focuses on a low-fat diet initially, gradual reintroduction of foods, and reporting fever, worsening pain or jaundice.
Inflammatory bowel disease splits cleanly for exam purposes. Ulcerative colitis is continuous, limited to the colon and rectum, and produces bloody diarrhoea with a risk of toxic megacolon. Crohn's disease is patchy, can affect anywhere from mouth to anus, involves the full thickness of the wall and produces fistulas, strictures and malabsorption. Both need nutritional support, monitoring for dehydration and electrolyte loss, and skin protection around frequent stools.
- •Pancreatitis: NPO, IV fluids, pain control, sit forward with knees flexed
- •Ulcerative colitis: continuous colonic involvement with bloody diarrhoea
- •Crohn's: skip lesions, transmural, fistulas and malabsorption
- •Toxic megacolon signs: distension, fever, tachycardia, absent bowel sounds
Ostomy care and discharge teaching
A healthy stoma is pink to red, moist and slightly raised. A pale stoma suggests anaemia or poor perfusion, and a dusky, purple or black stoma indicates ischaemia and requires immediate reporting. Mild bleeding when cleaning is normal because stomal tissue is vascular; persistent bleeding is not.
Output differs by location. An ileostomy drains liquid to pasty stool continuously and carries a genuine risk of dehydration and electrolyte loss, so fluid intake teaching is essential. A colostomy in the descending or sigmoid colon produces more formed stool and may become predictable enough for routine emptying.
Practical teaching includes cutting the appliance opening to fit closely without touching the stoma, emptying the pouch when one-third full to prevent leakage from weight, chewing food well to prevent blockage with an ileostomy, and reporting no output with cramping pain, which may indicate obstruction. Psychosocial support and referral to an ostomy nurse specialist are legitimate exam answers, not filler.