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.