1
min read
A- A+
read

GI Bleed Risk

GI Bleed Risk

Category / Primary Body System

  • Gastrointestinal System

Problem

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

Goal

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

Plan/Approach

  1. Monitoring for Signs and Symptoms

    • Monitor daily for signs and symptoms of GI bleeding, such as blood in stool, changes in stool color, and abdominal pain.
    • Monitor hematocrit (Hct) levels and other relevant lab values as ordered to detect anemia or blood loss.
  2. Reporting and Communication

    • Report any signs and symptoms of GI bleeding to the MD/RNP immediately to ensure prompt intervention.
  3. Dietary Management

    • Provide dietary consultations as needed to ensure the patient's diet supports healing and prevents further complications.
    • Implement a diet as ordered, focusing on easily digestible foods that do not irritate the GI tract.
  4. Medication Administration

    • Administer medications as ordered to manage bleeding and underlying conditions.
    • Review medications regularly to ensure they are appropriate and do not exacerbate bleeding.
  5. Laboratory Tests

    • Perform labs as ordered, including CBC, Hct, and other relevant tests, to monitor the patient’s condition and detect any complications early.
  6. Medication Reviews

    • Review medications as needed with the healthcare team to adjust dosages or switch medications if necessary to minimize bleeding risk.

Rationale

  1. Monitoring for Signs and Symptoms

    • Early detection of GI bleeding can prevent severe complications and allow for timely medical intervention.
  2. Reporting and Communication

    • Prompt reporting of any GI bleeding symptoms ensures immediate medical evaluation and treatment.
  3. Dietary Management

    • A proper diet can support GI healing and reduce the risk of further irritation or bleeding.
  4. Medication Administration

    • Correct medication management is crucial for controlling bleeding and treating underlying conditions effectively.
  5. Laboratory Tests

    • Regular lab tests help in monitoring the patient's condition, ensuring any changes are detected early and managed appropriately.
  6. Medication Reviews

    • Reviewing medications helps in preventing adverse effects and ensuring that the prescribed treatments are effective and safe.

Actions

  1. Monitoring for Signs and Symptoms

    • Check for signs of GI bleeding daily, documenting findings and any changes.
    • Monitor hematocrit and other relevant lab values as ordered.
  2. Reporting and Communication

    • Report any signs of GI bleeding (e.g., blood in stool, melena) to the MD/RNP immediately.
  3. Dietary Management

    • Consult with a dietitian to tailor the patient's diet to their needs and medical condition.
    • Implement and monitor the patient’s diet, ensuring it aligns with medical orders.
  4. Medication Administration

    • Administer prescribed medications, documenting administration and any side effects.
    • Conduct regular medication reviews with the healthcare team.
  5. Laboratory Tests

    • Perform lab tests as ordered, reporting and documenting the results promptly.
  6. Medication Reviews

    • Regularly review the patient's medications with the healthcare team to ensure efficacy and safety, making adjustments as necessary.
Feedback Form