Nursing Care Plan for GI Bleeding
10 Essential Nursing Diagnoses with Evidence-Based Interventions
Table of Contents
- Introduction to GI Bleeding Nursing Care
- Deficient Fluid Volume
- Risk for Shock
- Decreased Cardiac Output
- Impaired Gas Exchange
- Acute Pain
- Anxiety
- Activity Intolerance
- Imbalanced Nutrition: Less than Body Requirements
- Risk for Impaired Skin Integrity
- Ineffective Peripheral Tissue Perfusion
- Conclusion and Key Takeaways
- References
Introduction to GI Bleeding Nursing Care
Gastrointestinal bleeding represents a critical nursing challenge requiring prompt assessment and intervention. This nursing care plan focuses on comprehensive patient care management for individuals experiencing GI bleeding, addressing the multifaceted aspects of care without delving into the pathophysiology of the condition itself.
Key Nursing Priorities in GI Bleeding
- Establishing and maintaining hemodynamic stability
- Preventing complications associated with blood loss
- Managing patient comfort and anxiety
- Supporting adequate tissue perfusion
- Facilitating recovery and preventing recurrence
The following nursing care plan presents 10 essential nursing diagnoses commonly applicable to patients with GI bleeding. Each diagnosis includes related factors, defining characteristics, expected outcomes, evidence-based nursing interventions with rationales, and evaluation criteria.
#1: Deficient Fluid Volume
Related Factors
- Active loss of blood from GI tract (hematemesis, melena, or hematochezia)
- Decreased fluid intake due to nausea, vomiting, or NPO status
- Altered coagulation profile
- Medication effects (anticoagulants, NSAIDs)
Defining Characteristics
- Decreased blood pressure and increased heart rate
- Decreased skin turgor and dry mucous membranes
- Decreased urine output (<0.5 ml/kg/hr)
- Altered mental status (confusion, restlessness)
- Cool, pale, or clammy skin
- Weak peripheral pulses
- Decreased central venous pressure
Expected Outcomes
- Patient will maintain hemodynamic stability with vital signs within normal limits
- Patient will demonstrate adequate fluid balance evidenced by urine output >0.5 ml/kg/hr
- Patient will maintain skin turgor and moist mucous membranes
- Laboratory values (Hgb, Hct) will return to baseline or improve with interventions
Nursing Interventions and Rationales
| Nursing Interventions | Rationales |
|---|---|
| Monitor vital signs every 15 minutes initially, then every 1-2 hours as condition stabilizes | Frequent monitoring allows for early detection of deterioration and prompt intervention; tachycardia and hypotension are early indicators of hypovolemia |
| Establish at least two large-bore IV access sites (18G or larger) | Large-bore IVs facilitate rapid fluid and blood product administration when necessary for resuscitation |
| Administer crystalloid solutions and blood products as ordered | Replenishes intravascular volume, prevents shock, and maintains tissue perfusion; blood products replace lost red blood cells and clotting factors |
| Monitor intake and output strictly; document all visible blood loss (emesis, stool) | Provides quantitative assessment of fluid balance and helps estimate blood loss to guide replacement therapy |
| Monitor hemoglobin, hematocrit, and coagulation studies as ordered | Provides objective data regarding blood loss severity and effectiveness of interventions |
| Position patient in supine position with legs elevated slightly if hypotensive | Promotes venous return to the heart, improving cardiac output and tissue perfusion |
| Maintain accurate record of all sources of blood loss (nasogastric aspirate, vomitus, stool) | Helps quantify ongoing losses to guide fluid and blood replacement; also provides information about bleeding source location and status |
Evaluation
- Vital signs return to patient’s baseline
- Urine output maintains at >0.5 ml/kg/hr
- Skin turgor and mucous membranes return to normal
- Hemoglobin and hematocrit stabilize or improve
- Patient reports decreased dizziness and improved energy levels
#2: Risk for Shock
Risk Factors
- Active blood loss from GI tract
- Hypovolemia
- Decreased hemoglobin and hematocrit
- Impaired coagulation
- Inadequate compensatory mechanisms, especially in elderly patients
- Comorbid conditions affecting cardiac, respiratory, or renal function
