Defining Nursing Diagnosis Outcome Nursing Intervention Rationale Evaluation

Characteristics Identification
Subjective: Deficient fluid Long term: Independent: Hypovolemia due to GI Goals partially
“Naga suka ako volume related to After 1 week of  Assess vital signs, bleeding may lower BP and put met:
kagina sang aga nursing particularly Blood the patient at risk for After 1 week of
active fluid volume
sang mapula pula intervention, pressure. hypotensive episodes that lead nursing
loss as evidenced to shock.
nga dugo ”as Patient will be able intervention,
by massive  Monitor a fluid Patient will be
verbalized by the to maintain
vomiting balance chart by To monitor patient’s fluid
patient. adequate fluid able to maintain
monitoring the input volume accurately.
volume as adequate fluid
and output of the
Objective: Rationale: manifested by volume as
patient.
Vital signs: The deficient fluid stable Increased abdominal fullness manifested by
T: 36.5ºC volume associated Hemodynamics  Assess for signs of and distention, nausea or stable
PR: 85 bpm with with normal skin renewed bleeding renewed vomiting, and bloody Hemodynamics
RR: 22 cpm gastrointestinal turgor. after cessation of the diarrhea may indicate a return with normal skin
BP: 110/76 bleeding can be initial bleed of the bleeding turgor.
O2Sat: 95% caused by Short term:
decreased After 3 days of  Provide
This help assurance and
blood volume due psychological and
Reassessment: nursing, calming.
to emotional support to
BP: 94/63 mmHg intervention
the patient.
blood loss. This Patient will be able
HR: 98 bpm
may to demonstrate  Educate the patient
 Anxious To help the patient or the
lead to a decrease normal vital signs, (or guardian) on
 Confused guardian take ownership of the
in minimal bleeding how to fill out a patient’s care, encouraging
 Visible hand
blood flow and and balanced fluid balance. them to drink more fluid as
tremors
ineffective tissue intake and output needed, or report
 The skin was
perfusion in the
 cool and gastrointestinal any changes to the nursing
clammy with system. team.
 Maintain bedrest.
poor skin
Schedule the client’s
turgor and
activities and Activity and vomiting
weak pedal provide increases intraabdominal
pulses uninterrupted pressure and can predispose to
 occult blood References: periods of rest further bleeding.
(+) https://
nursestudy.net/gi-
Endoscopy bleed-nursing Dependent:
 An oozing diagnosis/  Monitor laboratory
Decreased hemoglobin and
bleeding from studies. CBC, WBC,
hematocrit, and platelet count
varix located hematocrit,
may indicate blood loss. and a
at the second hemoglobin, BUN
BUN to creatinine ratio. A
portion of the and Liver function.
BUN to creatinine ratio higher
duodenum than 30:1 correlates with an
was noticed. upper GI bleed. This reveals
any liver dysfunction which
Laboratory may be the cause of bleeding.
 hemoglobin  Informed consent
5.8 g/dL to protect the patient
 platelet count
92 000/µL  A Foley catheter
international was inserted. accurate
normalized monitoring of intake and
ratio output.
 WBC  Proper cross-
matching typing of
 patient blood was To ensure compatibility.
done.

 D5LR 1L started. replace water and electrolyte

1 unit of packed red loss in patients with low blood
blood cells volume or low blood pressure

 (PRBCs) PNSS 1L maintain the hemoglobin level

side drip above 8 g/dl with massive
bleeding or significant
comorbid conditions.

 Octreotide 50mcg inhibits both acid and pepsin

IV bolus. secretion, it prevents the
dissolution of freshly formed
clots at the site of bleeding
 Terlipressin IV was
initiated for 5 days
(2 mg every 4 h for
Used to treat bleeding caused
the first 3 days,
by esophageal
followed by 1 mg
varices.
every 4 h on the last
2 days) 8:00AM-
12:00NN-4:00PM-
8:00PM

 Tranexamic Acid Control bleeding

 500mg IVTT Q8H
for 2 days
8:00AM-4:00PM-
12:00MN Reduces intestinal
inflammation and blood loss
 Metronidazole 500
mg
IV-ANST Q6
12:00NN-6:00PM- Reduces the amount of acid in
12:00MN-6:00AM the stomach makes. It's used
for heartburn, acid reflux, and
gastroesophageal reflux disease
(GORD).
 Pantropazole 40 mg
OD in 60cc PNSS
via infusion over 15
mins 8:00AM