Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiological changes to the patient’s gastrointestinal concerns when in the intensive care unit
- Describe the medical assessments and therapies that apply to the critical care patient’s gastrointestinal system
- Apply nursing concepts and plan associated nursing care for the critical care patient’s gastrointestinal system
The gastrointestinal (GI) system is often overlooked for critical care patients because it may be viewed as less important than evidently life-sustaining body systems such as the cardiovascular or respiratory systems. However, the GI system plays an essential role in nutrient absorption, fluid and electrolyte balance, and provision of energy for the maintenance of overall body metabolism. Critically ill patients are at risk for adverse GI effects and complications if this system is not properly assessed and treated as part of the patient’s plan of care while in the ICU. For these reasons, care of the GI system should be a nursing priority in addition to the care provided for all other body systems.
Pathophysiological Insult to the Critical Care Patient’s GI System
The most common reason for admission to the ICU related to the GI system is acute bleeding. One of the main causes of GI bleeding is the presence of bleeding stress ulcers, usually in the stomach or intestines. These ulcers often begin as peptic ulcer disease (PUD) and can quickly become life-threatening if they rupture and bleed.
Another common cause of GI bleeding is related to esophageal varices: small veins that form when portal hypertension is present, often due to alcoholic cirrhosis liver disease. Esophageal varices are only able to withstand low blood pressure, so they are prone to rupture and bleeding, especially in patients with chronic hypertension.
Common assessment findings for patients with acute GI bleeding are:
- abdominal pain or cramping
- anemia
- cool, clammy skin
- decreased LOC
- decreased urine output
- hematemesis (bloody vomitus)
- hypoactive bowel sounds
- hypotension
- melena (bloody stools) and/or dark tarry stools
- tachycardia
Medical Assessments and Therapies
A complete blood cell count (CBC) and comprehensive metabolic panel can be used to detect the presence of GI bleeding. Results may show hemoglobin and hematocrit levels to be normal at first but then decreasing. Platelet count may initially increase to maintain clotting and stop the bleeding, but it decreases as platelets are used up. Other common laboratory values that may indicate a GI bleed are:
- elevated blood glucose level
- increased blood urea nitrogen (BUN) and serum creatinine levels
- increased partial thromboplastin time or increased prothrombin time
- increased serum lactate level
- increased white blood cell count due to inflammation
If an acute GI bleed is suspected, the patient will likely be scheduled for an emergent endoscopy. This procedure involves the insertion of an endoscope through either the esophagus (for upper GI bleeds) or rectum (for lower GI bleeds) to enable direct visualization of the potential bleeding site. During this procedure, if bleeding is noted, the provider can use a laser on the end of the scope to cauterize the bleeding so that it stops completely or at least slows.
Pharmacological Supports
There are several medications that are indicated for a critically ill patient experiencing an acute GI bleed. First, use of antibiotics is often implemented because the development of stress ulcers has been linked to bacterial infections by Helicobacter pylori (Zhang et al., 2021). Patients are prescribed a2-week course of antibiotics to eradicate the bacteria completely and prevent the development of additional ulcers in the future. Most patients experiencing bleeding from stress ulcers will also be recommended to take a PPI such as omeprazole (e.g., Prilosec) or pantoprazole (Protonix) to decrease gastric acid secretion and allow for complete healing of the ulcer. If the bleeding originates from esophageal varices, octreotide (Sandostatin) can be used to stop the bleeding. This medication works by reducing pressure within the portal vasculature, which slows bleeding. It is important to note that these medications should all be administered intravenously, because patients with acute GI bleeds should not ingest anything by mouth; this allows their GI system to rest and heal.
Nursing Care
Patients presenting with acute GI bleeds are immediately placed on “nothing by mouth” (NPO) restrictions. Thus, all medications will be administered intravenously instead of orally, and the patient will not be allowed to eat or drink until the bleeding has resolved. This allows the GI system to rest and heal without the added stress of having to process food and medications.
The immediate priority when caring for patients with acute GI bleeding is maintaining hemodynamic stability. Gastrointestinal bleeds can quickly become life-threatening without medical intervention. It is important for the nurse to closely monitor the patient’s hemodynamic status and vital signs and intervene as needed. Patients with GI bleeding may require IV fluid replacement or multiple blood transfusions to restore lost blood volume (DiGregorio & Alvey, 2022). They may also require the use of vasopressor medications if they are experiencing severe hypotension from the loss of blood. For patients requiring blood transfusions, it is important to ensure that informed consent has been obtained from either the patient or the patient’s DPOA agent if they are unable to give consent. Some patients will not be agreeable to receiving blood transfusions because of personal or spiritual beliefs.
The insertion of a nasogastric tube (NGT) is often indicated for patients with acute GI bleeding; therefore, nurses must be familiar with and comfortable performing this skill quickly at the bedside. After insertion, the NGT is typically connected to low, intermittent suction. This level of suction allows for blood and other gastric contents to be pulled out of the patient’s stomach in a slow, controlled manner.
Clinical Safety and Procedures (QSEN)
QSEN Competency: Safety
Definition: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Skills Checkoff: NGT Insertion
- Wash hands.
- Don appropriate personal protective equipment.
- Explain procedure to patient.
- Ask patient about potential contraindications (e.g., deviated septum, facial trauma).
- Check nostril patency. Have the patient occlude one nostril and assess breathing through the other nostril. Determine which nostril provides better airflow and should be left open.
- Estimate length of tube to be inserted by measuring the end of the tube from the tip of the patient's nose to the earlobe and then down to the xiphoid process. Mark this spot on the tube with tape or a marker or note the correct black measurement marking printed on the tube.
- Lubricate the tip of the NGT with KY jelly or petroleum-based lubrication.
- Gently insert the tip of the NGT into the chosen nostril and slide it along the nasal cavity floor, aiming the tube down and back.
- Have the patient take sips of water through a straw while you insert the tube to facilitate its passage down the esophagus. Continue advancing the tube until the predetermined length of tube has been inserted.
- If the patient is severely gagging or has a hoarse voice, or if oxygen saturation is decreasing, remove the tube immediately because it may be located in the airway.
- Use hospital protocol to check correct placement of NGT. This typically involves use of a chest X-ray or aspiration of gastric fluid to check pH.