Kyla Mae S.

Manarang BSN-2YB-8

Laboratory Course Task 8a

You are assigned to care for an 11-year-old client with gastrointestinal bleeding. The client already has an NGT inserted for gastric decompression. The doctor
ordered a diagnostic procedure to be done and to do gastric lavage to be prepared for the client. 1 Liter of cold PNSS was ordered as the irrigating solution. As a
nurse assigned:
1. What assessment would be observed from the patient?

The nurse looks for evidence of blood in the patient's stool and vomits to assess if there is a GI bleed. Assessing a patient's blood pressure, urine output, and
heart rate can help determine the degree of blood loss. A decrease in blood pressure and urine output, together with a rise in heart rate, might suggest severe
blood loss. Following that, any important discoveries are reported to a physician by the nurse.

2. As you have performed gastric lavage, create an FDAR charting for this patient.

DATE/ TIME FOCUS DATA, ACTION, and RESPONSE

DATA
March 06, 2022 Gastrointestinal
5:00 AM Bleeding
 Reports abdominal pain with a pain scale of 7 out of 10
 Reports weakness, fatigue, and dizziness
 Facial grimacing
 Rebound, involuntary guarding, extreme pain to palpation

ACTION

AT 5:00 AM
 Explained the procedure and take the consent
 Fasting at least for 4-6 hours prior to collection

AT 10:30 AM
 Monitored VS and charted
 Handwashing before handling the patient
 Gastric lavage procedure was done (1 Liter of cold PNSS was ordered as the irrigating solution)
 Provided comfort measures and provided an opportunity for the patient to rest
 Administered 20 mg Omeprazole as per doctor's order

RESPONSE

 The patient expressed relief from the discomfort of their condition