Any bleeding that takes place in the gastrointestinal tract is referred to as gastrointestinal (GI) bleeding. The esophagus, stomach, small and large intestine (colon), rectum, and anus are all parts of the GI tract. GI bleeding is not an illness in and of itself, but rather a sign of an underlying condition.
Upper and lower origins of bleeding are the two main divisions of GI bleeding. The ligament of Treitz sometimes referred to as the suspensory ligament of the duodenum, is the anatomical marker that delineates the upper and lower bleeding.
Upper GI bleeding (UGIB) occurs more frequently than lower GI bleeding (LGIB). Men are more likely than women to have vascular disorders and diverticulosis, which makes LGIB more prevalent in men. With age, the incidence rises.
In this article:
Nursing Process
It is important to treat hematochezia, hematemesis, or melena promptly. This usually requires admittance to an acute care hospital with consultation from a gastroenterologist and a surgeon. It is vital to determine the source and cause of bleeding and intervene.
Effective nursing care is essential for patients with gastrointestinal bleeding to alleviate symptoms, lower the risk of complications, and promote patient psychological well-being and prognoses. Nursing interventions are also implemented to prevent and mitigate potential risk factors.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to GI bleeding.
Review of Health History
1. Ask the patient about the current and past GI bleeding incidents.
Collect information about the current and previous episodes of GI bleeding. This can help analyze symptoms and possible causes, leading to a diagnosis and prompt treatment.
2. Review the patient’s medical history.
Review the patient’s medical records, past medical history, and comorbidities that may be relevant to potential causes of bleeding, such as:
- Varices
- Portal hypertension
- Alcohol abuse
- Smoking
- Ulcers
- H. pylori infection
- Diverticulitis
- Hemorrhoids
- Inflammatory bowel disease
- Stomach, esophagus, or colon cancer
3. Review the patient’s medication regimen.
The following medications can contribute to GI bleeding:
- Nonsteroidal anti-inflammatory drugs
- Anticoagulants
- Antiplatelet drugs
- Bismuth
- Iron
4. Assess the patient’s general symptoms related to GI bleeding:
The following symptoms are linked to GI bleeding:
- Abdominal pain
- Trouble swallowing
- Unintentional weight loss
- Nausea
- Retching
- Change in bowel habits
- Bloating
- Fatigue
Physical Assessment
1. Assess for GI bleeding.
Note the following GI bleeding symptoms:
- CNS: decreased mentation, decreased level of consciousness, lightheadedness, fainting (syncope), dizziness
- HEENT: pale eyes, mucosa, and lips
- Respiratory: decreased oxygen saturation, shortness of breath
- Cardiovascular: chest pain, tachycardia, hypotension
- Gastrointestinal: abdominal pain, abdominal cramping, presence of anal fissures, hemorrhoids, masses, bright red or coffee-ground blood in the vomitus (hematemesis), black, tarry stools (melena)
- Hematologic: anemia
- Integumentary: skin pallor
2. Monitor for symptoms of shock.
The patient can experience shock if the bleeding is severe. Shock symptoms include:
- Severely low blood pressure
- Orthostatic hypotension
- Supine hypotension
- Resting tachycardia
- Palpitations
- Rapid, bounding pulses
- Low (oliguria) or absent (anuria) urine output
- Decreased level of consciousness
- Syncope
3. Perform an abdominal examination.
Inspect for abdominal distension, prominent veins, or skin discoloration. Hyperactive bowel sounds upon auscultation are present in GI bleeding. Palpate for any abdominal tenderness or pain may indicate a possible perforation or ischemia.
4. Monitor the vital signs.
Vital signs can show indicators of GI bleeding complications (such as shock or hypovolemia). Watch out for tachycardia, tachypnea, and hypotension.
Diagnostic Procedures
1. Review serum lab values.
The following blood tests can indicate GI bleeding:
- Complete blood count reveals low hemoglobin and hematocrit, indicating blood loss.
- Coagulation profile reflects abnormal blood clotting. Increased international normalized ratio (INR), prolonged prothrombin time, and activated partial thromboplastin time are expected in GI bleeding.
- Lactate levels are elevated in GI bleeding.
- Liver function enzymes may be abnormal. An impaired liver cannot produce enough clotting factors, increasing the risk of bleeding.