Expected Outcomes
- Patient will not progress to hypovolemic shock
- Patient will maintain adequate tissue perfusion as evidenced by stable vital signs, warm extremities, and normal capillary refill
- Patient will maintain mental alertness and orientation
- Patient will demonstrate improved or stabilized hemodynamic parameters
Nursing Interventions and Rationales
| Nursing Interventions | Rationales |
|---|---|
| Assess for early signs of shock: tachycardia, tachypnea, decreased pulse pressure, anxiety, restlessness | Early recognition and intervention prevent progression to decompensated shock, which has higher morbidity and mortality |
| Monitor hemodynamic parameters including continuous cardiac monitoring and frequent vital signs | Provides real-time data on cardiovascular status and response to interventions |
| Assess skin color, temperature, capillary refill, and peripheral pulses every 1-2 hours | Changes in peripheral perfusion are early indicators of decreased cardiac output and compensatory mechanisms |
| Position patient flat with legs elevated 20-30 degrees unless contraindicated | Optimizes venous return to improve cardiac output during hypovolemia |
| Administer oxygen therapy as ordered to maintain SpO2 >94% | Ensures adequate tissue oxygenation during period of compromised oxygen-carrying capacity due to blood loss |
| Prepare for rapid infusion of fluids and blood products; use blood warmer for large volume transfusions | Prompt fluid replacement restores circulating volume; warming prevents hypothermia and associated coagulopathy |
| Monitor laboratory values (CBC, coagulation studies, electrolytes) and ABGs as ordered | Provides objective assessment of severity and guides interventions; acidosis may develop with tissue hypoperfusion |
| Administer vasopressors as prescribed if fluid resuscitation alone is insufficient | Supports blood pressure and tissue perfusion when hypovolemia persists despite adequate fluid replacement |
Evaluation
- Patient maintains MAP >65 mmHg without vasopressor support
- Patient demonstrates adequate peripheral perfusion with warm extremities and capillary refill <3 seconds
- Patient remains alert and oriented
- Urine output remains >0.5 ml/kg/hr
- Lactate levels normalize or decrease, indicating improved tissue perfusion
#3: Decreased Cardiac Output
Related Factors
- Reduced preload due to blood loss
- Compensatory tachycardia affecting ventricular filling time
- Decreased oxygen-carrying capacity from reduced hemoglobin
- Pre-existing cardiovascular conditions
- Electrolyte imbalances secondary to fluid shifts
Defining Characteristics
- Altered heart rate/rhythm (tachycardia or dysrhythmias)
- Decreased blood pressure, narrowed pulse pressure
- Decreased peripheral pulses
- Cold, clammy skin
- Decreased urine output
- Altered level of consciousness
- S3 heart sound (in severe cases or with pre-existing heart failure)
- Jugular vein flattening
Expected Outcomes
- Patient will maintain adequate cardiac output as evidenced by stable vital signs within patient’s baseline
- Patient will demonstrate adequate tissue perfusion to vital organs
- Patient will maintain mental alertness
- Patient will report decreased fatigue and improved activity tolerance
Nursing Interventions and Rationales
| Nursing Interventions | Rationales |
|---|---|
| Assess vital signs, heart sounds, and hemodynamic parameters (if available) every 1-2 hours or more frequently if unstable | Provides ongoing evaluation of cardiac function and effectiveness of interventions; changes may indicate worsening condition or improvement |
| Monitor ECG continuously for rate, rhythm, and ischemic changes | Tachycardia is a compensatory mechanism for decreased stroke volume; dysrhythmias may occur due to hypoxia or electrolyte imbalances |
| Administer blood products as ordered (packed red blood cells, platelets, FFP) | Restores oxygen-carrying capacity and improves cardiac output by increasing preload and decreasing compensatory tachycardia |
| Administer IV fluids as ordered, using fluid challenges with reassessment rather than continuous high-volume infusion | Improves preload without risk of fluid overload, especially important in patients with cardiac or renal compromise |
