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GL Bleed Care Plan help

Posted
klmomma klmomma (New) New

I have a pt that I took care of that had a colonoscopy which found 3 polyps which were removed.... while on coumadin (for st jude aortic valve replacement), which lead to a GI bleed with dizziness. Pt was re-admitted, stopped coumadin, another colonoscopy was performed and found some of the sites still bleeding and more clips were placed.

This pt had no pain (during the whole stay), was walking around performing ADL's independently, happy, etc. The only thing was he was pretty bored so when I came in to do vitals etc, he would talk a lot. During my care he was only there to monitor his INR because they were re-starting coumain for him to go home. No more blood in stool, having daily formed, soft stools, eating 100%, drinking great.... no obesity or diabetes. All vs wnl. I have to have a problem list, not nsg dx list and I am having a difficult time coming up with much. He did have difficulty sleeping in the hospital and I have the bleeding with low h&h... other than that I am stuck. Could think of tons of nursing diagnosis but can trace them all back to my two original problems.

any help would be greatly appreciated.