ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING

EXPLANATION
Subjective data: After several nursing
- Black stools for 3 days - Living in an unhealthy interventions:
- Lightheadedness - Acute Upper lifestyle can caused GI
- Complains of dizziness upon Gastrointestinal bleeding related to Short term
standing Bleeding related use of abusing drugs, - The client will
Objective data: to Peptic Ulcer alcohol and tobacco
demonstrate a
- Overweight male as manifested stable range of vital
products as well as signs.
- Anxious and restless by presence of overeating and body
melena, - The patient will have
fats system. A an absence of
HEENT/SKIN: dizziness, low
- Pallor common causes of gastrointestinal
hemoglobin
- Cool Acute upper GI bleeding as evidence
count and
- Moist skin bleeding are peptic by the
lightheadedness.
ulcer disease disappearance of
VITALS AND EXAMINATION: including from the melena
- Blood pressure: 120/80 mmHg prolonged term - Increase the
(sitting position) hemoglobin count
exposure of taking
90/60 mmHg (supine position) over 13 to 16 grams
medication such as
- Heart rate: 110/min per deciliter
Aspirin and NSAID’s - Patients skin color
Thready
can cause having will be normal
- Respiratory Rate: 20/min
- Temperature: 37.3 degrees peptic ulcer. Smoking - Educate the patients
centigrade can cause a person to family members
- Peripheral pulses are rapid and develop peptic ulcers about signs of
weak since one symptom of bleeding that needs
- Rounded abdomen having a peptic ulcer to be reported
- Hyperactive bowel sound is having a immediately.
- Moderate tenderness in the gastrointestinal Long term
epigastrium After one week of
bleeding which results
- Liver: 13 cm percussed, firm Nursing Intervention
to a black stool
(melena). Acute upper
 - Rectal examination: black, tarry GI bleeding may the patient will be
stool originate in the able to:
esophagus, stomach - Demonstrate a
Laboratory test results: and duodenum. healthy lifestyle
Hemoglobin- 9gm/dl through our patient
Upper GI bleeding
Hematocrit- 27% education
usually presents with
WBC- 13000/mm
melena or black tarry
BUN 45mg/dl
Creatinine- 1 mg/dl stools

Past health history of present illness: REFERENCES:

- He states of worsening of chronic (The Johns Hopkin,
epigastric burning, on and off for 3 2021)
years (Fundamentals of
- He takes (NSAIDS) for back pain nursing, pg. 289, vol
- Taking one Aspirin per day for 1, Kozier and
cardiac prophylaxis Erb’s,10th edition)
- He smokes two packs of cigarettes
www.ncbi.nlm.nih.gov
per day
- In the distant past he was told of
an ulcer but had no specific
treatment or evaluation
- He was treated for hypertension
for 8 years
- He has increased weight and
excellent appetite
INTERVENTION RATIONALE EVALUATION
Independent intervention: - Allows to understand patient’s feelings and communicate
well needed to improve patient care. - Goal met:
- To establish rapport - Assessing vital signs are used to measure the status of After days of intervention,
- Monitor client’s vital one’s body status. Having a low blood pressure is an initial the patient does not
signs most specially sign of hypovolemia due to GI bleeding and may put the experience bleeding as
BP and HR patient risk to shock. Looking for any indication Orthostasis evidenced by normal blood
- Assess any changes of which is the drip of 20 mm Hg in systolic pressure or 10 pressure, stable hemoglobin
skin condition mm Gg in diastolic pressure when changing position from count of 14 grams per
- Monitor hemoglobin supine to sitting indicates reduced circulating fluids. deciliter and desired color of
count - Skin conditions or color indicates blood loss and shock if stool
- Inform the patient to there is a presence of pale and cool skin condition Disappearance of pallor,
check the color of his - A low hemoglobin count can be due to blood loss due to cool and moist skin.
stool digestive bleeding such as ulcers. The patient demonstrates
- A bright red blood in stools indicates decreased of GI willingness changing his
Dependent Interventions: bleeding. While a stool that appears dark tarry is linked lifestyle away from cigarette
with upper GI bleeding which needs to be reported smoking and eating
- Celecoxib (Celebrex) immediately. excessively.
200 mg once a day for - Celecoxib treat pain, inflammation and stiffness. The clients family was able
back pain - Administer all doctors order in order to cure the illness to help the patient in
- Omeprazole (Prilosec) - Omeprazole indicate for a short- term treatment of peptic reporting or updating the
40mg once a day ulcer disease and heartburn in adults where most clients nurse regarding stool color.
heals within 4 weeks also was approved by FDA.
- The result of fecalysis and urinalysis will not be affected
due to consuming non colored foods and drinks.
Collaborative:
- Conducting routine fecalysis helps accurately detect
presence of blood in the stool, bacteria and parasite that
- Routine fecalysis are hard to find like Entamobia hystolytica, sometimes a
- Routine urinalysis one fecalysis test is not enough.
- Avoid colored foods
- For repeat fecalysis - Facilitate other laboratory test to know and be accurate
after 7 days with the diagnosis.
- Coordinate with - A proper diet plan should be given to lose body fats/
Dietician for dietary weight.
modifications. - The food color must be modified and must be given
- Refer to the attention thus it is not allowed for the patient to eat red
Nutritionist as well as meats, turnips, horseradish.
dietician about the - Considered in the setting of Melena to exclude a right-
color modification of sided colonic source of bleeding.
foods to be given to (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231512)
the patient. (Wayne,nurseslabs.com,2017)
- Colonoscopy (nursestudy.net,2021)