Lower GI Bleed: Result of bleeding from the small

intestine, large intestine, rectum, or anus. Can be

H & P: KL is 62-year-old
man. He works as a
sandblaster. He has had
#1 Priority: Risk for #2 Priority: Risk for # 3 Priority: Risk for #4 Priority: Knowledge deficit:
fluid volume deficit. anxiety. how to prevent another GI bleed.
silicosis for 12 years and take
significant blood loss.
Goal: Patient will have Goal: Patient will regain Goal: Patient will be free Goal: Patient will verbalize risk 40 mg of prednisone daily to
hemodynamic stability. fluid volume stability. from pain and anxiety. factors associated with GI bleed. manage it. He has severe
diarrhea, a large marron stool,
AD: Large maroon stool, 800 AD: BP 110/64 > 92/58. is agitated and pale. His vitals
AD: Active bleed. Heavy, AD: GI bleed induced from
mL marron stool, passing Patient is losing large amount
large amount of bright red of blood. Patient is pale and
significant blood loss. prednisone intake. are 110/64, 110, 28, 93%,
Undergoing a colonoscopy which NA: Educate patient on why
blood. diaphoretic.
can cause anxiety. prednisone is being decreased.
98.2 F. His fecal occult test is
NA: Increase IV fluids.
NA: Take vitals, increased
Trendelenburg position,
NA: Administer anxiety Avoid NSAID, antiplatelet, and positive. He has LR running
O2, increase fluids, call
physician, prepare for blood increased O2 with non-
medication. Reassure patient. alcohol. Educate on purpose of at 125 mL/hour and 5L of
Educate patient on procedures. esomeprazole. Administer
transfusion by inserting 2nd rebreather mask, take vitals,
E: Patient will be free from esomeprazole IV. Educate on S/S of O2/NC.
IV, verify informed consent, continuous pulse oximetry,
anxiety. GI bleed or anemia. Patient will be
strict I/O, keep NPO, insert insert indwelling catheter,
strict I/O. Administer IVF reevaluated in 2 months. KL passed 800mL marron
indwelling catheter. Assess E: Patient will verbalize
neuro. Auscultate heart, bolus. stool. Vitals are 92/58, 116,
E: Patient will regain fluid understanding of how to prevent GI
lungs, and bowels.
E: Bleeding has stopped. volume stability. bleed and when to seek help. 32, 93%. IVF bolus and
Patient is hemodynamically Meds: Midazolam for Meds: Decrease PRBCs are orders. ABG
stable. procedural anxiety. prednisone dosage. indicate respiratory alkalosis.
Procedure: Blood Administer dose of IV
transfusion and
Hgb is 7.8 g/dL and Hct is
Orders: IVF bolus of esomeprazole now. Take
colonoscopy r/t critical esomeprazole BID to 23%.
500 mL normal saline. 2
bleed. decrease likelihood of
units PRBCs STAT.
another GI bleed.
Orders: IVF bolus of 500
S/S: BP 110/64 > 92/58
Treatment: Patient will be
KL is taken to immediate
Pale, diaphoretic, altered
mL normal saline. 2 units
LOC reevaluated in 2 months. colonoscopy. He is passing a
PRBCs STAT. large amount of bright red
Treatment: Colonoscopy
S/S: Pale, diaphoretic, blood. He is paler,
altered LOC diaphoretic, and has an
Labs: Hgb 7.8 g/dL, Hct
23%
altered LOC. Bleeding is
ABGs: Respiratory cauterized.
alkalosis
Tests: Positive Fecal
Occult Prednisone dosage is
S/S: BP 110/64 > 92/58
Treatments, S/S
lowered. New omeprazole
Pale, diaphoretic, altered prescription.
AD = Assessment Meds (include
LOC
Data pertinent assessment
Nursing AND info that correlates
H&P: History and Medical Dx & patho Dx & NA = Nursing actions with meds), Labs,
R/T AND Tests, Therapies (OT,
Physical
E=Evaluation PT, RT, ST, etc.)