2. Obtain a sample for a stool exam.
Stool samples may have obvious bright red bleeding. Dark, black stools signal old bleeding or bleeding of the upper digestive tract. A fecal occult blood test can be completed at the bedside to assess for hidden blood in the stool.
3. Assist with endoscopy.
A tube with a tiny camera at the end is put into the mouth (upper GI endoscopy) or the rectum (lower GI endoscopy). It allows visualization of the gastrointestinal tract and inspection for any bleeding. These procedures can also offer treatment with injection, thermal coagulation, or hemostatic clips/bands.
4. Consider other imaging scans.
- Capsule endoscopy uses a capsule the size of a vitamin that contains a tiny camera to visualize the small intestine. You swallow the capsule, and a recorder receives images as the capsule passes through the digestive system.
- Flexible sigmoidoscopy utilizes a tube with a light and camera. It is inserted through the rectum to visualize any bleeding.
- Balloon-assisted enteroscopy allows for the management or treatment of the bleeding source. It uses a specialized scope that can view the small intestine in places where other tests utilizing an endoscope cannot.
- Angiography detects and treats active bleeding vessels. A contrast dye is introduced into an artery, and X-rays are taken. Bleeding is managed by embolization or intra-arterial vasopressin.
- CT angiography (CTA) shows active bleeding blood vessels.
- Enteroscopy visualizes the small bowel for bleeding.
- Nuclear scintigraphy is the most sensitive test for detecting active lower GI bleeding.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with GI bleeding.
Detect the Underlying Cause
1. Manage the bleeding.
Gastrointestinal bleeding frequently ceases on its own. If not, the type of treatment depends on where the bleeding originated and the severity.
2. Correct the underlying cause.
The initial step in the acute management of GI bleeding is to detect the cause of the bleeding. This could be as simple as discontinuing anticoagulant medications or as complex as surgery.
3. Rest the bowel.
Allow the GI tract to rest in processing food by instituting NPO orders. It prevents irritation to the GI tract and allows recovery during treatment.
Administer Supportive Care
1. Administer oxygen as prescribed.
If the patient is hypoxic, provide oxygen as ordered, typically via nasal cannula. However, patients with ongoing hematemesis or altered mental status may require intubation.
2. Maintain hydration.
At least two large-bore peripheral IVs are required for adequate IV access. Normal saline or lactated Ringers solution is preferred to support fluid resuscitation.
3. Transfuse blood products.
Transfusions are utilized for bleeding to restore missing blood components.
- Packed red blood cell (PRBC) transfusions are prescribed for hemoglobin levels less than 7 g/dL.
- Platelet transfusion is initiated whenever the platelet count falls below 50,000/microL.
4. Reverse anticoagulation.
Patients receiving warfarin or heparin may require reversal agents (vitamin K or protamine sulfate) to stop the effects of blood thinning medications.
5. Administer medications as ordered.
Medications are administered to manage or stop the bleeding. These include:
- Proton pump inhibitors (PPIs) are used for upper GI bleeding to stop acid production and can be continued or stopped once the source of the bleeding is identified.
- Prokinetics like erythromycin and metoclopramide promote gastric emptying and clear the stomach of blood, clots, and food for better visualization prior to endoscopy.
- Somatostatin and its analog octreotide are vasoactive medications that can treat variceal bleeding by preventing the release of vasodilatory hormones.
- Antibiotics are considered a preventative measure in patients with cirrhosis to stop bacterial translocation (passage of bacteria outside the GI tract). It is mainly given prior to endoscopy.
Prepare for Diagnostic or Surgical Procedures
1. Remove the blood and clots.
Drain the fresh blood and blood clots through a nasogastric tube (NGT) lavage prior to endoscopy for better visualization.
2. Consider the placement of a Sengstaken-Blakemore tube.
The placement of a Sengstaken-Blakemore tube should be considered in patients as a last resort who exhibit massive GI bleeding due to varices.
3. Anticipate possible surgery.
Patients with significant bleeding or hemodynamic instability who have bleeding that is unresponsive to other treatments should undergo surgery as soon as possible. A bowel resection or colectomy may be required.
4. Stop the bleeding from diverticulitis.
Colonoscopy with bipolar probe coagulation, epinephrine injection, or metal clips is utilized in diverticular bleeding.
