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    Assessment Diagnosis Planning Implementation Evaluation

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    Ivy Villalobos
    1. The patient presented with black, tarry stool and lightheadedness and was assessed to be at risk for gastrointestinal bleeding related to gastrointestinal reflux and malnutrition based on her symptoms and medical history of untreated peptic ulcer. 2. The nursing care plan aimed to reduce gastrointestinal bleeding over 72 hours through monitoring of vital signs and intake/output, discontinuing NSAIDs, intravenous therapy, limiting anti-inflammatory drugs, and educating the patient on lifestyle changes. 3. After 72 hours of intervention, the patient's gastrointestinal bleeding had resolved, hemoglobin increased, blood pressure and skin color normalized, and the patient was able to meet nutritional needs and practice disease management.

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    Assessment Diagnosis Planning Implementation Evaluation

    Uploaded by

    Ivy Villalobos
    3K views3 pages
    1. The patient presented with black, tarry stool and lightheadedness and was assessed to be at risk for gastrointestinal bleeding related to gastrointestinal reflux and malnutrition based on her symptoms and medical history of untreated peptic ulcer. 2. The nursing care plan aimed to reduce gastrointestinal bleeding over 72 hours through monitoring of vital signs and intake/output, discontinuing NSAIDs, intravenous therapy, limiting anti-inflammatory drugs, and educating the patient on lifestyle changes. 3. After 72 hours of intervention, the patient's gastrointestinal bleeding had resolved, hemoglobin increased, blood pressure and skin color normalized, and the patient was able to meet nutritional needs and practice disease management.

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    GI-BLEEDING-NCP (2)

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    1. The patient presented with black, tarry stool and lightheadedness and was assessed to be at risk for gastrointestinal bleeding related to gastrointestinal reflux and malnutrition based on her symptoms and medical history of untreated peptic ulcer. 2. The nursing care plan aimed to reduce gastrointestinal bleeding over 72 hours through monitoring of vital signs and intake/output, discontinuing NSAIDs, intravenous therapy, limiting anti-inflammatory drugs, and educating the patient on lifestyle changes. 3. After 72 hours of intervention, the patient's gastrointestinal bleeding had resolved, hemoglobin increased, blood pressure and skin color normalized, and the patient was able to meet nutritional needs and practice disease management.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    3K views3 pages

    Assessment Diagnosis Planning Implementation Evaluation

    Uploaded by

    Ivy Villalobos
    1. The patient presented with black, tarry stool and lightheadedness and was assessed to be at risk for gastrointestinal bleeding related to gastrointestinal reflux and malnutrition based on her symptoms and medical history of untreated peptic ulcer. 2. The nursing care plan aimed to reduce gastrointestinal bleeding over 72 hours through monitoring of vital signs and intake/output, discontinuing NSAIDs, intravenous therapy, limiting anti-inflammatory drugs, and educating the patient on lifestyle changes. 3. After 72 hours of intervention, the patient's gastrointestinal bleeding had resolved, hemoglobin increased, blood pressure and skin color normalized, and the patient was able to meet nutritional needs and practice disease management.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    The key takeaways are that the patient is experiencing GI bleeding which is causing lightheadedness and black tarry stools. Vital signs are abnormal and lab results show anemia. Interventions include IV fluids, medication changes, lifestyle modifications and health education.

    The patient's chief complaint is recent worsening of chronic epigastric burning and passing black, tarry stool that is malodorous and lightheadedness 3 times per day.

    Objective findings include facial pallor, cool moist skin, abdominal tenderness, hyperactive bowel sounds, black tarry stool, low hemoglobin and hematocrit levels.

    PILAR COLLEGE OF ZAMBOANGA CITY, INC.

    R.T. Lim Boulevard, Zamboanga City


    Tertiary Education Department
    Nursing Program

    ACTIVITY SHEET FOR NURSING CARE PLAN

    Name of Student: Santos, Samson, Salve and Villalobos Date: Sept 8,2021 Rating: ___________________
    Year & Section: BSN2D Activity No: 1 Remarks: ___________________

    ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION


    Subjective cues: Goal of care: After 72 hours of intervention:
    Patient verbalize that Risk of Gastrointestinal - Assess patient - Patient observe
    “I’m passing black, tarry Bleeding related to After 8 hours of vital signs and absence of GI bleeding.
    stool that is malodorous and Gastrointestinal Reflux intervention monitor blood - Patient appears to be
    lightheadedness 3x days” and Malnutrition; eternal - Patients will have pressure. alert and oriented with
    feeding. Evidence by absence of GI - Monitor input normal skin color
    Patient complain for recent black stool, bleeding, and output of - Patient was able to
    worsening of a chronic lightheadedness, increase level of patient and normalize her Blood
    epigastric burning which she hyperactive bowel sound hemoglobin, record its pressure and increase
    had been a problem off/ on and history of untreated normalize blood characteristic. in hemoglobin count.
    for years. peptic ulcer. pressure, alert - Discontinue - Patient was able to
    and oriented and patient intake of meet nutritional
    Patient state that “She has normal skin color. NSAID’s to reduce requirement needed.
    told of an ulcer in distant - Review patient exacerbate And obtain enough
    past but had no specific medication intestinal issues. fluid intake
    evaluation and treatment for regimen and - Administer - Patient was able to
    the same.” lifestyle issue. patient practice disease
    - Encourage intravenous management with
    Objective cues: patient to therapy as ADL’s and promote
    Vital signs: increase fluid prescribe. healthy lifestyle
    T= 980 f intake at least - Limit patient routine.
    BP= 150/ 90 mmHg (Supine) 2000ml per day intake of anti- - Patient was able to
    HR= 110/min (supine) - Encourage inflammatory demonstrate proper
    BP= 90/60 mmHg (Standing) patient alcohol drugs. medication regimen,
    HR= Thready (Standing) and smoking - Commence fluid and enumerate at least
    RR= 20/min cessation balance chart 3 factors causing GI
    - Educate patient monitor patient bleeding
    HE-ENT/ SKIN: about the causing fluid volume - Patient successfully
    - Facial Pallor factor of GI intake. stop use of cigarettes
    - Cool moist skin bleeding - Provide patient and willing to
    education about participate in
    Abdomen & Rectal risk of alcohol preparation of healthy
    Examination: and use of variation of food.
    - Round abdomen cigarette.
    - Moderate - Suggest changes
    tenderness in the in lifestyle and
    epigastrium. assist client to
    - The liver is incorporate
    percussed to 13cm: disease
    and edge feels firm. management into
    - Presence of ADLs, and
    hyperactive bowel preparation of
    sounds. healthy variation
    - Reveals black, tarry of food.
    stool.

    Laboratory tests:
    Hemoglobin= 9gm/dl
    Hematocrit= 27%
    MCV= 90
    WBC= 13,000/mm
    PT/PTT= normal
    BUN= 45mg/dl
    Creatinine= 1.0mg/dl

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