NUR 111 (Nursing Care of Clients with Life –

Threatening Conditions, Acutely Ill/Multi-organ

Problems, High Acuity and Emergency
STUDENT ACTIVITY SHEET Situation)
BS NURSING / FOURTH YEAR
Session # 11

LESSON TITLE: Upper Gastrointestinal Bleeding and Materials: MS notebook, paper, pen, index card,
Abdominal Compartment Syndrome and bond paper (short & long size)
LEARNING TARGETS: References:
At the end of the lesson, the student nurses can: Smeltzer S.C., & Bare B.G. (2010) Brunner and
1. Describe upper gastrointestinal bleeding and Suddarth’s Textbook of Medical- Surgical Nursing.
abdominal compartment syndrome; Lippincott William & Wilkins
2. Identify the signs and symptoms of UGIB;
3. Discuss nursing interventions of UGIB; Sommer S., Johnson J. (2013) RN Adult Medical
4. Discuss the risk factors of abdominal compartment Surgical Nursing. Assessment Technology
syndrome; and Institute, LLC.
5. Explain the therapeutic measure of ACS https://www.nurseslab.com

LESSON PREVIEW/REVIEW (10 minutes)

Instruction: Name at least 5 types of dysrhythmias.

Types of Dysrhythmias:

1.
2.
3.
4.
5.

MAIN LESSON (60 minutes)

Description

Upper gastrointestinal bleeding is characterized by the sudden onset of bleeding from the GI tract at a site (or sites)
proximal to the ligament of Treitz.
Most upper GI bleeds are a direct result of peptic ulcer erosion, stress related- mucosal disease, that may evidence as
superficial erosive gastric lesion to frank ulcerations, erosive gastritis (secondary to use or abuse of NSAIDs, oral
corticosteroids, or alcohol) or esophageal varices (secondary to hepatic failure).
In addition to these, Mallory-Weiss tears can cause gastroesophageal bleeding as a result of severe retching and
vomiting, but the bleeding tends to be less severe than in other types.

Hospitalized critically ill patients are at heightened risk for stress related mucosal disease, particularly if they are intubated
and mechanically ventilated and/or evidencing coagulopathies

Signs and Symptoms

 Melena and hematemesis
 Pain
 Hypovolemic shock

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Physical Examination

Vital signs Skin Cardiovascular Abdominal Other

 BP < 90 mm Hg  Pale,  Weak, thready  Maybe tender  Hematemesis

 HR > 100 diaphoretic pulse with guarding  Melena
beats/min  Cool, clammy  Capillary refill >  Bowel sounds  Bloody stool
 RR: tachycardia  Jaundice 3 sec hyperactive or with fetid odor
 Temperature: absent  Coffee ground
maybe elevated gastric aspirate

Acute Care Patient Management

Nursing Diagnosis:
 Deficient fluid volume related to blood loss from hemorrhage.
Outcome Criteria
 Patient alert and oriented
 Skin, pink, warm, and dry
 CVP 2 to 6 mm Hg
 PAS 15 TO 30 mm Hg
 PAD 5 to 15 mm Hg
 BP 90 to 120 mm Hg
 MAP 70 to 105 mm Hg
 HR 60 to 100 beats/min
 Urine output 30 ml/hr

Patient Monitoring
1. Obtain pulmonary artery pressure, central venous pressure and blood pressure every 15 minutes during acute
episodes to evaluate fluid needs and the patient’s response to therapy.
2. Monitor fluid volume status. Measure intake and output hourly to evaluate renal perfusion.
3. Measure blood loss if possible.
4. Continuously monitor ECG for dysrythmias and myocardial ischemia.

Patient Assessment
1. Assess patient for increases restlessness, apprehension or altered consciousness, which may indicate decreased
cerebral perfusion.
2. Assess hydration status.
3. Be alert for recurrence of bleedings.

Diagnostic Assessment
1. Review Hgb and Hct levels to determine the effectiveness of treatment or worsening of the patient’s condition.
2. Review clotting factors and serum calcium levels if multiple transfusions have been give.
3. Review serial BUN levels.
4. Review serial ABGs to evaluate oxygenation and acid-base status.
5. Review the result of endoscopic evaluation.