5. Apply thermal therapy.
Lower GI bleeds caused by angiodysplasia (abnormal tortuous blood vessels in the GI mucosa) can be treated with thermal therapy (such as electrocoagulation and argon plasma coagulation).
6. Prevent complications of bleeding.
If not treated promptly or correctly, gastrointestinal bleeding can have serious implications. When a patient experiences upper or lower gastrointestinal bleeding, the following issues could arise:
- Respiratory Distress
- Myocardial infarction
- Infection or sepsis
- Shock
- Death
Educate on Preventing Recurrent GI Bleeds
1. Limit the use of NSAIDs.
Long-term use of nonsteroidal anti-inflammatory drugs and aspirin causes mucosal injury that can lead to bleeding. Avoid or limit the use of these medications as instructed by a healthcare provider.
2. Quit smoking.
Smokers are more likely to experience peptic ulcers and slowed healing, placing them at risk for GI bleeds.
3. Reduce alcohol intake.
Excessive alcohol intake irritates and erodes the GI tract but also damages the liver, which affects clotting and increases the risk of GI bleeding.
4. Manage inflammatory and infectious conditions.
H. pylori infection causes peptic ulcers and increases the risk of GI bleeding. Inflammatory conditions like diverticulitis, Crohn’s disease, or colitis can result in GI bleeding if not controlled. Instruct on adherence to medication regimens.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for gastrointestinal bleeding, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for gastrointestinal bleeding.
Acute Pain
Acute pain associated with gastrointestinal bleeding can be caused by gastrointestinal perforation or ischemia. This is due to a decrease in blood flow and oxygen in the gastrointestinal system.
Nursing Diagnosis: Acute Pain
Related to:
- Gastrointestinal perforation
- Gastrointestinal ischemia
As evidenced by:
- Changes in BP, pulse, and respiratory rate
- Guarding position of the affected area
- Restlessness
- Report of abdominal pain
- Report of heartburn
Expected outcomes:
- Patient will be able to verbalize relief or control of pain.
- Patient will be able to appear relaxed and able to sleep or rest appropriately.
Assessment:
1. Assess the client’s pain characteristics.
The assessment of pain includes the location, characteristics, severity, palliative, and precipitating factors of the pain. The nurse can assess by asking the patient to rate their pain with the use of pain assessment tools applicable to the patient and determine whether the pain is constant, aching, stabbing, or burning. It’s important to also assess the exact location of abdominal pain.
2. Examine the patient’s pain indicators, both verbal and nonverbal cues.
The disparity between verbal and nonverbal signs may disclose clues about the severity of pain, the need for additional management, and the intervention’s effectiveness.
3. Assess coping mechanisms of the patient.
Coping mechanisms assist the patient in enduring, minimizing, and managing stressful circumstances. The nurse can ask and observe for coping mechanisms that the patient uses.
Interventions:
1. Administer pharmacologic pain management as ordered.
Because it doesn’t induce side effects like stomach pain and bleeding, acetaminophen is typically seen as being safer than other nonopioid pain medicines. Antacids without aspirin and proton pump inhibitors may alleviate heartburn.
2. Evaluate the effectiveness of pharmacologic pain management.
Because pain perception and alleviation are subjective, it is best to evaluate pain management within an hour after administration of medication. If the client is unable to communicate, the nurse should assess the patient’s physiological and nonverbal pain cues.
3. Provide comfort measures and non-pharmacologic pain management.
The nurse can provide comfort measures such as frequent positioning, back rubs, and pillow support. The nurse can also provide non-pharmacologic pain management interventions such as relaxation techniques, guided imagery, and appropriate diversional activities to promote distraction and decrease pain.
4. Plan rest periods and create a conducive environment for sleeping and resting.
Rest increases coping abilities by reducing fatigue and conserving energy. Reduce interruptions and group tasks to allow for a quiet, restful environment.
Deficient Fluid Volume
Deficient fluid volume associated with gastrointestinal bleeding can be caused by decreased blood volume due to blood loss. This may lead to a decrease in blood flow and ineffective tissue perfusion in the gastrointestinal system.
