Nursing Care Plan

Assessment Diagnosis Rationale Planning Intervention Rationale Evaluation

Objectives:
Patient appears
weak and
lethargic, sub
conjunctiva is pale,
lips are dry and
pale, slow capillary
refill, skin is cold,
dry with poor skin
turgor, Palms and
sole of feet is pale.
Hgb: 77g/L (140-
160)
Hct: 22% (40-54)














Deficient fluid
volume related
to active fluid
loss due to
gastrointestinal
bleeding as
evidenced by
Hgb of 77g/L
and Hct 22%
Severe bleeding
may reduce the
flow of blood to
the brain, causing
confusion,
disorientation,
sleepiness, and
even extremely
low blood
pressure (shock).
Slow, chronic
blood loss may
cause symptoms
and signs of
anemia (such as
weakness, easy
fatigue, paleness
[pallor], chest
pain, and
dizziness).

Source: Merck
Manual 2012
edition p.213
Short term:
After 8 hours of
nursing
intervention the
patient will be
able to Exhibit
relevant normal
levels of
laboratory value
such as in
hemoglobin and
red blood cell
level


Long term:
After 3 days of
nursing
intervention the
patient will be
able to maintain
adequate fluid
and electrolyte
balance.
Independent:
-Assess patient general
condition and establish
rapport

-Assess vital signs
-Raise bedside rails
-Do bed bath and
changing of bed linens
- Note patients
individual physiological
response to bleeding

-Monitor intake and
output (I&O), and
correlate with weight
changes.
- Maintain bed rest;
prevent vomiting and
straining at stool.

- Provide clear/bland
fluids when intake is
resumed. Avoid
caffeinated and
carbonated beverages
Dependent:
-Facilitate in blood
transfusion

- Administer
medications, as indicated



Collaborative:
- Monitor laboratory
studies, e.g.:Hb, Hct, RBC
count;

-To know condition of
patient and to gain trust
and cooperation from the
client
- To gather baseline data
- To provide safety
- To promote hygiene

- Worsening of symptoms
may reflect continued
bleeding or inadequate
fluid replacement.
- Provides guidelines for
fluid replacement.


- Activity/vomiting
increases intra-abdominal
pressure and can lead to
further bleeding.
- Caffeine and carbonated
beverages stimulate
hydrochloric acid (HCl)
production, possibly
potentiating rebleeding.

- Transfused all blood
components that are low
in the laboratory results.
- Histamine (H2)-receptor
antagonists may be given
parenterally during
bleeding to reduce HCL
acid production

-To monitor effectiveness
of therapy and to monitor
patients status.
Short term:
After 8 hours of
nursing intervention
the patient had to
Exhibited relevant
normal levels of
laboratory value
such as in
hemoglobin and red
blood cell level


Long term:
After 3 days of
nursing intervention
the patient had
maintained
adequate fluid and
electrolyte balance.