Machine Translated by Google

Name : Muhammad Alvin Fuzail Iyaz

SID : P1337420621035
Class : 2A3 RKI

BLEEDING UPPER GI PROBLEM

Machine Translated by Google

WOC BLEEDING UPPER GASTROINTESTINAL

Machine Translated by Google
Nursing diagnoses Goals and Outcome Criteria
Fluid volume deficit related to gastrointestinal After carrying out nursing care for ….. perfusion
bleeding disorders adequate peripheral tissue with outcome criteria:
Activity intolerance related to
Blood pressure drop
Patient awareness composmentis
Vital signs
Urine output 0.5-1.0 ml/kg BW/hour Warm
palpation Normal skin turgor Capillary Refill Time
within normal limits (< 2 seconds) Client says he
can do normal activities
The client does not feel weak anymore
Intervention
record Hb and Ht values before and after the patient
loses blood
monitor signs and symptoms
persistent bleeding i.e. vomiting blood
and bloody stools
monitor blood coagulation components (PT,
PTT, and platelets)
Observe vital signs Monitor urine
output every hour,
note urine color and weigh daily Record
characteristics of vomiting and/or drainage.
Record individual physiological responses
patient to bleeding, for example mental
changes, weakness, restlessness, anxiety,
pallor, sweating, tachypnea, increased
temperature. Monitor input and output and
associated with changes in body weight.
Maintain bed rest; prevent vomiting and strain
during defecation.
Collaborative observation of electrolyte results
serum
Laboratory examination collaboration; for example
Hb/Ht
Machine Translated by Google

Bibliography

HAPSARI, HP (2017, June 15). library.poltekkes-pdg. NURSING CARE IN PATIENTS WITH HEMATEMESIS MELENA EC
HEPATIC CIRRSIS IN NON SURGICAL IRNA DISEASE ROOM IN RSUP DR. M. DJAMIL PADANG.
POLTEKKES Kemenkes PADANG.
http://library.poltekkes-pdg.ac.id/repository/HARLINA_PRATIWI_HAPSARI_KTI_D-III_KEPERAWATAN_PADA.pdf

AGAPE SEO, R. (2019, July 25). repository.poltekeskupang. NURSING CARE IN TN. DBE WITH HEMATEMESIS
MELENA IN THE LOTUS ROOM, PROF. DR. WZ JOHANNES KUPANG. HEALTH POLYTECHNIC MINISTRY OF
HEALTH KUPANG. http://repository.poltekeskupang.ac.id/1432/1/001.KTI%20R.A.SEO.pdf