Patient Management
1. Maintain a patent airway. Administer supplemental oxygen as ordered.
2. Administer colloids as ordered to restore intravascular volume.
3. Type and crossmatch for anticipated blood products.
4. Evacuate stomach contents with nasogastric tube and initiate lavages with room temperature water or saline to clear
blood clots from the stomach.
5. Continue to monitor the patient closely once stabilized.
6. Vitamin K or fresh-frozen plasma (FFP) may be ordered to correct coagulation deficiencies.
7. Explain all procedures and tests to the patient to help alleviate anxiety and decreased tissue oxygen demands.

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ABDOMINAL COMPARTMENT SYNDROME

In most critically ill adults, normal intra-abdominal pressure (IAP, the pressure in the abdominal cavity) is 5 to 7 mm Hg.
IAH is defined as IAP of 12 mm Hg or more; abdominal compartment syndrome is a sustained IAP of 20 mm Hg or more,
with or without an abdominal perfusion pressure of less than 60 mm Hg and new organ dysfunction or failure.

Primary abdominal compartment syndrome results from direct injury to the abdomen or pelvic region such as in cases
of blunt or penetrating trauma or ruptured abdominal aortic aneurysm. Early surgical or interventional radiologic treatment
often is needed for this condition.

Secondary abdominal compartment syndrome doesn't originate from the abdominopelvic region; for example, this
condition can occur in patients with severe shock who required massive fluid loading due to hemorrhage, sepsis, capillary
leak, or major burns.

Risk factors for abdominal compartment syndrome include trauma;

 burns;
 liver transplantation;
 abdominal conditions such as massive ascites, abdominal surgery, or intraperitoneal bleeding (which raise IAP);
 retroperitoneal conditions such as a ruptured abdominal aortic aneurysm, bleeding from a pelvic fracture, and
pancreatitis;
 and surgeries or illnesses such as sepsis that require large-volume fluid replacement.

The gastrointestinal, hepatic, cardiovascular, respiratory, renal, and central nervous systems can be affected by
abdominal compartment syndrome.

 Gastrointestinal: decreased abdominal perfusion pressure, decreased perfusion to abdominal organs, bacterial
translocation, multiple organ failure, and low tolerance to enteral feeding.
 Hepatic: jaundice, increased serum liver enzymes, and coagulopathy can occur as pressure increases and
hepatic arterial flow decreases.
 Cardiovascular: tachycardia; decreased stroke volume, venous return, and cardiac output (secondary to
increased IAP and compression of the inferior vena cava); increased systemic vascular resistance; and increased
risk for venous thrombosis.
 Respiratory: tachypnea, hypoxia, increased intrathoracic pressure, and decreased tidal volume. The increasing
pressure displaces the diaphragm cephalad, which reduces intrathoracic volume and increases intrathoracic
pressure, leading to hypercapnia and hypoxemia.
 Renal: decreased renal perfusion and glomerular filtration rate if the retroperitoneal and renal parenchyma are
compressed, increased production of antidiuretic hormone (which can cause hyponatremia), and oliguria or
anuria. If not corrected, decreased renal perfusion can lead to renal dysfunction and renal failure.
 Central nervous system: increased intracranial pressure, increased agitation, mental status changes, and a
reduced Glasgow Coma Scale score

Most patients who develop abdominal compartment syndrome are critically ill and can't communicate signs and
symptoms. Patients who can communicate may report malaise, weakness, lightheadedness, dyspnea, or abdominal pain.

Assessment
 Physical assessment findings of abdominal compartment syndrome include a tense, distended abdomen,
progressive oliguria, and increased ventilatory requirements.
 Other findings may include hypotension, tachycardia, elevated jugular venous pressure, jugular venous
distension, peripheral edema, abdominal tenderness, acute pulmonary decompensation, and evidence of
hypoperfusion (cool skin, obtundation, restlessness, and lactic acidosis).
 Obtain a baseline IAP measurement for patients who have two or more risk factors for IAH or abdominal
compartment syndrome. Although IAP can be measured in several ways, the bladder pressure method is the
most reliable measurement via indirect means. Measure IAP at end-expiration.5 If the patient has IAH, obtain
serial IAP measurements throughout the patient's critical illness.

Therapeutic Measures
Temporary measures may be used to reduce IAP.
 A paracentesis may be performed to remove ascitic fluid and reduce pressure.

