Gi Bleed Nursing Care Plan

What is a gastrointestinal (GI) bleed?

A gastrointestinal (GI) bleed refers to bleeding in the digestive tract, which includes the esophagus, stomach, small intestine, or large intestine. It may present as upper gastrointestinal bleeding (esophagus, stomach, or duodenum) or lower gastrointestinal bleeding (colon or rectum). Bleeding can be overt, with visible bright red blood in vomit or stool, or occult, marked by symptoms like lightheadedness, abdominal pain, and fainting.

Causes and risk factors

Common causes of GI bleeding include peptic ulcer disease, inflammatory bowel disease (such as Crohn's disease or ulcerative colitis), diverticulosis, tumors, or vascular malformations. Risk factors include:

• Use of nonsteroidal anti-inflammatory drugs (NSAIDs) or blood thinners.
• Alcoholism leading to gastritis, ulcers, or liver disease.
• Older age, especially in individuals with comorbidities.
• Men are at higher risk due to conditions like diverticulosis and vascular disorders.

Symptoms of GI bleed

Symptoms range from mild to severe and may include:

• Fatigue, pallor, or abdominal pain.
• Vomiting blood (hematemesis) or passing black, tarry stools (melena).
• Signs of shock, such as low blood pressure and rapid heart rate, in severe cases.

Nursing diagnosis and interventions

Nurses play a critical role in diagnosing and addressing the condition through thorough assessment, prompt interventions, and continuous monitoring.

• Assessment: Nurses monitor vital signs, such as blood pressure and heart rate, to identify signs of shock. Evaluate stool and vomit for bright red blood or melena. Track laboratory values like platelet count and hemoglobin to assess the severity of the bleeding risk.
• Nursing interventions: Administer prescribed medications, ensure IV fluid replacement, and prepare the patient for procedures like endoscopy.
• Evaluation: Advice on lifestyle changes, including avoiding nonsteroidal anti-inflammatory drugs, alcohol, and smoking, to reduce recurrence.

How does our nursing care plan for GI bleed work?

You can use this GI bleeding nursing care plan template to adopt a structured and comprehensive approach for effectively managing GI bleeding by following these steps:

Step 1: Gather patient information

After accessing the template from this guide, begin by completing the patient information section. Include the patient’s name, age, gender, and date of birth. Document relevant medical history, especially conditions like inflammatory bowel disease, peptic ulcer disease, or prior episodes of gastrointestinal bleeding.

Step 2: Conduct a comprehensive assessment

Collect subjective and objective data to evaluate the patient’s condition. Note symptoms like tarry stools, fresh blood in vomit or stool, or altered mental status due to decreased blood volume. Assess vital signs, including blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature, to monitor for instability.  

Step 3: Establish diagnosis

Summarize findings to identify whether the patient is experiencing an acute gastrointestinal bleed or acute lower gastrointestinal bleeding. Specify contributing factors like NSAID use, alcohol consumption, or conditions affecting the GI tract, such as lower GI tract disorders. The diagnosis guides interventions for stabilizing the patient and managing recurrent bleeding risks.

Step 4: Define goals and outcomes

Set clear, actionable goals. Short-term goals should focus on stabilizing vital signs, achieving hemostasis, and improving lab values. Long-term goals aim to prevent recurrence, maintain adequate fluid volume, and educate the patient on avoiding triggers like NSAIDs. Ensure outcomes prioritize achieving stable vital signs and addressing underlying conditions.

Step 5: Plan and document interventions

Outline interventions, including administering IV fluids to restore volume, proton pump inhibitors to reduce gastric acid, and drug therapy for clot stabilization. Monitor for changes in tarry stools or new signs of gastrointestinal bleeding. Evaluate progress in stabilizing the patient’s condition and preventing future GI bleeds. Use the Evaluation section to document patient responses and adjust the GI bleed care plan as needed.

When would you use this template?

A GI bleed nursing care plan can be used in various scenarios where a patient presents with gastrointestinal bleeding. Some situations where this care plan might be implemented include:

Hospitalized patients

Individuals admitted to hospitals due to gastrointestinal bleeding, which could result from ulcers, gastritis, inflammatory bowel disease, diverticulosis, or other GI disorders.

Emergency room visits

Patients arriving at the emergency room with symptoms such as hematemesis (vomiting blood), melena (black, tarry stools), hematochezia (bright red blood in stools), or signs of significant blood loss.

Post-surgical complications

After certain surgeries involving the gastrointestinal tract, there can be complications leading to bleeding that require immediate attention and management.

Chronic conditions

Patients with chronic gastrointestinal conditions, such as peptic ulcers or esophageal varices, may experience recurrent bleeding episodes, necessitating ongoing nursing care plans.

Outpatient clinics

Individuals receiving outpatient care for chronic gastrointestinal bleeding conditions who experience sudden onset or exacerbation of bleeding symptoms might require immediate intervention and a structured care plan.

Benefits of using the GI Bleed Nursing Care Plan Template

Implementing a GI Bleed Nursing Care Plan Template ensures a structured approach to managing GI bleeds. Here are the benefits of using the template:

Early detection and targeted interventions

The template allows you to document key symptoms such as abdominal pain, upper GI bleeding, and changes in bowel habits, allowing for early detection of potential complications. By distinguishing between upper GI bleed and lower GI bleeding, nurses can implement specific interventions tailored to the underlying cause, improving treatment accuracy.

Monitoring and managing risk factors

The care plan allows for careful monitoring of risk factors that could increase bleeding risk, including the use of blood-thinning medications. This proactive approach ensures that high-risk patients, such as those with a history of inflammatory bowel disease, are closely monitored and appropriate steps are taken to minimize complications.

Ensuring fluid and electrolyte balance

Maintaining fluid and electrolyte balance is crucial in managing GI bleeds. The care plan also provides a section for evaluation. For instance, you can document and evaluate hydration status through mucous membrane assessment and continuous monitoring of fluid balance. This helps prevent dehydration and supports the patient’s overall stability, reducing the risk of further complications from blood loss.

Comprehensive and holistic care

By focusing on the underlying cause of the GI bleed, the care plan enables nurses to address both immediate and long-term needs. It ensures that necessary interventions, such as administering blood products or using medications to control bleeding, are timely and appropriate, improving patient outcomes and preventing recurrent bleeding.