| Position patient to optimize venous return (supine with legs elevated or left lateral position) | Maximizes venous return and cardiac filling, improving stroke volume and cardiac output |
| Monitor for signs of fluid overload during resuscitation (crackles, JVD, S3 heart sound) | Aggressive fluid resuscitation may lead to volume overload, especially in patients with pre-existing cardiac dysfunction |
| Administer supplemental oxygen to maintain SpO2 >94% | Ensures maximal oxygen saturation of remaining hemoglobin to optimize tissue oxygenation |
| Minimize oxygen demand by maintaining normothermia and providing adequate pain control | Reduces cardiac workload by decreasing metabolic demand and sympathetic stimulation |
Evaluation
- Heart rate returns to normal range for patient (usually <100 bpm)
- Blood pressure remains within patient’s normal range
- Skin becomes warm and dry with normal color
- Urine output remains >0.5 ml/kg/hr
- Patient demonstrates improved level of energy and maintains mental alertness
- Central venous pressure readings (if available) normalize (2-6 mmHg)
#4: Impaired Gas Exchange
Related Factors
- Decreased oxygen-carrying capacity due to blood loss
- Increased oxygen demand due to tachycardia and stress response
- Altered ventilation-perfusion ratio due to hypovolemia
- Potential aspiration of blood or emesis in upper GI bleeding
- Pre-existing pulmonary conditions
Defining Characteristics
- Tachypnea
- Dyspnea
- Decreased oxygen saturation
- Cyanosis (late sign)
- Restlessness, confusion
- Abnormal arterial blood gases (decreased PaO2, increased PaCO2, decreased pH)
- Use of accessory muscles for breathing
Expected Outcomes
- Patient will maintain adequate oxygenation with SpO2 >94% (or at patient’s baseline)
- Patient will demonstrate normal respiratory rate and pattern
- Patient will report decreased shortness of breath
- Patient will have clear breath sounds on auscultation
- Patient will maintain normal arterial blood gas values
Nursing Interventions and Rationales
| Nursing Interventions | Rationales |
|---|---|
| Monitor respiratory rate, depth, and pattern every 1-2 hours or more frequently if unstable | Identifies early signs of respiratory compromise and allows for prompt intervention before decompensation |
| Monitor oxygen saturation continuously and arterial blood gases as ordered | Provides objective measurement of oxygenation status and acid-base balance |
| Elevate head of bed 30-45 degrees unless contraindicated by hypotension | Improves lung expansion and decreases work of breathing; also reduces risk of aspiration |
| Administer oxygen therapy as prescribed, titrating to maintain SpO2 >94% (or at patient’s baseline) | Compensates for decreased oxygen-carrying capacity due to anemia from blood loss |
| Auscultate lung fields every 2-4 hours, noting adventitious breath sounds | Detects early signs of fluid overload, atelectasis, or aspiration |
| Encourage deep breathing exercises and incentive spirometry every 1-2 hours while awake | Prevents atelectasis and improves alveolar ventilation, particularly important in patients on bed rest |
| Position patient to optimize ventilation-perfusion matching (upright, semi-Fowler’s, or lateral position depending on patient condition) | Maximizes lung expansion and ventilation, improving gas exchange |
| Administer blood products as ordered to improve oxygen-carrying capacity | Restores hemoglobin levels to improve oxygen delivery to tissues |
Evaluation
- Patient maintains SpO2 >94% (or at baseline) with or without supplemental oxygen
- Respiratory rate returns to normal range (12-20 breaths/minute)
- Patient demonstrates normal breathing pattern without use of accessory muscles
- Arterial blood gases return to normal or baseline values
- Patient reports improved comfort with breathing
- Lungs are clear to auscultation
#5: Acute Pain
Related Factors
- Inflammation or irritation of GI mucosa
- Abdominal distention from blood in GI tract
- Tissue ischemia due to decreased perfusion
- Invasive procedures (NG tube placement, IV insertion, endoscopy)
- Movement or positioning while hemodynamically unstable
- Underlying conditions causing the GI bleeding
Defining Characteristics
- Verbal report of pain (abdominal, epigastric, rectal)
- Guarding behavior or positioning to avoid pain
- Facial expressions of pain
- Increased heart rate or blood pressure during pain episodes
- Diaphoresis