Nursing Diagnosis: Deficient Fluid Volume
Related to:
- GI hemorrhage
- Hematochezia
- Hematemesis
- Abdominal cancer
- Bleeding ulcers
- Abdominal or rectal fistulas
As evidenced by:
- Hematochezia
- Hematemesis
- Melena
- Abdominal pain
- Resting tachycardia
- Orthostatic hypotension
- Weakness
- Nausea and/or vomiting
- Decreased skin turgor
Expected outcomes:
- Patient will be able to maintain adequate fluid volume as evidenced by stable vital signs, balanced intake and output, and capillary refill <3 seconds.
- Patient will be able to demonstrate efficient fluid volume as evidenced by stable hemoglobin and hematocrit.
Assessment:
1. Assess nutritional status.
The nurse must take into account the current consumption, weight fluctuations, oral intake issues, supplement use, tube feedings, and other variables (e.g., nausea and vomiting) that may have an adverse impact on fluid intake.
2. Monitor intake and output.
To track and record trends, the nurse must maintain precise intake and output (I&O) documentation. This includes measurements of all intake (oral and IV) as well as losses through vomiting, urine, and bloody stools.
3. Evaluate lab results.
Closely monitoring hemoglobin and hematocrit is essential with GI bleeding. Hemoglobin is the oxygen-carrying component of blood while hematocrit reflects blood volume. Low levels of Hgb and Hct signal blood loss.
Interventions:
1. Assist the healthcare provider in treating underlying issues.
Collaboration with the healthcare provider is necessary to determine the root cause of decreased fluid volume and bleeding. Stopping the source of gastrointestinal bleeding will also control the fluid volume deficiency.
2. Provide a sufficient amount of free water with meals and a nutritionally balanced diet or enteral feedings.
Avoid using formulas that are too hyperosmolar or heavy in protein. Proper nutrition reduces the risk of anemia and enhances general health. Along with oxygenation, organs require nutrients like antioxidants, vitamins, and minerals to function.
3. Review and Administer prescribed medications.
Examine the client’s prescription, over-the-counter (OTC), herbal, and nutritional supplements to find any substances that might affect fluid and electrolyte balance or may be a cause of GI bleeding. Proton-pump inhibitors may be prescribed to curb stomach acid production.
4. Administer blood products.
PRBCs are a common intervention for GI bleeding. The nurse can ensure the patient is type and cross-matched to prepare for blood transfusions.
Imbalanced Nutrition: Less Than Body Requirements
Gastrointestinal bleeding occurs due to various gastrointestinal disorders, including peptic ulcer disease, gastric cancer, and inflammatory bowel disease. With GI bleeding, the patient will experience nutrient malabsorption, deficient fluid volume, anemia, and other GI symptoms.
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements
Related to:
- Disease process
- Nausea and vomiting
- Food aversion
- Loss of appetite
- NPO status
- Nutrient malabsorption
As evidenced by:
- Abdominal pain
- Abdominal cramping
- Abdominal distension
- Body weight less than the ideal weight for age and gender
- Hyperactive bowel sounds
- Lethargy
- Pale mucous membranes
- Vomiting
Expected outcomes:
- Patient will not experience alterations in albumin, iron levels, or electrolytes.
- Patient will maintain weight within acceptable parameters.
Assessment:
1. Assess the patient’s eating pattern and diet.
Gastrointestinal bleeding is associated with several gastrointestinal disorders that affect eating patterns and appetite. Identifying the patient’s eating patterns and diet can help formulate an appropriate treatment approach to correct nutritional deficits.
2. Assess past and current medication use.
Medications like corticosteroids and NSAIDs can cause gastrointestinal toxicity, peptic ulcer formation, and nutrient malabsorption, which can cause gastrointestinal bleeding.
3. Assess laboratory studies along with fluid and electrolyte levels.
Gastrointestinal bleeding causes not only blood loss but also fluid and electrolyte loss and nutrient malabsorption that can lead to conditions like iron-deficiency anemia.
Interventions:
1. Administer fluid and electrolyte replacement.
The initial supportive therapy for patients with gastrointestinal bleeding includes fluid and electrolyte replacement to reverse hypovolemia and correct electrolyte deficiencies caused by the bleeding.
2. Minimize NPO status.
Patients with gastrointestinal bleeding are often kept NPO for 48-72 hours to help improve gastrointestinal pH, reduce the risk of rebleeding, and stabilize clots. Patients at low risk for rebleeding may receive early enteral nutrition.