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  Endogastric tubes may be used for gastric drainage and enemas used to decompress the bowel.
 Analgesics and sedatives sometimes are used to help improve abdominal wall compliance, although in some
patient’s chemical paralytics are needed to achieve abdominal wall relaxation.
 Positioning the patient prone can reduce pressure on the vena cava and facilitate venous return.
 The most effective treatment for abdominal compartment syndrome is surgical abdominal decompression,
typically through a midline incision.
 The abdominal muscle fascia is usually left open and an alternate dressing closure is used.
 Wound management involves maintenance of this dressing and various drainage systems, such as vacuum-
assisted closure systems.
 Once the cause of the IAH is controlled, the abdomen can be closed. This may necessitate the use of skin grafts.

Nursing Interventions
 Because of tissue necrosis, patients with abdominal compartment syndrome are at risk for infection. Monitor the
patient's vital signs and surgical wound closely
 Report signs and symptoms of infection to the healthcare provider.
 Be aware of all complications that can occur systemwide with abdominal compartment syndrome, and assess the
patient each shift; more frequently if abnormalities occur
 Assess the patient's pain using a valid and reliable pain intensity rating scale.
 If the patient needs more analgesia than is prescribed, notify the healthcare provider.
 Perform a gastrointestinal assessment every shift or more frequently if needed, assessing for abdominal
distention, discoloration, and firmness. Assess bowel sounds.
 Assess the patient's nutritional status and ambulation status for changes from baseline.
 For patients who had surgery, assessment is essentially the same as for pre-surgery patients with abdominal
compartment syndrome.

 Monitor for signs and symptoms of infection (drainage, fever, abdominal distension and firmness, increased pain);
monitor nutrition, ambulation, and bowel sounds; and monitor intake and output, particularly if the patient has
wound drainage, anorexia, or decreased fluid intake.
 Because surgery to repair abdominal compartment syndrome can be extensive, provide emotional support for
patients and families and monitor for psychological changes. Consult the patient's healthcare provider about
referrals to social workers, chaplains, or counseling services as appropriate.

Patient Education
 Patients who've had surgery for abdominal compartment syndrome should be taught the signs and symptoms of
infection and to notify their healthcare provider immediately if they notice these signs and symptoms or have pain
(or worsening pain) at the operative site.
 Patients also should report decreased appetite and fluid intake.
 Teach patients about their prescribed pain medications and to notify their healthcare provider if their pain isn't
adequately controlled.
 Encourage patients to keep follow-up appointments with their healthcare providers.
By understanding abdominal compartment syndrome and how to promptly recognize it and intervene, you could help your
patient avoid complications and death.

CHECK FOR UNDERSTANDING (25 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:

Multiple Choice

1. The nurse is caring for a female client with active upper GI bleeding. What is the appropriate diet for this client during
the first 24 hours after admission?
A. Nothing by mouth
B. Regular diet
C. Clear liquids
D. Skim milk
ANSWER: ________

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RATIO:___________________________________________________________________________________________
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2. Kevin has a history of peptic ulcer disease and vomits coffee-ground emesis. What does this indicate?
A. His gastric bleeding occurred 2 hours earlier
B. He has fresh, active upper GI bleeding
C. He needs transfusion of packed RBC
D. He needs immediate saline gastric lavage
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
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3. Which diagnostic tests would be used first to evaluate a client with upper GI bleeding?
A. Upper GI series
B. Arteriography
C. Endoscopy
D. Hemoglobin level and hematocrit
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
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4. A male client with extreme weakness, pallor, weak peripheral pulses, and disorientation is admitted to the emergency
department. His wife reports that he has been “spitting up blood.” A Mallory-Weiss tear is suspected, and the nurse begins
taking a client history from the client’s wife. The question by the nurse that demonstrates her understanding of Mallory-
Weiss tearing is:
A. “Tell me about your husband’s alcohol usage”
B. Has your husband recently fallen or injured his chest?”
C. “Is your husband being treated with tuberculosis?”
D. “Describe spices and condiments your husband uses on food.”
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

5. A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The
client develops a sudden, sharp pain in the mid epigastric area along with a rigid, boardlike abdomen. These clinical
manifestations most likely indicate which of the following?
A. The esophagus has become inflamed
B. Additional ulcers have developed
C. An intestinal obstruction has developed
The ulcers have perforated
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
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6. Patient admitted to ER has profuse bright-red hematemesis. During initial care of the patient, the nurse's first priority is to:
A. perform a nursing assessment of patient's status
B. establish 2 IV sites
C. obtain a thorough health history
D. perform a gastric lavage with cool tap water in prep for endoscopic exam
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

