Case Study: GI Bleed

[kathrynn815]

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.

I was thinking that my nursing diagnosis for the patient is anemia related to GI bleed related to Peptic Ulcer Disease? Do you agree or have any other input?

I need a nursing diagnosis with interventions.

Thank you!

[feelix, RN]

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.

[nurseprnRN, BSN, RN]

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.

[IamLissaLpn]

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!