1. Obtain patient's history of previous episodes of GI bleeding and/or significant history, use of NSAIDs and/or warfarin.
2. Perform hand hygiene and don clean gloves, gown, and goggles.
3. Assess airway patency, breathing, and circulation (ABCs). Anticipate possible intubation and provide breathing support as necessary. Intiate two large-bore IVs of a crystalloid solution.
4. Obtain blood samples as ordered (when initiating IV therapy).
5. Perform neurologic assessment.
6. Obtain vital signs and oxygen saturation via pulse oximetry, and place the patient on a cardiac monitor. Assess vital signs frequently (every 5 to 10 minutes). Note that significant changes in vital signs with postural changes indicate an acute blood loss of approximately 20% or more.
7. Assess pain status and provide analgesics if indicated and prescribed.
8. Inspect the oropharynx, nasopharynx, abdomen, perineum, and anal canal. Inspect, auscultate, and palpate the abdomen for abdominal distension, masses, tenderness, guarding, rigidity. Percuss for dullness.
9. Assist the physician or advanced practice nurse with digital rectal examination or anoscopy.
10. Insert a urinary catheter to assess color, amount, and consistency and to monitor urine output.
11. Place the patient in the left lateral decubitus position with the bed in Trendelenburg position or semi-Fowler's position.
12. Insert a gastric tube in the mouth or nose using lubricating jelly and topical anesthetics. If the gastric tube is inserted via the mouth, a bite block with a hole for the tube to pass through is preferable.
13. Verify tube placement.
a. Use a 60-ml syringe and aspirate gastric contents, saving the initial sample for a toxicology screen; assess the appearance of the aspirate. Gastric contents may be cloudy, grassy green, straw, tan, brown, clear, or off-white.
b. Test the pH of the aspirate. Gastric pH is acidic and should be less than 6.
c. Detect ETCO2 using a capnometer or a colormetric ETCO2 detector.
d. Verify placement via chest radiograph when patient is at risk for malposition of the tube or other methods are inconclusive.
14. Pour room temperature normal saline solution or tap water into an irrigation container.
15. Draw up the solution using a 60-ml syringe, and inject it into the gastric tube. Alternatively, use a preassembled gastric lavage setup.
16. Infuse approximately 200 to 300 ml per aliquot.
17. Aspirate or drain the solution from the stomach and discard it into a measured basin.
18. Repeat this procedure until active bleeding ceases (i.e., fluid return is clear) or until the patient is transferred to the endoscopy unit.
19. Measure and record the volume of irrigant and aspirant.
20. The physician or advanced practice nurse may order a chest radiograph to exclude aspiration pneumonia and/or esophageal perforation, and abdominal radiographs to exclude perforated viscus and/or ileus.
21. Discard supplies, remove gloves, and perform hand hygiene.
22. Document the procedure in the patient's record.