3. Provide small frequent feedings.
Gastrointestinal bleeding is often accompanied by nausea and vomiting, which can further aggravate imbalanced nutritional intake. Providing small frequent meals reduces early satiety, decreases the incidence of vomiting, and allows the gastrointestinal tract to heal.
4. Encourage the patient to avoid gastric irritants.
Caffeine, alcohol, soda, and spicy foods should be avoided as they can cause further gastrointestinal irritation and rebleeding.
5. Refer the patient to a dietitian.
A dietitian can help plan appropriate and well-balanced meals while correcting nutritional deficits. Dietary recommendations include foods rich in iron, like meat, seafood, and nuts, along with whole grains, fruits, and vegetables, and low in salt, added sugars, and fats.
Ineffective Tissue Perfusion
Ineffective tissue perfusion associated with gastrointestinal bleeding can be caused by any bleeding from the mouth to the anus depending on the location. The loss of blood can decrease oxygenation and perfusion to the tissues.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Upper GI bleeding
- Lower GI Bleeding
- Gastrointestinal perforation
- Gastrointestinal ischemia
- Peptic ulcer disease
- Tears or inflammation in the esophagus
- Diverticulosis and diverticulitis
- Ulcerative colitis
- Crohn’s disease
- Colonic polyps
- Colon cancer
- Stomach cancer
- Esophageal cancer
As evidenced by:
- Hematochezia
- Hematemesis
- Melena
- Abdominal pain
- Resting tachycardia
- Orthostatic hypotension
- Supine hypotension
- Nausea and/or vomiting
Expected outcomes:
- Patient will be able to demonstrate effective tissue perfusion as evidenced by hemoglobin and hematocrit within normal limits
- Patient will be able to verbalize an understanding of gastrointestinal bleeding, the treatment plan, and when to contact a healthcare provider.
Assessment:
1. Assess vital signs.
Recognize persistent hypotension, which may lead to abdominal organ hypoperfusion. The nurse can monitor the vital signs of the patient, especially alterations in the blood pressure and pulse rate which may indicate the presence of bleeding.
2. Assess for the presence of bleeding.
Take note of any circumstances that may impair the gastrointestinal system’s perfusion and circulation (e.g., major trauma with blood loss and hypotension, septic shock). Bowel ischemia and gastrointestinal (GI) hypoperfusion can be caused by blood loss, hypovolemic or hypotensive shock, or both.
3. Assess the client’s history of bleeding or coagulation disorders.
Determine the client’s history of cancer, coagulation abnormalities, or previous GI bleeding to determine the client’s risk of bleeding issues. The nurse can interview the client and review the health history to determine the risk factors and bleeding history of the client.
Interventions:
1. Collaborate with the interdisciplinary team in creating the plan of care.
Collaboration of an interdisciplinary team improves communication and continuity of care. It also allows the development of an appropriate and suitable treatment plan that will improve systemic perfusion and organ function of the client.
2. Administer fluids, blood, and electrolytes as prescribed.
The goal of fluid resuscitation is to improve tissue perfusion and stabilize hemodynamics. To make up for blood and fluid loss and to keep GI circulation and cellular function intact, IV fluids, blood products, and electrolytes are often required.
3. Administer prescribed medications.
Give prescribed prophylactic medications, such as antiemetics, anticholinergics, proton pump inhibitors, antihistamines, and antibiotics. These will lessen fluid loss and neutralize stomach acid hopefully preventing further irritation of the GI mucosa.
4. Prepare for endoscopy or surgery.
An endoscopy procedure may be necessary to determine the location and cause of GI bleeding. Surgery may be necessary if bleeding is severe and tests can’t visualize the source.
Risk for Decreased Cardiac Output
In severe GI bleeding and blood loss, the patient may experience decreased cardiac output from hypovolemia.
Nursing Diagnosis: Risk for Decreased Cardiac Output
Related to:
- Disease process
- Blood loss
- Altered afterload
- Altered heart rate
- Altered heart rhythm
- Altered stroke volume
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and the nursing interventions are directed at the prevention of signs and symptoms.
Expected outcomes:
- Patient will maintain vital signs within normal limits, adequate urine output, and adequate tissue perfusion.
