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Advanced Medical-Surgical Nursing (NUR 463) Hematemesis Information Nursing Processes

John Marsh
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University of Rhode Island

Advanced Medical-Surgical Nursing (NUR 463)

Hesi Med Surg Study Guide – Hematemesis Information Nursing Processes

Please use this guide as such, a guide however remember to utilize the basics, the nursing
process, ABC’s and prioritize accordingly.
 Hematemesis (vomiting blood) – typically upper GI bleed
a. What to assess?
i. Remember ABC’s (pt having diff breathing?), check vital signs first*
ii. Assess stool (blood present? – if so, what color. Dark red = upper GI
bleed, usually more serious)
iii. Check if they are on iron supplements
iv. Worried about hypovolemic shock
1. S/S: restlessness, agitation, inc HR and RR, cool, pale, sweaty
 Open vs Close angle glaucoma
b. Def: condition characterized by inc intraocular pressure (IOP > 22 mmHg) r/t
aqueous fluid being inadequately drained from eye  gradual painless vision
loss. Generally asymptomatic in early stages (seen in reg eye exam)
i. No cure, can be treated pharmacologically and surgically
c. Patient teaching
i. Develop a teaching plan that includes the following: (p. 131)
1. Careful adherence to eye-drop regimen can prevent blindness
2. Vision already lost cannot be restored
3. Eyes drops are needed for rest of life
a. Eye drops used to cause pupillary constriction – mvmt
4. ***Proper eye-drop instillation technique. Obtain a return
a. Wash hands and external eye
b. Tilt head back slightly
c. Instill drop into lower lid, s touching the lid c the tip of
the dropper
d. Release lid, and sponge excess fluid from lid and cheek
e. Close eye gentle, and leave closed for 3-5 min
f. Apply gentle pressure on inner canthus to decrease
systemic absorption
g. (Caution: Vision may be blurred for 1-2 hrs post admin
and adaption to dark environments difficult r/t
pupillary constriction (FALL RISK))
i. Blurring tends to dec c inc use of meds



Advanced Medical-Surgical Nursing (NUR 463) Hematemesis Information Nursing Processes

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