- Muscle tension
- Restlessness
Expected Outcomes
- Patient will report pain at an acceptable level (≤3/10 or per patient goal)
- Patient will demonstrate improved comfort through relaxed facial expression and body positioning
- Patient will identify effective pain management strategies
- Patient will maintain physiological parameters within normal range during pain episodes
Nursing Interventions and Rationales
| Nursing Interventions | Rationales |
|---|---|
| Assess pain comprehensively using appropriate pain scale, including location, quality, intensity, duration, and aggravating/relieving factors | Provides baseline for pain management and helps differentiate between pain sources; location may provide clues about bleeding site |
| Administer prescribed analgesics, avoiding NSAIDs and being cautious with opioids in hemodynamically unstable patients | NSAIDs may worsen bleeding; opioids may mask symptoms and cause respiratory depression in unstable patients |
| Position patient comfortably with support to abdomen as needed | Reduces muscle tension and provides comfort without pharmacological intervention |
| Apply warm compress to abdomen if not contraindicated and if patient reports it provides relief | Promotes muscle relaxation and increases local circulation, potentially reducing discomfort |
| Provide gentle handling during procedures, particularly nasogastric tube management | Minimizes trauma and discomfort from necessary interventions |
| Teach and encourage relaxation techniques (deep breathing, guided imagery) | Provides non-pharmacological pain management strategies and gives patient some control over their pain experience |
| Reassess pain 30 minutes after intervention and regularly throughout care | Evaluates effectiveness of interventions and guides adjustments to pain management plan |
| Document pain characteristics, interventions, and effectiveness | Promotes continuity of care and helps identify effective individual pain management strategies |
Evaluation
- Patient reports pain controlled at acceptable level (≤3/10 or patient goal)
- Patient demonstrates relaxed posture and facial expression
- Patient uses non-pharmacological pain management techniques effectively
- Vital signs remain stable during pain episodes
- Patient participates in necessary care activities with minimal discomfort
#6: Anxiety
Related Factors
- Fear related to sight of blood (hematemesis, melena, hematochezia)
- Concern about health status and prognosis
- Acute change in health status
- Unfamiliar healthcare environment
- Discomfort from symptoms and treatments
- Uncertainty about diagnostic procedures and treatments
- Physiological response to blood loss (tachycardia, tachypnea)
Defining Characteristics
- Expressed concerns or fears
- Restlessness or fidgeting
- Increased heart rate and respiratory rate
- Vigilance or scanning behavior
- Difficulty concentrating
- Voice quivering
- Focus on self
- Insomnia
- Increased questioning or seeking reassurance
Expected Outcomes
- Patient will verbalize decreased anxiety
- Patient will demonstrate reduced physical symptoms of anxiety
- Patient will use effective coping strategies to manage anxiety
- Patient will verbalize understanding of condition, procedures, and treatment plan
Nursing Interventions and Rationales
| Nursing Interventions | Rationales |
|---|---|
| Establish a therapeutic relationship using calm, confident communication | Creates trust and provides reassurance; nurse’s demeanor can significantly impact patient’s anxiety level |
| Assess anxiety level using standardized assessment tools | Provides objective baseline and allows for monitoring of interventions’ effectiveness |
| Provide clear, concise information about the patient’s condition, procedures, and what to expect | Knowledge reduces fear of the unknown; understanding improves sense of control and reduces anxiety |
| Explain all procedures before performing them, using simple language | Preparation reduces surprise and anxiety; understanding promotes cooperation |
| Create a calm environment by reducing unnecessary noise and activity | Environmental stimuli can increase anxiety; quiet promotes relaxation |
| Encourage the presence of a support person when appropriate | Familiar presence provides emotional support and security |
