- Acute Pain related to Gastrointestinal perforation and Gastrointestinal ischemia as evidenced by Guarding position of the affected area and Report of abdominal pain, heartburn
- Deficient Fluid Volume related to GI haemorrhage and Hematemesis as evidenced by Melena and Abdominal pain
- Imbalanced Nutrition: Less Than Body requirements Related to NPO status and Nutrient malabsorption as evidenced by Body weight less than the ideal weight for age and gender and Hyperactive bowel sounds
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Verbal reports from the patient Expressions of pain, such as crying Unpleasant feeling Objective data: -Significant changes in vital signs -Changes in appetite or eating patterns -Changes in sleep patterns -Guarding or protective behaviours | Acute Pain related to Gastrointestinal perforation and Gastrointestinal ischemia as evidenced by Guarding position of the affected area and Report of abdominal pain, heartburn | Patient will be able to verbalize relief or control of pain. Patient will be able to appear relaxed and able to sleep or rest appropriately. | 1. Administer pharmacologic pain management as ordered. Because it doesn’t induce side effects like stomach pain and bleeding, acetaminophen is typically seen as being safer than other nonopioid pain medicines. Antacids without aspirin and proton pump inhibitors may alleviate heartburn. 2. Evaluate the effectiveness of pharmacologic pain management. Because pain perception and alleviation are subjective, it is best to evaluate pain management within an hour after administration of medication. If the client is unable to communicate, the nurse should assess the patient’s physiological and nonverbal pain cues. 3. Provide comfort measures and non-pharmacologic pain management. The nurse can provide comfort measures such as frequent positioning, back rubs, and pillow support. The nurse can also provide non-pharmacologic pain management interventions such as relaxation techniques, guided imagery, and appropriate diversional activities to promote distraction and decrease pain. 4. Plan rest periods and create a conducive environment for sleeping and resting. Rest increases coping abilities by reducing fatigue and conserving energy. Reduce interruptions and group tasks to allow for a quiet, restful environment. | Patient verbalized relief or control of pain. Patient appears to be relaxed and able to sleep or rest appropriately. |
| Subjective data: Objective data: -Haematochezia -Hematemesis -Melena -Abdominal pain -Resting tachycardia -Orthostatic hypotension -Weakness -Nausea and/or vomiting -Decreased skin turgor | Deficient Fluid Volume related to GI haemorrhage and Hematemesis as evidenced by Melena and Abdominal pain | Patient will be able to maintain adequate fluid volume as evidenced by stable vital signs, balanced intake and output, and capillary refill <3 seconds. Patient will be able to demonstrate efficient fluid volume as evidenced by stable haemoglobin and haematocrit | 1. Assist the healthcare provider in treating underlying issues. Collaboration with the healthcare provider is necessary to determine the root cause of decreased fluid volume and bleeding. Stopping the source of gastrointestinal bleeding will also control the fluid volume deficiency. 2. Provide a sufficient amount of free water with meals and a nutritionally balanced diet or enteral feedings. Avoid using formulas that are too hyperosmolar or heavy in protein. Proper nutrition reduces the risk of anemia and enhances general health. Along with oxygenation, organs require nutrients like antioxidants, vitamins, and minerals to function. 3. Review and administer prescribed medications. Examine the client’s prescription, over the counter (OTC), herbal, and nutritional supplements to find any substances that might affect fluid and electrolyte balance or may be a cause of GI bleeding. Proton-pump inhibitors may be prescribed to curb stomach acid production. 4. Administer blood products. PRBCs are a common intervention for GI bleeding. The nurse can ensure the patient is type and cross-matched to prepare for blood transfusions. | Patient maintained adequate fluid volume as evidenced by stable vital signs, balanced intake and output, and capillary refill <3 seconds. Patient demonstrated efficient fluid volume as evidenced by stable haemoglobin and haematocrit |
| Subjective data: verbalizes about reduced body weight Objective data: -Abdominal pain -Abdominal cramping -Abdominal distension -Body weight less than the ideal weight for age and gender -Hyperactive bowel sounds -Lethargy -Pale mucous membranes -Vomiting | Imbalanced Nutrition less than Body requirements Related to NPO status and Nutrient malabsorption as evidenced by Body weight less than the ideal weight for age and gender and Hyperactive bowel sounds | Patient will not experience alterations in albumin, iron levels, or electrolytes. Patient will maintain weight within acceptable parameters | 1. Administer fluid and electrolyte replacement. The initial supportive therapy for patients with gastrointestinal bleeding includes fluid and electrolyte replacement to reverse hypovolemia and correct electrolyte deficiencies caused by the bleeding. 2. Minimize NPO status. Patients with gastrointestinal bleeding are often kept NPO for 48-72 hours to help improve gastrointestinal pH, reduce the risk of rebleeding, and stabilize clots. Patients at low risk for rebleeding may receive early enteral nutrition. 3. Provide small frequent feedings. Gastrointestinal bleeding is often accompanied by nausea and vomiting, which can further aggravate imbalanced nutritional intake. Providing small frequent meals reduces early satiety, decreases the incidence of vomiting, and allows the gastrointestinal tract to heal. 4. Encourage the patient to avoid gastric irritants. Caffeine, alcohol, soda, and spicy foods should be avoided as they can cause further gastrointestinal irritation and rebleeding. 5. Refer the patient to a dietitian. A dietitian can help plan appropriate and well-balanced meals while correcting nutritional deficits. Dietary recommendations include foods rich in iron, like meat, seafood, and nuts, along with whole grains, fruits, and vegetables, and low in salt, added sugars, and fats. | Patient relieved from experiences from alterations in albumin, iron levels, or electrolytes. Patient maintained weight within acceptable parameters |