Case Study: GI Bleed

kiszi, RN · Feb 21, 2014

anemia is a medical diagnosis, not a nursing diagnosis. You should have a list of nursing diagnoses in your syllabus or med-surg book. Think "impaired", "deficit", etc.

nurseprnRN, BSN, RN · Feb 21, 2014

Where is your nursing assessment of his condition? This is all medical diagnoses.

See, you are falling into the classic nursing student trap of trying desperately to find a nursing diagnosis for a medical diagnosis without really looking at your assignment as a nursing assignment. You are not being asked to find an auxiliary medical diagnosis-- nursing diagnoses are not dependent on medical ones. You are not being asked to supplement the medical plan of care-- you are being asked to develop your skills to determine a nursing plan of care. This is complementary but not dependent on the medical diagnosis or plan of care.

In all fairness, we see ample evidence every day that nursing faculty sometimes have a hard time communicating this concept to new nursing students. So my friend Esme and I do our best to reboot you and get you started on the right path. :)

Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts should come first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period. This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. "

"Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological." "Surgery" counts for a physical injury-- after all, it's only expensive trauma. :)

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related (causative) factor. (Exceptions: "Risk for..." diagnoses do not have defining characteristics, they have risk factors.) You cannot make them up, either. Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle or iPad at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised! Wonder where you learned that??? :)

I know that many people (and even some faculty, who should know better) think that a "care plan handbook" will take the place of this book. However, all nursing diagnoses, to be valid, must come from NANDA-I. The care plan books use them, but because NANDA-I understandably doesn't want to give blanket reprint permission to everybody who writes a care plan handbook, the info in the handbooks is incomplete. Sometimes they're out of date, too-- NANDA-I is reissued and updated q3 years, so if your "handbook" is before 2012, it may be using outdated diagnoses.

We see the results here all the time from students who are not clear on what criteria make for a valid defining characteristic and what make for a valid cause.Yes, we have to know a lot about medical diagnoses and physiology, you betcha we do. But we also need to know about NURSING, which is not subservient or of lesser importance, and is what you are in school for.

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings and at least one of the related / caustive factors are present. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.

I hope this gives you a better idea of how to formulate a nursing diagnosis using the only real reference that works for this.

Now, we're going to look at where to go for outcomes and interventions. I think you can probably imagine what you might want to see for an outcome. It would probably have something to do with no increase in pain due to decreased circulation, or perhaps no increase in tissue injury, you might also consider some of the educational components, so one of your outcomes might be that the patient describes..., so you understand that he knows more about his disease.

I'm going to recommend two more books to you that will save your bacon all the way through nursing school, starting now. The first is NANDA, NOC, and NIC Linkages: Nursing Diagnoses, Outcomes, and Interventions. This is a wonderful synopsis of major nursing interventions, suggested interventions, and optional interventions related to nursing diagnoses. For example, on pages 113-115 you will find Confusion, Chronic. You will find a host of potential outcomes, the possibility of achieving of which you can determine based on your personal assessment of this patient. Major, suggested, and optional interventions are listed, too; you get to choose which you think you can realistically do, and how you will evaluate how they work if you do choose them.It is important to realize that you cannot just copy all of them down; you have to pick the ones that apply to your individual patient. Also available at Amazon. Check the publication date-- the 2006 edition does not include many current nursing diagnoses and includes several that have been withdrawn for lack of evidence.

The 2nd book is Nursing Interventions Classification (NIC) is in its 6th edition, 2013, edited by Bulechek, Butcher, Dochterman, and Wagner. Mine came from Amazon. It gives a really good explanation of why the interventions are based on evidence, and every intervention is clearly defined and includes references if you would like to know (or if you need to give) the basis for the nursing (as opposed to medical) interventions you may prescribe. Another beauty of a reference. Don't think you have to think it all up yourself-- stand on the shoulders of giants.

Let this also be your introduction to the idea that just because it wasn't on your bookstore list doesn't mean you can't get it and use it. All of us have supplemented our libraries from the git-go. These three books will give you a real head-start above your classmates who don't have them.

Esme12, ASN, BSN, RN · Feb 21, 2014

thread moved for best response.

Welcome to AN! The largest online nursing community!

Is this a real patient? What semester are you? Welcome to AN! The largest online nursing community! I see that this is your first post. We are happy to help but we need to see what you think first!