- Patient will maintain an asymptomatic cardiac rhythm without signs and symptoms of decreased cardiac output.
Assessment:
1. Assess the patient’s heart rate and rhythm.
Compensatory tachycardia is a common response for patients experiencing low blood pressure and bleeding to reduce cardiac output.
2. Assess and monitor the patient’s complete blood count.
While hemoglobin and hematocrit levels do not immediately help identify the degree of gastrointestinal blood loss, they can provide a baseline for guiding further treatment. Initially, hematocrit will be within normal limits but will decline 4-6 hours after fluid replacement since, at the time of GI bleed, plasma and RBC loss are equal.
3. Assess the patient’s BUN level.
Blood urea nitrogen (BUN) will significantly increase in patients with gastrointestinal bleeding. With a significant hemorrhage, the gastrointestinal bacteria will break down proteins causing increased BUN levels.
Interventions:
1. Monitor the patient’s urine output.
Urine output is one of the best measures to determine vital organ perfusion. An indwelling catheter is typically inserted to ensure accurate urine output monitoring. Declining urine output can indicate decreased cardiac output and kidney perfusion as the heart has less blood to pump due to the bleeding.
2. Perform hemodynamic monitoring.
Hemodynamic monitoring monitors blood circulation and determines heart functionality. It is essential in patients with gastrointestinal bleeding to accurately and promptly assess blood pressure and the effectiveness of fluid resuscitation.
3. Administer supplemental oxygenation as needed.
Supplemental oxygenation can help correct and prevent hypoxemia in patients at risk for developing decreased cardiac output. It increases blood oxygen saturation.
4. Administer intravenous fluids as indicated.
Patients with gastrointestinal bleeding can experience fluid and electrolyte imbalances leading to decreased cardiac output. Generally, an isotonic crystalloid solution like lactated Ringer’s solution is often ordered.
5. Prepare and initiate blood transfusions as ordered.
Blood transfusions are indicated with gastrointestinal bleeding to help prevent decreased cardiac output. Whole blood, packed red blood cells, or fresh frozen plasma may be used for fluid volume replacement.
6. Prepare the patient for surgical intervention.
If gastrointestinal bleeding is severe, surgical intervention like endoscopy to repair and resolve the bleeding may be indicated to prevent further circulatory compromise.
7. Administer drug therapy as indicated.
During the acute phase of gastrointestinal bleeding, medications are administered to help decrease the bleeding, decrease hydrochloric acid secretion, and neutralize present stomach acid. An acidic environment can alter platelet function and interfere with clot stabilization, worsening bleeding, and cardiac output.
References
- Cleveland Clinic. (2022, June 27). Gastrointestinal (GI) bleeding: Symptoms, diagnosis, treatment. Retrieved April 2023, from https://my.clevelandclinic.org/health/diseases/23391-gastrointestinal-gi-bleeding
- DiGregorio, A. M., & Alvey, H. (2020, August 24). Gastrointestinal bleeding – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK537291/
- DiGregorio, A. M., & Alvey, H. (2022, June 11). Gastrointestinal bleeding – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. Retrieved April 2023, from https://www.ncbi.nlm.nih.gov/books/NBK537291/
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Hinkle, J. L., & Cheever, K. H. (2018). Management of Patients with Gastric and Duodenal Disorders. In Brunner and Suddarth’s textbook of medical-surgical nursing (14th ed., pp. 3426-3452). Wolters Kluwer India Pvt.
- Mayo Clinic. (2020, October 15). Gastrointestinal bleeding – Diagnosis and treatment – Mayo Clinic. Retrieved April 2023, from https://www.mayoclinic.org/diseases-conditions/gastrointestinal-bleeding/diagnosis-treatment/drc-20372732
- Overview of gastrointestinal bleeding – Gastrointestinal disorders – MSD manual professional edition. (n.d.). MSD Manual Professional Edition. https://www.msdmanuals.com/professional/gastrointestinal-disorders/gastrointestinal-bleeding/overview-of-gastrointestinal-bleeding
- St. Luke’s Hospital. (n.d.). Multimedia encyclopedia. Retrieved April 2023, from https://www.stlukes-stl.com/health-content/health-ency-multimedia/1/003137.htm