| Teach and encourage relaxation techniques such as deep breathing, progressive muscle relaxation, or guided imagery | Provides patient with tools to self-manage anxiety and increases sense of control |
| Administer anti-anxiety medications as prescribed | Pharmacological management may be necessary when anxiety is severe or non-pharmacological measures are insufficient |
Evaluation
- Patient reports decreased feelings of anxiety
- Patient demonstrates reduced physical manifestations of anxiety (normal vital signs, relaxed posture)
- Patient applies relaxation techniques effectively when anxious
- Patient asks appropriate questions that demonstrate understanding of condition and care
- Patient engages cooperatively in treatment plan
#7: Activity Intolerance
Related Factors
- Decreased oxygen-carrying capacity due to blood loss
- Reduced cardiac output
- Imbalance between oxygen supply and demand
- Prolonged bed rest
- Weakness associated with acute illness
- Increased metabolic demands during healing
Defining Characteristics
- Abnormal heart rate or blood pressure response to activity
- Exertional dyspnea
- Weakness or fatigue
- Verbal report of fatigue or weakness
- Pallor or cyanosis with activity
- Dizziness or lightheadedness with position change or activity
Expected Outcomes
- Patient will demonstrate improved tolerance to progressive activity
- Patient will maintain stable vital signs during activity
- Patient will report decreased fatigue and increased energy levels
- Patient will perform activities of daily living with minimal assistance as condition improves
Nursing Interventions and Rationales
| Nursing Interventions | Rationales |
|---|---|
| Assess activity tolerance using a standardized scale (e.g., Borg Scale) and monitor vital signs before, during, and after activity | Provides objective measurement of tolerance and guides progression of activity; abnormal responses warrant modification of activity plan |
| Plan care activities with rest periods in between | Conserves energy and prevents excessive fatigue |
| Implement a progressive activity plan starting with passive range of motion and advancing to sitting, standing, and ambulation as tolerated | Gradual progression prevents cardiovascular decompensation while preventing complications of immobility |
| Assist with activities of daily living as needed, encouraging self-care as tolerated | Provides necessary support while promoting independence and preventing deconditioning |
| Monitor hemoglobin and hematocrit levels and correlate with activity tolerance | Provides objective data regarding oxygen-carrying capacity, which directly affects activity tolerance |
| Teach energy conservation techniques (prioritizing activities, using assistive devices, sitting for tasks when possible) | Helps patient manage limited energy effectively to accomplish necessary activities |
| Ensure adequate oxygen therapy during activity if prescribed | Supports increased oxygen demand during activity |
| Consult with physical therapy for individualized exercise program as appropriate | Provides expert guidance for safe reconditioning based on patient’s specific limitations |
Evaluation
- Patient demonstrates improved activity tolerance with stable vital signs during progressive activity
- Patient reports decreased fatigue with activity
- Heart rate and blood pressure return to baseline within 3-5 minutes after activity
- Patient performs self-care activities with minimal or no assistance
- Patient maintains oxygen saturation >94% (or at baseline) during activity
#8: Imbalanced Nutrition: Less than Body Requirements
Related Factors
- Decreased oral intake due to NPO status for procedures
- Nausea and vomiting associated with GI bleeding
- Fear of triggering recurrent bleeding with food intake
- Altered taste perception due to medications or nasogastric tube
- Increased metabolic demands during healing and blood regeneration
- Malabsorption related to rapid GI transit time with bleeding
Defining Characteristics
- Insufficient food intake
- Weight loss
- Poor muscle tone
- Weakness and fatigue
- Abnormal laboratory values (decreased albumin, prealbumin, total protein)
- Lack of interest in food
- Altered taste sensation
Expected Outcomes
- Patient will maintain or achieve appropriate weight for height and frame
- Patient will consume adequate dietary intake to meet metabolic needs