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7. You promote hemodynamic stability in a patient with upper GI bleeding by:
A. Encouraging oral fluid intake.
B. Monitoring central venous pressure
C. Monitoring laboratory test results and vital signs
D. Giving blood, electrolyte and fluid replacement
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

8. Your patient has a GI tract that is functioning, but has the inability to swallow foods. Which is the preferred method of
feeding for your patient?
A. TPN
B. PPN
C. NG feeding
D. Oral liquid supplement
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

9. A 24-year-old man undergoes a laparotomy after a gunshot wound to the abdomen. The patient has multiple injuries
including significant liver laceration, colon injuries, multiple small bowels and an injury to the intrahepatic vena cava. The
patient receives 34 units of packed red blood cells, 15 liters of crystalloid, 11 units of FFP, and 12 pack of platelets. The
patient’s abdomen is packed close and he is taken to the intensive care unit for further resuscitation. Which of the
following is sequela of abdominal compartment syndrome?
A. Decreased systemic vascular resistance
B. Increased intracranial pressure
C. Decreased plasma renin and aldosterone
D. Decreased peak airway pressure
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

10. The patient is at risk for developing intra-abdominal hypertension (IAH) after surgery to correct abdominal trauma. In
which way will the nurse measure the progress of this complication?
A. Monitoring the amount of respiratory distress exhibited by the patient
B. Monitoring the amount of gastrointestinal tube drainage
C. Measurement of abdominal distention
D. Monitoring transurethral bladder pressure
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________

11. A patient has severe abdominal compartment syndrome and will undergo surgical decompression. The nurse will
expect to administer which drugs before this surgery to help reduce unstable cardiac dysrhythmias? Select all that apply
A. Furosemide
B. Vasopressin
C. Sodium Bicarbonate
D. Epinephrine
E. Mannitol
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

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12. A 52-year-old man was referred to the clinic due to increased abdominal girth. He is diagnosed with ascites by the
presence of a fluid thrill and shifting dullness on percussion. After administering diuretic therapy, which nursing action
would be most effective in ensuring safe care?
A. Measuring serum potassium for hyperkalemia
B. Assessing the client for hypovolemia
C. Measuring the client’s weight daily
D. Documenting precise intake and output.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________

13. A client with suspected gastric cancer undergoes an endoscopy of the stomach. Which of the following assessments
made after the procedure would indicate the development of a potential complication?
A. The client displays signs of sedation
B. The client demonstrates lack of appetite
C. The client complaints of a sore throat
D. The client experiences a sudden increase in temperature.
ANSWER: ________
RATIO:___________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________

14. Thrombus formation is a danger for all postoperative clients. The nurse should act independently to prevent this
complication by:
A. Encouraging adequate fluids
B. Performing active -assistive leg exercise
C. Massaging gently the legs with lotion
D. Applying elastic stocking
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
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15. Oxygen 3L/min by nasal cannula is prescribed for Joey who is admitted to the hospital for chest pain. The nurse
institutes safety precautions in the room because oxygen:
A. Supports combustion
B. Converts to an alternate form of matter
C. Has unstable properties
D. Is inflammable
ANSWER: ________
RATIO:___________________________________________________________________________________________
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RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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3. ANSWER: ________
RATIO:_______________________________________________________________________________________
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4. ANSWER: ________
RATIO:_______________________________________________________________________________________
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5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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6. ANSWER: ________
RATIO:_______________________________________________________________________________________
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7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________

RATIO:_______________________________________________________________________________________
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11. ANSWER: ________

RATIO:_______________________________________________________________________________________
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12. ANSWER: ________

RATIO:_______________________________________________________________________________________
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13. ANSWER: ________

RATIO:_______________________________________________________________________________________
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14. ANSWER: ________

RATIO:_______________________________________________________________________________________
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15. ANSWER: ________
RATIO:_______________________________________________________________________________________
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LESSON WRAP-UP (25 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

Al Strategy: Buzz Group

Instruction: You will form into groups (compose of 4-6 students) in order to discuss answer to question prompt by the
instructor. You will be given 3 minutes to discuss among yourselves prior to sharing it with the class.

(For Related Learning Experience, please refer to your clinical instructor.)

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