Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed

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Outline

Pathophysiology

Bleeding along the lining of the Gastrointestinal Tract is hard to recognize because it is not something you can see immediately, or necessarily get imaging or laboratory test work to discover the cause of bleeding right away. Upper GI bleeds will come out as dark black tarry stools and lower GI bleeds will come out as bright red bleeding. Also, monitor for blood in the vomit, and be aware of coffee ground emesis because blood can curdle in the acidic stomach environment.

Etiology

The bleeding along the GI tract is from a perforation somewhere in the intestines or stomach. Can be caused by too much acid (ulcer), an abnormal formation in the colon (tumor, polyp, hemorrhoids), inflammation of the lining (diverticulitis, colitis) or any sort of trauma to the GI tract.

Desired Outcome

Controlling and stopping of the bleeding, vital signs back to baseline, normal blood counts such as hemoglobin.

GI Bleed Nursing Care Plan

Subjective Data:

Subjective Data:

  • Weakness
  • Dizziness
  • Abdominal pain

Objective Data:

Objective Data:

  • Pale skin
  • Lethargy
  • Hypotension

Tachycardia

Nursing Interventions and Rationales

  • Monitor Hemoglobin (HGB)
  • HGB: Hemoglobin (Hbg), an iron containing compound, is the main protein in Red Blood Cells (RBCs). It enables oxygen and carbon dioxide (CO2) to bind to RBCs for transport throughout the body.
  • This is the most commonly looked at lab value to assess need for a blood transfusion. Every institution, Doctor, and person is different but as a general rule, a hemoglobin below 8 requires a blood transfusion.
  • Monitor heart rate and blood pressure
  • When the heart is low on fluids to fill it, it will start beating faster and your pressure gets lower. If the patient’s BP gets too low, they will start to shunt blood to their vital organs. 
  • If patient becomes hypotensive, put them in reverse trendelenburg, give them fluids, and get the physician.
  • A patient’s heart can only beat fast for so long so monitor the heart rhythm while you work on getting the volume back into their cardiovascular system.
  • Administer blood products
  • This requires a blood match (Remember your ABO compatibility and Rh factor).
  • When administering the blood, remember to have the blood product double checked with another nurse. Vital signs every 
  • Administer pantoprazole (Protonix) Potential surgical intervention to stop the bleeding
  • Give pantoprazole (Protonix), a proton pump inhibitor (PPI) that decreases the amount of acid in the GI lining. This reduces the ulceration which could be (and most likely is) causing the GI bleed.
  • If it is not able to stop the bleeding, potential surgical intervention may be needed to stop the bleed.
  • Also-To be noted is the use of anticoagulants (warfarin, aspirin, heparin, etc.). Ask all your patients if they take an anticoagulant regardless of their issues, it is important to know.
  • 12 lead ECG
  • Having low amounts of blood most definitely affects the heart. Make sure that the heart is still lub-dubbing as it should be.
  • Assess for bleeding in stool GI bleed:
  • This entails my least favorite thing to do, and the nurse doesn’t even do it, but the nurse usually needs to be present because it invades the patient’s self respect and dignity. Therefore you get to be in the patient’s visual field while they are being pillaged in their back end.
  • The provider will place a gloved finger into the rectum and needs to have feces on it when it comes out. The feces is placed on a hemoccult card where a developing solution is married with the stool giving the provider insight of whether or not there is blood in the stool. If the card turns blue it is positive for blood.
  • As a nurse you will ask the patient if they have black/tarry stools (upper GI bleed) or bright red blood (lower GI bleed) in their stools.
  • Fall precautions
  • The patient is at an increased risk for fall. This means that it is super important to educate the patient on using the call light if they need to get up and assisting with any mobilization of the patient.

Writing a Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed

A Nursing Care Plan (NCP) for GI (Gastrointestinal) Bleed starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

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Transcript

Let’s go over GI bleed and how we can put this into a nursing care plan. Okay, we are going to first have to do our assessment, right? We’ve got to collect all of that data, which is just our assessment findings. First subjective and objective. Subjective data is going to be what the patient’s reporting, so let’s say our patient is reporting that they’re really weak and dizzy from all that blood loss that they’re having. They could also have some abdominal pain happening because it hurts when those GI tracts are bleeding, and shouldn’t be. 

 

Our objective data, so what the nurse observes, or lab work shows us, those kinds of things. These are hard facts. So, I witnessed that this hypothetical patient is pale, they’re tachycardic because they are trying to pump the blood that it does have around the body as quickly as they can, hypotensive is also something I could witness on my patient because we’ve lost some blood volume, and maybe I noticed that the patient’s really lethargic. 

 

Let’s take this data and analyze it. This analysis is going to help us to diagnose and prioritize. So, what’s the problem? Well, my client is losing blood through their GI tract, right? We have a GI bleed and maybe for my patient, I saw the blood in the stool. Okay, that would be how I knew that would be a problem. So, what needs to be improved? Well, the bleeding needs to be stopped, so we need to stop the bleeding. We can give blood replacement if needed for those symptoms that the patient’s having, diet changes, maybe some medication problems, because let’s just add that my patient said that they’ve taken NSAIDS for two straight weeks, right, that’s going to increase our risk of bleeding. So, maybe some med changes, things like that are things for my patient that could be improved. 

