Nursing Diagnosis
Increase risk of Gastrointestinal bleeding which includes your esophagus, stomach, small intestines, large intestines, colon, rectum, and anus related to inflammation or minor ulcerations of the stomach lining as evidence by black, foul smelling stool that contains blood.
Assessment:
Assess for ingestion of irritating foods
Assess for previous infection of the gastrointestinal tract or emotional stress
Assess the patients stool and vomit for signs and color of blood
Assessing for a drop in patient's blood pressure and urine output and a increase in heart rate as it may indicate significant blood loss
Head to toe assessment looking for pale skin, grimacing, mental awareness and pain
Plan:
By April 30, 2014 at 1500 patient will have adequate nutrition, stress management controlled and patient will be free of bleeding in the stomach. Patients stool will be free from blood and foul smell.
Nursing Interventions:
1. Monitor patients vital signs for blood pressure, temperature, pulse, respirations, and oxygen levels.
2. Monitor signs for possible gastrointestinal bleeding like vomiting blood and black, foul smelling stool.
3. Prescribe a diet to avoid irritating foods such as coffee, or a low acid diet.
4. Provide emotional support to keep patients anxiety decreased
5. Monitor intake and output to see if there is blood in urine
6. Teach patient about the preventive measures of smoking which can lead to bleeding of the gastrointestinal tract
Evaluation:
Patients anxiety will be decreased, vital signs will remain stable and will be free of blood in urine. Patient follows and understands prescribed diet and understands the importance of smoking prevention.
Assessment:
Assess for ingestion of irritating foods
Assess for previous infection of the gastrointestinal tract or emotional stress
Assess the patients stool and vomit for signs and color of blood
Assessing for a drop in patient's blood pressure and urine output and a increase in heart rate as it may indicate significant blood loss
Head to toe assessment looking for pale skin, grimacing, mental awareness and pain
Plan:
By April 30, 2014 at 1500 patient will have adequate nutrition, stress management controlled and patient will be free of bleeding in the stomach. Patients stool will be free from blood and foul smell.
Nursing Interventions:
1. Monitor patients vital signs for blood pressure, temperature, pulse, respirations, and oxygen levels.
2. Monitor signs for possible gastrointestinal bleeding like vomiting blood and black, foul smelling stool.
3. Prescribe a diet to avoid irritating foods such as coffee, or a low acid diet.
4. Provide emotional support to keep patients anxiety decreased
5. Monitor intake and output to see if there is blood in urine
6. Teach patient about the preventive measures of smoking which can lead to bleeding of the gastrointestinal tract
Evaluation:
Patients anxiety will be decreased, vital signs will remain stable and will be free of blood in urine. Patient follows and understands prescribed diet and understands the importance of smoking prevention.