GI Bleed Care Plan Revision

Category / Primary Body System: Gastrointestinal System

Problem:

The patient is at risk for complications due to a diagnosis of gastrointestinal (GI) bleed.

Goal:

The patient will exhibit no signs of GI bleed-related complications, such as low hematocrit (Hct) levels, for the next 90 days.

Plan/Approach:

1. Vital Signs and Symptom Monitoring: Conduct regular monitoring for signs and symptoms of GI bleeding, including melena, hematochezia, and hematemesis. Assess vital signs every 4 hours to monitor for changes indicative of acute blood loss (e.g., tachycardia, hypotension).

2. Laboratory Testing: Order complete blood count (CBC) daily to monitor Hct and hemoglobin levels. Additional tests may include coagulation profile and blood type and screen, as necessary.

3. Dietary Management: Implement a GI-protective diet as tolerated. Initially, NPO (nothing by mouth) status may be required, progressing to clear liquids and then to a full liquid diet as tolerated and based on physician guidance.

4. Medication Administration: Administer prescribed medications, including proton pump inhibitors (PPIs), antacids, or other gastroprotective agents, to manage and prevent further bleeding. Review and adjust medications as needed to avoid those that may exacerbate GI bleeding, such as NSAIDs.

5. Endoscopy and Diagnostic Procedures: Prepare the patient for possible endoscopic examination or other diagnostic procedures to identify the source of bleeding and for therapeutic interventions as ordered by the healthcare provider.

6. Education and Counseling: Provide patient and family education regarding the signs and symptoms of GI bleeding, the importance of adhering to the dietary restrictions, medication regimen, and when to seek immediate medical attention.

Rationale:

Regular monitoring of vital signs and symptoms enables early detection of bleeding exacerbations or complications. Daily CBCs are crucial for tracking the patient's blood loss and response to treatment. Dietary management helps minimize further GI irritation. Prescribed medications aim to reduce gastric acidity, protect the GI lining, and prevent rebleeding. Diagnostic procedures are essential for identifying the bleeding source and guiding treatment. Education ensures the patient and family are informed and engaged in the care process.

Actions:

• Implement a standardized protocol for the monitoring of patients with GI bleed, including frequency of vital sign checks and symptom assessments.
• Schedule daily CBC tests and additional labs as indicated by the patient's condition.
• Collaborate with the dietitian to provide appropriate dietary recommendations and adjustments based on the patient's current status and tolerance.
• Ensure that the nursing staff is trained on the administration of GI bleed-specific medications and the potential side effects.
• Coordinate with the gastroenterology team for timely endoscopic evaluations.
• Develop patient education materials focused on managing GI bleeding at home and recognizing signs that require immediate medical attention.

DALL·E Prompt:

Create an infographic that outlines the management of gastrointestinal bleeding, including steps for monitoring signs and symptoms, dietary recommendations, medication guidance, and the importance of endoscopic evaluations. Highlight key points for patient education on recognizing and responding to signs of GI bleeding.