2. 1 Close observation of vital signs and blood pressure: massive hemorrhage in the digestive tract can lead to shock, and the main cause of hemorrhagic shock is insufficient blood volume, which is manifested by decreased blood pressure and decreased pulse pressure difference; Observation of pulse condition: the change of pulse condition is the main sign of observing shock, the pulse condition is accelerated in the early stage of shock and slow in the late stage of shock; Body temperature observation: The body temperature of patients with blood loss is mostly lower than normal or does not increase. After the general shock is corrected, low or moderate fever may occur, generally ≤38.5℃, lasting for several days or weeks. The reason is that the decomposition products are absorbed after bleeding, the blood volume is reduced, and the thermoregulatory center is out of balance, leading to fever. If the body temperature is ≥38.5℃, infection after bleeding should be considered. If the body temperature continues or does not rise after fever, re-bleeding should be considered.
2.2 Observe the nature of hematemesis, the amount of blood in stool and gastrointestinal bleeding > > 60 ml, which can lead to black, tar-like and fishy stool; The amount of bleeding is large, the blood stays in the intestine for a short time, and dark red or bright red stool may appear. Hematemesis can appear above the pylorus, while melena appears below the pylorus. Repeated hematemesis or black stool is frequent and thin, suggesting continuous bleeding.
2.3 Observing urine volume can reflect systemic circulation and renal blood flow, so it is necessary to correctly observe the 24-hour inflow and outflow.
2.4 Observing consciousness and limbs, there are no obvious symptoms when the bleeding amount is below 5%, dizziness, dizziness, thirst and other symptoms can appear when the bleeding amount is above 5%, and shock symptoms such as irritability, apathy and cold limbs can appear when the bleeding amount is above 20%.
2.5 Observe whether there are signs of rebleeding. Patients with upper gastrointestinal bleeding often get sick repeatedly. After the bleeding is controlled, it is still necessary to observe whether there is any rebleeding. For example, the patient vomited blood repeatedly, the stool was black, the color changed from dark black to dark red, and even the vomit turned bright red. Unstable blood pressure and pulse indicate rebleeding.
Step 3: Nursing
3. 1 Replenish the blood volume in time, quickly establish two venous passages, replenish the blood volume in time, and quickly start the rescue treatment, but also avoid pulmonary edema or rebleeding caused by excessive and rapid transfusion, thus aggravating the condition.
3.2 Strengthen basic nursing posture nursing: absolutely stay in bed when bleeding, take supine position, and tilt your head to one side to prevent suffocation caused by hematemesis; Dietary care: when severe hematemesis or obvious bleeding occurs, you must fast. If the bleeding does not continue after 24 hours, a small amount of warm liquid and digestible diet can be given. After the condition is stable, instruct patients to eat regularly and quantitatively, eat less and eat more meals, avoid eating rough, cold, spicy and other irritating foods, and prohibit smoking, drinking, strong tea and coffee. Oral care: after each hematemesis, do oral care in time to reduce the smell of blood in the mouth, so as not to cause nausea and vomiting again, and at the same time increase the comfort of patients; Skin care: keep the skin clean and the bed clean and dry, and clean things in time after vomiting blood and defecation.
3.3 Psychological Nursing Psychological nursing refers to that in the whole nursing process, nurses actively influence patients' psychological state through various ways and channels to achieve their best physical and mental state. The necessary condition is that nurses should establish good interpersonal relationship with patients.
And have a deeper understanding and accurate evaluation of the existing psychological problems [1]. Without a correct understanding of the disease, patients are prone to nervous fear and aggravate bleeding. In particular, patients with recurrent bleeding feel gloomy, negative and pessimistic because of the heavy economic burden brought to their families by repeated hospitalization, and lose confidence in treatment. Therefore, it is particularly important to do effective psychological care. The calm attitude, friendly language, serious questions and answers, decisive decision-making, calm, calm and skilled operation of medical staff can give patients a sense of security, reduce their mental tension and fear, and are conducive to the establishment of a good nurse-patient relationship and the cooperation of further treatment.
3.4 Instructions for drug use should be strictly in accordance with the doctor's advice, and be familiar with the pharmacological effects, precautions and adverse reactions of the drugs used. For example, when dropping pituitrin to stop bleeding, the speed should not be too fast, so as not to cause abdominal pain, arrhythmia and myocardial infarction [2], and blood products such as potassium supplementation and blood transfusion should be carried out according to the doctor's advice.
3.5 Nursing care of three-cavity and two-bag tube compression hemostasis Check whether there is air leakage before intubation, and observe the patient's complexion and consciousness at any time during intubation. After intubation, the pressure of gastric balloon should be kept at 50 mmHg~70 mmHg, and the pressure of esophageal balloon should be kept at 35 mmHg~45 mmHg. The color and quantity of drainage fluid should be closely observed, and balloon gas should be released after 24 hours of intubation to avoid mucosal necrosis caused by long-term compression. In view of the progress of drug therapy and endoscopic therapy in recent years, balloon compression is not recommended as the first choice for hemostasis [3].
3.6 Patients with cyanosis should take oxygen, those in shock should keep warm, those who are nervous should be given diazepam, and patients with liver disease should be prohibited from barbiturates, phenothiazine and morphine.
3.7 Health guidance teaches some common sense of this disease to family members, so that they have a certain understanding of the treatment process, get the cooperation of family members, and help doctors solve some practical problems; Teach patients and their families to identify early signs of bleeding and emergency measures, stay in bed when hematemesis or melena occurs, keep quiet and reduce physical activity; Help to master the etiology, prevention and treatment knowledge of diseases and syndromes and reduce the risk of rebleeding; Maintain a good attitude and optimism, treat diseases correctly, arrange life reasonably, and enhance physical fitness. You should quit smoking and drinking, take medicine under the guidance of a doctor, don't use it by prescription, and take certain drugs carefully. In a word, upper gastrointestinal bleeding is acute, dangerous and fast-changing, which is easy to cause hemorrhagic shock and circulatory failure and is life-threatening. If correct diagnosis, effective hemostasis treatment and careful nursing can make patients turn the corner, improve the cure rate and reduce the mortality rate, so as to achieve the purpose of rehabilitation.