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Case Study: GI Bleed

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Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

right but even before a diagnosis of cirrhosis.....what organ can show IMPAIRMENT? There is a specific diagnosis that addresses this.....you have no diagnostic evidence of cirrhoiss but his drinking habit place him at risk for .....liver impairment.

Care plans in school are to teach you what to look for in a patient. All the possible complications and implications in caring for your patient. Here are a few that I can see apply

Anxiety

Decreased Cardiac Output

Deficient Fluid Volume

Acute Pain

Ineffective Health Maintenance

Risk for impaired Liver Function

do you see why I choose these?

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

right but even before a diagnosis of cirrhosis.....what organ can show IMPAIRMENT? There is a specific diagnosis that addresses this.

Care plans in school are to teach you what to look for in a patient. All the possible complications and implications in caring for your patient. Here are a few that I can see apply

Anxiety

Decreased Cardiac Output

Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body

Defining Characteristics

Altered Heart Rate/Rhythm

Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia

Altered Preload

Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain

Altered Afterload

Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings

Altered Contractility

Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds

Behavioral/Emotional

Anxiety; restlessness

Deficient Fluid Volume

Acute Pain

Ineffective Health Maintenance

Pattern of regulating and integrating into daily living a therapeutic regimen for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals

[h=4]Defining Characteristics[/h] Failure to include treatment regimens in daily living; failure to take action to reduce risk factors; ineffective choices in daily living for meeting health goals; reports desire to manage the illness; reports difficulty with prescribed regimens

[h=4]Related Factors (r/t)[/h] Complexity of health care system; complexity of therapeutic regimen; decisional conflicts; deficient knowledge; economic difficulties; excessive demands made (e.g., individual, family); family conflict; family patterns of health care; inadequate number of cues to action; perceived barriers; perceived benefits; perceived seriousness; perceived susceptibility; powerlessness; regimen; social support deficit

Risk for impaired Liver Function

At risk for a decrease in liver function that may compromise health

[h=4]Risk Factors[/h] Hepatotoxic medications (e.g., acetaminophen, statins); HIV co-infection; substance abuse (e.g., alcohol, cocaine); viral infection (e.g., hepatitis A, B, C, E, Epstein-Barr)

Thank you so much for your guidance! I had this problem with my last case study because I think too broad and I missed such a simple nursing diagnosis. Would it be too much to ask if after I write my case study that I send it to you just as guidance? I see that you have been a nurse for 35 years and clearly you are very knowledgable! I appreciate how you made me think through this and not just telling me the answer.. that's what I need!

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

it's all in learning what to look for....go simple not global. Eventually, if he keeps bleeding he will probably drop his blood pressure....however if you recognize it early and do some fluid replacement you will prevent this potentially catesrophic complication from occurring.

Post it here so many students can benefit. I am always here (except recently I've been sick) and so is GrnTea. Show us your effort and we will give you what you need

The other thing you see with chronic liver impairment is a gradual increase in size of the portal veins, which crawl around the top of the stomach and esophagus and become varicosed due to the high pressure in them, same as the varicosed veins in legs...esophageal varices. A varix (the singular) can bleed like holy hell and can be torn by hard vomiting. I'm not saying he has those, because we don't know, but if he does, the excrement will hit the impeller really, really hard.

Livers are also responsible for growing clotting factors (I will leave it to you to find out which ones-- I recommend Joyce LeFever Kee's classic Laboratory Studies and Diagnostic Tests with Nursing Implications, a great place to learn rationales and preps and stuff). Even if he has no esophageal varices, think things might be harder to deal with if he has disturbed coags?

Also, what happens to people when they are regular drinkers and then they are prevented from drinking? (What vital signs might such a person have? What else?)

All of these you want to look at when you are searching for nursing diagnoses.

I always told my students to work backwards.

First ask yourself what did you do for your patient. That is your intervention. For example, you inserted an NG tube, monitored vital signs like heart rate, respirations, and blood pressure.

Why did those interventions is, for example, you suspect the patient's circulatory system is not working like it should; That will help you make a nursing diagnosis. Now look up your NANDA diagnoses matching for example Impaired perfusion (I don't have a diagnosis book in front of me)

the you will state why is the circulation impaired? That will give you your 'related to' part.

the last part 'as evidenced by' will come from your assessment data, for example: Skin cool, clammy, pale; HR 124, BR 30; Urine out put 10mL/Hr, BP 90/35, NG tube output 200 mL, bright red.

That completes your diagnosis.

The last thing you will determine is your goals. For example, where do you want your BP, heart rate and respirations to remain.

What you don't want to do is, go into the doctor's territory and call it a GI bleed, or in other words, make a medical diagnosis. Your diagnosis will be determined by the interventions you can perform within your scope of practice. So, you can say Altered Perfusion, but not GI bleed.

Edited by feelix

You can certainly call a physician and say that your patient is putting out frank blood through the NG tube :).

And I disagree completely with the backwards diagnosis thing. "I've ordered chemotherapy for you. You've got leukemia. Let's draw some blood to see why you're anemic and fatigued. Good to meet you this morning." Would you trust the physician who does this? No. Assessment first, diagnosis second, plan of care to follow.

Your taking vital signs are not interventions, they are assessments. The NG tube is part of a medical plan of care, although your assessment of what comes out of it is nursing.

Your goals are not nursing goals related to the nursing diagnosis.

GI Bleed is not "altered perfusion."

In keeping with the backwards theme today, I don't even know how to start to say how misguided this is. Were you an actual clinical instructor?

I always told my students to work backwards.

First ask yourself what did you do for your patient. That is your intervention. For example, you inserted an NG tube, monitored vital signs like heart rate, respirations, and blood pressure.

Why did those interventions is, for example, you suspect the patient's circulatory system is not working like it should; That will help you make a nursing diagnosis. Now look up your NANDA diagnoses matching for example Impaired perfusion (I don't have a diagnosis book in front of me)

the you will state why is the circulation impaired? That will give you your 'related to' part.

the last part 'as evidenced by' will come from your assessment data, for example: Skin cool, clammy, pale; HR 124, BR 30; Urine out put 10mL/Hr, BP 90/35, NG tube output 200 mL, bright red.

That completes your diagnosis.

The last thing you will determine is your goals. For example, where do you want your BP, heart rate and respirations to remain.

What you don't want to do is, go into the doctor's territory and call it a GI bleed, or in other words, make a medical diagnosis. Your diagnosis will be determined by the interventions you can perform within your scope of practice. So, you can say Altered Perfusion, but not GI bleed.

Grn Tea - I loved your post - I keep a binder in my tote with all the details of my job duties and advice like this, I plan on printing it out and filing in the how to do care plan section. I have worked primarily in LTC as an LPN for the past 30 yrs. I am taking my pre-req's to finally get my RN. I am 48, I learn something new everyday despite being at this job for the past 4 yrs. I struggle with care plans... I have not done them since the 80's. I was recently trained to be a relief charge nurse so 1-2 days a week so I am now responsible for updating existing plans and starting new ones for new admits. Your post is going to be VERY helpful... thanks for sharing!

Edited by IamLissaLpn
added name of person i was writing to