Care plans are all about the patient and the patients problems. Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...:)

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning (write measurable goals/outcomes and nursing interventions)
Implementation (initiate the care plan)
Evaluation (determine if goals/outcomes have been met)

Tell me your assessment...What does this patient need? Tell me about your patient

kathrynn815 · Feb 21, 2014

What about risk for shock due to sudden blood loss and that PUD should be investigated as the underlying cause for the bleed? This is all of the info I was given for the case study, no labs or anything.

kathrynn815 · Feb 21, 2014

Thank you! I am in my second semester of Nursing school and this is for MedSurg. I was thinking about risk for shock due to sudden blood loss and that PUD should be investigated as the underlying cause for the bleed? This is all of the info I was given for the case study, no labs or anything. From here I can continue with my planning and evaluation. Any thoughts? Thank you :)

Esme12, ASN, BSN, RN · Feb 21, 2014

What are you using for you nursing diagnosis resource?

Mr. S, a 50 year old man, has been admitted to the Medical Surgical unit with a diagnosis of GI Bleed. He drove himself to the Emergency Department (ED) after vomiting bright red blood twice within 6 hours. He arrives on the unit alert and oriented X 3 but appears anxious. He is able to provide only a vague history but admits to drinking a “few “ last weekend. He knows that he is “supposed to stop drinking” and takes “something for his stomach,” but cannot recall the name of the medication. He reports intermittent dizziness and fatigue that has been worsening over the past 2 days. His skin is dry and pale. His abdomen is slightly distended. He reports pain (4 on a scale of 10) in the midepigastric area. Capillary refill is longer than 3 seconds, blood pressure 140/90mm Hg, pulse rate is 110 beats/min, resp rate is 24 breaths/min, and temperature 99 degrees F

Looking at this assessment....what NURSING DIAGNOSIS would you think appropriate?

Each nursing diagnosis has certain criteria (symptoms) that the patient must have in order to use that diagnosis. What symptoms does your patient display?

kathrynn815 · Feb 21, 2014

NANDA nursing diagnosis

nurseprnRN, BSN, RN · Feb 21, 2014

You can't be using the NANDA-I 2012-2014 and choose anemia as a nursing dx, because it's not in there. I don't know where you might have found that. You would not be in charge of continuing diagnostic measures for PUD; that is a medical dx and the medical diagnostic process isn't yours, it's the physicians'.

What's another huge risk for bleeding in drinkers? HINT: It's due to problems a little east an south of the stomach, mostly ...

And still, have you looked at the risk factors listed for "Risk for shock"? There is a very specific list of them, on page 435, and I don't see any of it in your description of the patient scenario. That's not to say it might not develop (and as luck would have it, probably will....we can name that tune in three notes), so you would continually reassess.

Something else? HINTS: Respiratory rate. Elevated temp. Drinker. Hematemesis. All important signs ... what else can you anticipate? A nursing plan of care isn't a point in time, and I think your faculty would be happy to see you think longer-term.

Esme12, ASN, BSN, RN · Feb 21, 2014

Looking at your given scenario? What would you be concerned about? Is this patient deficient in fluid volume? Is he showing signs of decreased cardiac output? Is his pain acute? Is he managing his self health management effectively? Is he at risk for impaired liver function?

look at deficient fluid volume.....NANDA-IDefinition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level

Defining Characteristics: Change in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness

Related Factors (r/t): Active fluid volume loss; failure of regulatory mechanisms

Does your patient fit these criteria?

kathrynn815 · Feb 21, 2014

I am using risk for shock as my nursing diagnosis because of his blood loss, anxiety, tachycardia, and tachypnea. His temp will also continue to rise and will need to be monitored. Alcohol also acts as a blood thinner on the body and if he is taking something for his stomach, that could have additive effects causing stomach bleeding?

Am I getting warmer? lol

Esme12, ASN, BSN, RN · Feb 21, 2014

no you are not...your patient has other pressing diagnosis that need immediate attention.

THINK about this what would be your concern in caring for this patient. They are bleeding but the most pressing issue would be volume loss right? That is what he is being symptomatic with at the present....poor cap refill, tachycardia, anxiety, pale dry skin right? So replacing volume would be a concern do you see this? The next is he has acute pain.

What else do you SEE not what you think he might develop. LOOK AT THE PATIENT WHAT DOES HE NEED!