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Patient Name: E.

R Age/Gender: 92 years old / Female Medical Diagnosis: Upper Gastro Intestinal Bleeding Goal: After 2-3 hours of nursing interventions, the patient will maintain normal blood volume and proper oxygenation

CUES

NURSING DIAGNOSIS

SCIENTIFIC REASON

Subjective: “namumutla sya”, as verbalized by the SO.

Ineffective tissue perfusion r/t decrease circulating blood volume

UPPER GI BLEEDING

 BLOOD VOLUME

Objective: -pale skin - capillary refill (4-5 sec) -dizziness -body weakness -lab suggest an decrease in HCT and HGB VS TAKEN AS FOLLOWS:
Temp: 36.6 BP: 120/80 RR: 20 PR: 78

 O2 CIRCULATION

O2 IN THE CELL

INEFFECTIVE TISSUE PERFUSION

the client was maintained blood volume and proper oxygenation -for baseline parameters -for proper lung expansion -to maximize blood flow to the stomach enhancing digestion.Encouraged patient proper breathing exercise -Encourage rest after meals DEPENDENT: -administered IVF -Administer O2 if prescribed -Administer Medications COLLABORATIVE: -Monitor HCT and HGB RATIONALE EVALUATION After 2-3 hours of nursing interventions. -to replace fluid loss -to provide enough oxygen -to treat condition such as Gastric Bleeding -to determine severity of the condition .INTTERVENTION INDEPENDENT: -Monitored and recorded vital signs .