 

My priority for my hypothetical patient is a few different things. Educating the client was going to be a priority on all those NSAIDS, and not to take them so often. Also safety, I think, is a huge priority for this patient, but really our overall priority for this patient is going to be to get that bleeding to stop, or at least not to continue and reduce. 

 

So this is where we ask our how? How did we know it was a problem? This is where you’re going to link the data that you’ve collected. Whatever assessment you’ve done on your patient clinical, you’re going to link that data together. I saw blood on my client, my hypothetical client,  in the stool, so I knew it was a problem because of that. I also had my patients tell me about their NSAID use frequency, and then I also saw hemoglobin was low. So, this patient was showing me that they were really losing blood and then witnessing the blood loss. 

 

How would I address it? Well, I’m going to be monitoring, right? Lots of assessments. So we’re going to monitor things like the vital signs and hope that they improve. We’re going to be monitoring lab work like the hemoglobin, those are our big things to address. How would I know it gets better? Well, I’m going to know it gets better if we can fix it, fix the problem, right? If it’s fixed, if that bleeding is stopped or reduced, those are the big things. I’m also going to know it gets better if maybe my patient won’t be as lethargic anymore and really, the big thing is that I won’t see blood anymore, in their stool because we fixed it. 

 

Now, this is where we are going to translate our high level nursing concepts. So, for my patient, I have a medical patient. I am going to use safety as a nursing concept. I’m going to use pharmacology because there are some medications that can help to fix this GI bleed problem, and then patient education, right? We should never take NSAIDS as often as my patient was, so just educating them on that. 

 

Now we’re going to transcribe. This is where we’re going to have our problems and priorities, the data that we’re collecting. This is just our assessment that we are doing. Intervention, so what are we going to do to help fix whatever data is collected? And then our rationale, which is why, why are we doing our intervention? Then what do we expect to see happen? 

 

Okay. So safety, pharmacology, and inpatient education. First with safety, so things that we would witness on a patient that would show us that the safety was not as good, but it’s more of a concern. The biggest thing here is looking for things that could show us this client is at a safety risk. So, let’s say my patient was more dizzy and super lethargic, right, they’re at a safety risk for falls. So our intervention, my intervention would be a fall risk, you know, assessment on the patient and fall risk interventions. Things like the socks that have the grips on them to prevent falls, call bell in reach, things like that. My rationale, or why am I doing it well, because I’m going to prevent a fall and further complications from happening. My expected outcome is that I won’t have any further complications. 

 

Our pharmacology, so the patient status. So, we saw the patient was hypotensive, and that bleeding was occurring from the GI tract, so we need to have some interventions that can help this. So for my client, we can give some IV fluids that are going to help replace that volume, help with the hypotension, blood products also to help with that and to fix the cause of the blood loss,  and then Protonix, just to help with that bleeding. And we’ll get to why. So why? Well, we said the IV fluids are going to replace the volume and hopefully we’re going to help correct that hypotension, and then the Protonix, because this is going to decrease the acid in the tract and decrease ulceration, which is a big reason why patients have GI bleeds is from, you know, peptic ulcers or just different kinds of ulcers along the GI tract. So by doing this, it can help decrease it from making it worse and then hopefully, that patient stops bleeding and their GI tract can repair. Okay, our expected outcomes, we are decreasing hypotension is our expected outcome. Our vital signs will be within normal limits, always awesome, and then we are decreasing the ulceration that’s happening. 

 

Alright, education. Well, my patient needs to know that NSAIDS should not be taken so often. Our data that was collected was that NSAIDS were taken a lot, and then I just put in here for this hypothetical patient, that perhaps they’re also on warfarin, which is a blood thinner. It makes them more at risk for bleeds. So, interventions, well, I’m going to educate on medications like frequency, that maybe they shouldn’t take them, like how long is too long to take them, that kind of thing. And then rationale. So why am I doing it? Well, because it’s going to hopefully reduce further bleeding or more bleeding from occurring. And then diet education we can also give, like a bland diet to help reduce acid production in the stomach, just keeping it bland and simple. 

Okay, my expected outcomes, well, I really want my patient to verbalize and demonstrate that they have an understanding, that is going to be your expected outcome. Anytime you have patient education as your problem or priority, because it really shows that they get it. They understand, and the education is complete. 

 

Alright, let’s review our key points. So we have assessment data being done by collecting information. Remember, that’s just our data collection, that’s subjective and objective data. Then, we’re going to analyze that information, which is going to help to diagnose and prioritize.  Asking our “how” questions will help to plan, implement and evaluate.  And then translate, those concise terms, and then transcribe, so use whatever form works for you and put your care plan on paper. 

 

Alright guys, check out all the care plans that we have available for you on NURSING.com. We love you. Now, go out and be your best self today and as always, happy nursing!

 

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