Care Plan for GI Bleed

Category / Primary Body System

• Gastrointestinal System

Problem

• Patient is at risk for complications due to diagnosis of GI bleed.

Goal

• Patient will be free from GI bleed-related complications (e.g., low hematocrit level) for 90 days.

Plan/Approach

1. Monitoring and Reporting

   • Monitor daily for signs and symptoms of GI bleeding (e.g., blood in stool)
   • Report any signs and symptoms of GI bleeding to the physician or nurse practitioner immediately

2. Dietary Management

   • Ensure dietary consistency as needed to manage GI bleeding
   • Adhere to the prescribed diet to minimize irritation to the GI tract

3. Medication Management

   • Administer medications as ordered
   • Review medications regularly for potential GI irritants or anticoagulants

4. Laboratory Monitoring

   • Conduct regular lab tests as ordered to monitor hematocrit and hemoglobin levels
   • Monitor other relevant lab values to detect any abnormalities early

5. Patient Education

   • Educate the patient on signs and symptoms of GI bleeding
   • Instruct the patient on the importance of adhering to the prescribed diet and medication regimen

Rationale

1. Monitoring and Reporting

   • Early detection of GI bleeding signs allows for prompt intervention, reducing the risk of severe complications.

2. Dietary Management

   • A consistent, non-irritating diet helps prevent further GI irritation and bleeding, promoting healing.

3. Medication Management

   • Proper administration and regular review of medications ensure that potential GI irritants are minimized and therapeutic effects are maximized.

4. Laboratory Monitoring

   • Regular lab tests help track the patient's blood levels, ensuring any drop in hematocrit or hemoglobin is addressed promptly.

5. Patient Education

   • Educating the patient empowers them to participate in their care, improving adherence to the treatment plan and early reporting of symptoms.

Actions

1. Monitoring and Reporting

   • Check the patient's stool daily for signs of blood (e.g., melena, hematochezia).
   • Observe for other signs of GI bleeding such as coffee-ground emesis, pallor, dizziness, or hypotension.
   • Immediately report any abnormalities to the physician or nurse practitioner.

2. Dietary Management

   • Collaborate with a dietitian to ensure the patient's diet is appropriate for their condition.
   • Educate the patient on foods to avoid and those that are safe to consume.
   • Monitor the patient’s adherence to the diet and address any concerns or challenges they face.

3. Medication Management

   • Administer prescribed medications at the correct dosages and times.
   • Regularly review the patient's medication list with the healthcare team to identify and discontinue any drugs that may exacerbate GI bleeding.
   • Monitor the patient for side effects and therapeutic efficacy of the medications.

4. Laboratory Monitoring

   • Schedule and perform lab tests as ordered, including complete blood count (CBC) to monitor hematocrit and hemoglobin levels.
   • Review lab results promptly and communicate any significant changes to the healthcare team.

5. Patient Education

   • Provide the patient with written and verbal information about the signs and symptoms of GI bleeding.
   • Teach the patient the importance of following the prescribed diet and medication regimen.
   • Encourage the patient to report any symptoms or concerns immediately.