ASSESSMENT NURSING BG PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE S
Subjective Data: Fluid volume Patient is an Short Term: Monitor vital signs. For baseline After 4 hours of
“n/a” deficit related alcohol drinker Client will be data and nursing
to upper GI which leads to able to maintain monitor interventions the
bleeding. upper gi fluid volume at changes. client was able
bleeding. functional to maintain fluid
Objective Data: Alcohol makes level. volume at
Occult blood (+) stomach produce Assess client’s Sign of functional level.
Pallor more acid than response to worsening
Cold clammy usual, which can hemorrhage such as condition.
skin in turn cause worsening of
gastritis (the
Restlessness symptoms.
inflammation of
the stomach
lining). This Closed monitoring Basis for fluid
triggers stomach of I and O volume
pain, vomiting, replacement.
diarrhea and, in
heavy drinkers, Maintain client at To avoid
even bleeding. bed rest and with no abdominal
bathroom privileges pressure that
as indicated. may aggravate
bleeding.

Administer blood For fluid

transfusion of PRBC replacement.
with pre- BT med of
Paracetamol IV

Administer ferrous To treat iron

sulfate as deficiency
prescribed. anemia.