- Patient will demonstrate normal laboratory values for nutritional parameters
- Patient will verbalize understanding of nutritional needs during recovery
Nursing Interventions and Rationales
| Nursing Interventions | Rationales |
|---|---|
| Assess nutritional status using standardized tool (e.g., Malnutrition Screening Tool) and monitor weight daily or as appropriate | Establishes baseline and allows for ongoing monitoring of nutritional status; weight changes reflect fluid status and nutritional adequacy |
| Monitor laboratory values reflecting nutritional status (albumin, prealbumin, total protein, transferrin, hemoglobin) | Provides objective data regarding protein status and effectiveness of nutritional interventions |
| Consult with dietitian for individualized nutrition assessment and plan | Provides expert guidance for optimal nutrition support based on patient’s specific needs, including increased protein and iron requirements |
| Administer prescribed parenteral or enteral nutrition if oral intake is inadequate or contraindicated | Ensures adequate nutrition when oral intake is not possible or sufficient; prevents protein catabolism and supports healing |
| Progress diet as tolerated, from clear liquids to full diet, following post-bleeding protocol | Gradual progression reduces risk of recurrent bleeding and allows monitoring of tolerance |
| Offer small, frequent meals rather than three large meals when oral intake resumes | Improves tolerance and intake by reducing gastric distention and associated discomfort |
| Provide oral hygiene before meals and remove noxious stimuli from environment | Enhances appetite and improves taste perception, particularly important for patients with altered taste or nasogastric tubes |
| Administer prescribed iron supplements and vitamin supplements | Supports red blood cell production and repletes nutrient stores depleted by bleeding and poor intake |
Evaluation
- Patient maintains stable weight or demonstrates appropriate weight gain
- Patient consumes 75-100% of daily nutritional requirements
- Patient’s laboratory values improve or normalize
- Patient verbalizes understanding of nutritional needs during recovery
- Patient tolerates prescribed diet without nausea, vomiting, or recurrent bleeding
#9: Risk for Impaired Skin Integrity
Risk Factors
- Prolonged bed rest or immobility
- Decreased tissue perfusion due to hypovolemia
- Altered nutritional status
- Altered metabolic state
- Impaired circulation
- Frequent diarrhea with melena
- Moisture from diaphoresis or incontinence
- Decreased sensory perception in critically ill patients
Expected Outcomes
- Patient will maintain intact skin throughout hospitalization
- Patient will demonstrate absence of pressure injuries
- Patient and/or caregiver will verbalize understanding of skin protection measures
- Perianal area will remain clean, dry, and intact despite frequent bowel movements
Nursing Interventions and Rationales
| Nursing Interventions | Rationales |
|---|---|
| Assess skin condition thoroughly every shift, particularly over bony prominences and perianal area | Early identification of skin breakdown allows prompt intervention; perianal area is at high risk due to frequent melena |
| Use a validated risk assessment tool (e.g., Braden Scale) on admission and regularly thereafter | Identifies specific risk factors and guides preventive interventions based on individual risk level |
| Reposition patient at least every 2 hours or more frequently if high risk | Reduces pressure on any one area, maintaining tissue perfusion and preventing ischemia |
| Use appropriate pressure-redistribution surfaces (specialty mattress, heel protectors) based on risk assessment | Reduces interface pressure between bony prominences and support surface, decreasing risk of pressure injuries |
| Keep skin clean and dry, using pH-balanced cleansers; provide prompt cleaning after episodes of melena or incontinence | Maintains skin integrity by removing irritants; acidic pH helps maintain skin’s acid mantle and protective barrier |
| Apply moisture barrier cream to perianal area after cleansing | Protects skin from irritation caused by frequent exposure to stool, particularly melena which may be more irritating |
