OK, LPN to be, here you go. . .I'm assuming this is a class assignment because, honestly, if you are needing to include
Ineffective tissue perfusion as a nursing diagnosis after a GI bleed, this patient is in some kind of trouble.
Deficient fluid volume would probably be a better diagnostic choice. However, since you have asked for ineffective tissue perfusion. . .
First, you need to assemble the physical assessment and history data that you have collected that will support this diagnosis. The patient should also have at least one or more of the following symptoms (according to NANDA):
- hypoactive or absent bowel sounds
- nausea
- abdominal distension
- abdominal pain or tenderness
Chest pain and the low H&H can also be included as a symptom of this particular diagnosis. I would also include the dark tarry stools although dark tarry stools are more a symptom of a slower upper GI bleed because the blood has had time to be digested. Acute upper GI bleeders are usually puking the blood and blood clots out. Acute pain is not specific enough. You need to identify exactly where this acute pain is.
There must also be a cause for the patient's decrease in oxygen resulting in failure of the tissues to be nourished at the capillary level. So, hypovolemia and/or a decreased hemoglobin concentration in the blood is what is existing.
Second, the nursing interventions for your care plan will then be things that address each of the symptoms that have brought you to the nursing diagnosis. So, you have listed chest pain, dark tarry stools, low H&H and acute pain (exact site unknown to me). Here are some suggestions of nursing interventions for these symptoms:
Chest Pain- Note time, location, quality, duration and any measures that relieve the pain (large blood losses may result in decreased perfusion and ischemia of cardiac tissue and the risk of an MI in a patient with already existing cardiac disease is a concern.)
- Monitor heart rate and rhythm (Dysrhythmias and ischemic changes can occur because of hypoxia.)
- Collaborative (with doctor's order): provide supplemental oxygen (treatment for hypoxia)
Dark, tarry stools (melena)- Note time, amount, and consistency of any stools (helps to determine the existence of hemorrhage)
- Auscultate for bowel sounds
- Palpate abdomen
- Observe and note abdomen for symmetry, swelling or other untoward signs
- Made sure a bedpan, commode or assistance to bathroom is available to patient
- Clean area around anus gently after each stool (Scrubbing and use of drying soaps frequently will put patient at risk for skin breakdown)
- Collaborative (with doctor's order): Guiac stools for occult blood and record results.
Low H&H- Monitor laboratory studies (helps to determine blood replacement need and monitor effectiveness of therapy, such as transfusion)
Pain (assuming it's abdominal)- Note time, location, intensity on a 0-10 scale of any abdominal pain, especially if it occurs suddenly and is severe and radiating to the shoulder (Continued severe or sudden onset of pain may be a symptom of tissue ischemia secondary to vasoconstrictors being given to control bleeding, intestinal perforation, or the onset of peritonitis. Comparisons of the intensity of pain experienced assists in determining the development of any complications.)
- Observe and note nonverbal evidence of pain such as restlessness, reluctance to move, guarding of abdomen, rapid heart rate, and sweating (Nonverbal cues are used with verbal statements of patient to help determine the severity of the problem)
- Provide frequent oral care (Bad breath from standing oral secretions while patient is NPO can aggravate nausea and give rise to gingivitis and other dental problems.)
- Collaborative (with doctor's order): give analgesics (promotes comfort and rest)
Goals/Outcomes:
- Patient will be free of signs of bleeding in stools.
- Patient's H&H will be stabilized.
- Patient's tissue perfusion will be maintained or improved.
- Patient will verbalize relief of pain.
- Patient will be able to rest.
Hope this is helpful and gives you an idea of where to go with this. The listings of interventions is not complete. I'm sure there are more nursing interventions you can think of to add. If you have an actual patient in mind that you are writing this for, it is always better to go with the actual symptoms and problems they are experiencing. Seriously, by the time a patient gets to the ineffective tissue perfusion stage of GI bleeding they are in shock, have a mesentery infarct or peritonitis and nearly dying or at death's door and other more serious problems are going on that are going to take precedence to keep the patient alive.
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