Clinical Findings

Neuro: Anxiety.

Resp: Shortness of breath.

CV: Tachycardia, hypotension.

Skin: Coolness, pallor, diaphoresis.

GI/GU: Bright red or dark coffee ground–appearing emesis, blood or “coffee grounds” in NGT drainage, distended, rigid, and/or tender abdomen, nausea, black stools.

MS: Weakness, fatigue.

Possible Causes: Gastric ulcer, duodenal ulcer, gastric erosions, esophagitis, esophageal varices, Mallory-Weiss syndrome, carcinoma, peptic ulcer, polyps, salicylates, NSAIDs, corticosteroids, leukemia, uremia, blood dyscrasias, hemorrhagic gastritis.

Collaborative Management

Vomiting blood is an emergency; STAT page physician.

• Position Pt upright to prevent aspiration and respiratory compromise—or turned to one side if altered LOC, debilitated, or inadequate gag reflexes.
• Suction oropharynx if Pt cannot clear vomitus or secretions.
• Monitor pulse oximetry and LOC.
• Assess respiratory status and lung sounds.
• Assess skin color and temperature, capillary refill.
• Assess VS supine and standing (if feasible), and document difference.
• Assess abdomen for distention, tenderness, guarding, peristalsis, and rigidity.
• Provide emesis basin if Pt alert and can maintain airway.
• Differentiate that Pt has vomited, not expectorated, blood.
• Establish IV (consider starting two large-bore IVs), and administer IVF or blood products as ordered.
• If Pt has an NGT and you notice streaks of blood, it may be minor irritation of mucosa from NGT; however, notify physician promptly if copious.
• Hematest emesis; assess amount and characteristics.
• Assess for use of anticoagulants, NSAIDs, or steroids.
• Check if Pt has been previously typed and crossmatched and if any blood products are available in blood bank.
• Prepare Pt for immediate transfer to ICU if unstable; monitor VS frequently (every 5 min if unstable).
• For stable Pts who do not require immediate ICU care, initiate more frequent monitoring of Pt status, initiate any new procedures, and administer all newly ordered medications.
• Place an NG tube if ordered, and connect to low intermittent suction.
• Monitor laboratory studies (CBC, electrolytes, blood urea nitrogen [BUN], prothrombin time [PT]/partial thromboplastin time [PTT]/international normalize ratio [INR], arterial blood gases; type and crossmatch).
• Insert a urinary catheter, and monitor UO hourly (to assess renal perfusion).
• Monitor serial hemoglobinhematocrit (Hgb/Hct).
• Provide oral hygiene and other comfort measures after episodes of vomiting.