| Minimize friction and shear during repositioning by using proper transfer techniques and lift sheets | Friction and shear damage superficial layers of skin and impair microcirculation |
| Maintain adequate hydration and nutrition | Supports tissue integrity and healing; dehydration and malnutrition increase skin vulnerability |
Evaluation
- Patient’s skin remains intact throughout hospitalization
- Patient demonstrates absence of pressure injuries, redness, or skin breakdown
- Perianal skin remains intact despite exposure to melena
- Patient and/or caregiver verbalize understanding of skin protection measures
- Braden Scale score improves or remains stable
#10: Ineffective Peripheral Tissue Perfusion
Related Factors
- Decreased circulating blood volume due to blood loss
- Reduced cardiac output
- Vasoconstriction as compensatory mechanism for hypovolemia
- Reduced oxygen-carrying capacity due to decreased hemoglobin
- Altered blood flow due to bed rest or positioning
Defining Characteristics
- Diminished or absent peripheral pulses
- Skin color changes (pallor or cyanosis)
- Cool extremities
- Delayed capillary refill (>3 seconds)
- Altered sensations in extremities (numbness, tingling)
- Decreased skin temperature in affected area
- Weak peripheral pulses
Expected Outcomes
- Patient will demonstrate improved peripheral circulation as evidenced by strong peripheral pulses
- Patient will maintain warm extremities with normal color
- Patient will demonstrate capillary refill <3 seconds
- Patient will report absence of numbness or tingling in extremities
Nursing Interventions and Rationales
| Nursing Interventions | Rationales |
|---|---|
| Assess peripheral circulation every 1-4 hours (pulses, capillary refill, color, temperature, sensation) | Provides ongoing evaluation of tissue perfusion and early detection of deterioration or improvement |
| Document peripheral pulses using a standard scale (0-4+) | Ensures consistent assessment and facilitates recognition of changes in perfusion status |
| Administer prescribed fluids and blood products to restore circulating volume | Increases cardiac output and improves peripheral perfusion by restoring intravascular volume |
| Position extremities at or below heart level unless contraindicated | Promotes gravity-assisted perfusion to distal extremities |
| Avoid positions that compromise circulation (crossing legs, sharp knee bends, high Fowler’s position for extended periods) | Prevents additional compromise to already impaired peripheral circulation |
| Implement passive and active range of motion exercises when hemodynamically stable | Improves circulation through muscle contraction and prevents complications of immobility |
| Apply compression stockings as ordered if not contraindicated | Improves venous return, prevents venous stasis, and reduces risk of thrombosis |
| Monitor for complications of impaired tissue perfusion (skin breakdown, paresthesia, pain) | Early identification of complications allows prompt intervention to prevent tissue damage |
Evaluation
- Patient demonstrates strong, palpable peripheral pulses
- Extremities are warm with normal color
- Capillary refill returns to <3 seconds
- Patient reports normal sensation in extremities
- Patient maintains intact skin in areas at risk for pressure injury
Conclusion and Key Takeaways
Effective nursing care for patients with GI bleeding requires a comprehensive approach addressing multiple dimensions of care. The 10 nursing diagnoses outlined in this care plan highlight the most critical aspects of care management, from hemodynamic stability to psychological well-being. Priorities include:
- Immediate assessment and intervention for fluid volume deficit and risk for shock
- Ongoing monitoring of vital signs, hemodynamic parameters, and laboratory values
- Careful attention to tissue perfusion and oxygenation
- Pain management and comfort measures
- Psychological support and anxiety reduction
- Prevention of complications through early mobility, nutritional support, and skin integrity maintenance
This nursing care plan serves as a foundation for individualized care, which should be adapted based on the patient’s specific presentation, comorbidities, and response to treatment. Regular reassessment and adjustment of the care plan are essential as the patient’s condition evolves.
References
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