First, it wasn't so long ago that I was in your shoes, and I remember what it's like. Here's the nerd "5 cents on GI bleeds"
--When they come from the ER with a note that they had melena or bloody vomit, I call the ER back and actually speak with the nurse that had the pt. How much blood? What color? When? Did you get a HGB before and what's the HGB after? Did the doc know? Yes, I know they're busy too, but that's need to know on the floor.
--Crawl the pt's chart for any meds that could cause bleeding and see if you can get a APTT/PT/INR when they get there, if there's only one in the ER. If the person's been on lovenox at home, you may need to get an order for protamine, and if they've been on coumadin, you may need Vitamin K to get them back to a baseline. It'll help make the FFP or PRBCs work better at restoring semi-normal coag numbers. Especially, ESPECIALLY if the person is on dialysis, they may have a high rate of heparin on board and no kidney function to excrete it -- and dialysis doesn't take out heparin. And since protamine can crash a BP, don't wait until the BP's already in the toilet.
--If you get an active bleed (bright red blood from anywhere, and more than a "dot"), say the magic phrase to your charge nurse -- "I need some help in here!" We're still new, and while we might be the most "book smart" folks in the world, you need experienced eyes when someone starts circling the drain. I had a person bleeding out, and thought I was being a "nervous nellie" about the amount of blood until I got my charge nurse in the room (15 yrs experience), she took one look at the blood and went "holy ####!" And yes, that person went to the unit.
--Know your shock values. If a person looses more than 750ml, shock can begin (compensated/uncompensated, not the point here). And they had to have already lost something, else what brought them to the ER? Look at the total volume of fluid loss, and the time lost. I had a guy who lost 300ml of melena with clots over a period of 6 hours, compensating with blood, but nothing could compensate for when he dropped 800ml into the BSC and promptly had a seizure. Less than 300, no biggy was getting NS @ 100 in one vein and PRBCs x2 in the other, but he went into instant hypovolemic shock with the big gush. I woke up pretty much every doc/surgeon I could get my hands on, screaming for help, guy went to ICU and he still died. When I've got someone like that now, I have a "bleed table" posted in the room -- I keep track of bloody output, with orders to the CNAs to let me see it before they flush it.
--From now on, when you get a GI bleed, you'll know to either look for a "call if systolic less than whatever" or if there's not such an order, call and get one. I work nights, and I try to "front load" my doctor calls...something like this:
"Hey, Dr. X, this is Nerd over on East 3. I'm calling about Mr. R in 304, came in the GI bleed. ER said he had 1 tarry stool and 1 bright red emesis, approx 150 ml in the ER. I don't see an order for me to call you if the HGB falls below 8 or the SBP falls below 90 -- last lab the HGB's 8.3. The pt's been on coumadin for hx of afib, INR is 3.58, do we want to do a little vitamin K just to give him some help while we're waiting for the FFPs, or maybe some hespan since the lab's going to take 45 minutes and I can get 250 in before the FFP's ready?"
Without sounding like "hey, doc, you forgetting something?" you're letting him/her make the decision on what he wants to be alerted on, and you're also letting him know what happened in the ER -- hopefully, you'll get orders on "call if HGB less than 8, or transfuse x if less than 8, or hespan if SBP less than 90," or whatever. The docs also see you as proactive, which helps with their comfort level.
--with a GI bleed, assume this patient's sole goal in life is to bleed to death and die on your shift. Do everything you can go thwart that goal.
Good luck, we need it out there...