Acute Upper Gastrointestinal Bleeding - Essay Example

Applying Standardized Terminologies in Practice Applying Standardized Terminologies in Practice Introduction The paper is on a patient that arrives to the hospital with active gastrointestinal bleeding. The patient is in stable condition, alert and oriented. Upon interrogation the patient reported to have had two large bright red stools and a history of diverticulosis and GERD. No blood has been noted since the patient was referred to me. The vital signs of the patient were within normal range with a blood pressure of 103/62, heart rate of 72 beats per minute, respiration rate of 12 breaths per minute and oxygen saturation was found to be 97 on room air. The aim of the paper is to give an overview of the patient’s condition giving a detailed description of his complaints and current status. The paper will assess the medical condition of the patient as well as his family history and other aspects of his life in order to derive the appropriate intervention approaches. There will also be an assessment on the impact the condition will have on his family and ways how potential adverse effects can be minimized. The interventions that will be made to assist the patient will be on the basis of the MD’s orders as well as the knowledge I have acquired during my nursing career dealing with similar conditions. The paper will acknowledge the individuality of each patient when assessing and helping the patient. In addition, the paper will also devise a plan on how to monitor the progress of the patient and outcome of treatment. Body The patient was referred to me with the actual diagnosis of active gastrointestinal bleeding (Herdman, 2011). The G.I bleeding in the patient places him at risk of several other health complications. Prolonged loss of blood may lead to anemia as there is a reduction in the red blood cells. In addition, the patient is also at risk of hypovolemia which may cause hypovolemic shock (Herdman, 2011). The patient’s wife has a good job and she has a good and is capable of catering for the family. Furthermore, she can afford to for the patient’s hospital care and financial support for the full period of treatment. The patient came to the hospital with his wife, who was very cooperative with the hospital staff and stayed until she had to leave for work. The wife and the patient do not smoke or consume alcohol. In terms of health promotion, the patient is fully ready for treatment and his environment is supportive of any approach. Nursing assessment Family The patient states that he has a stable office job, and has been working as a software engineer for almost ten years. The patient states his wife works as an auditor and is the head of her auditing department. The patient has a son who is thirteen years old and his parents are business owners so they are not under his care. The patient lives in a good middle class community. The wife of the patient states that she is capable of monitoring her husband during the treatment, however, the patient states that he is fully capable of following any treatment plan. The patient also states that he has the discipline to follow specific diet regimes. However, one of the problems is that the patient is reluctant to stay in the hospital and stated that he would prefer to undergo treatment at home. Physical Assessment The general inspection was normal and the patient was fully conscious and alert. The patient had a decrease in his blood pressure to 103/62; however, it was within the normal range. Previously the patient had a blood pressure of 118/70. Other vital signs were within normal range with respiration of 12 breaths per minute. The patient had a heart rate of 72 beats per minute, which was slightly increased from 68 beats per minute. The oxygen saturation was within normal range at 97 on room temperature. The patient reported that he had two bright red stools. The patient also has a history of diverticulosis and GERD. The color of the patient’s stool shows that there is bleeding in GI tract. The GI bleeding has resulted in a slight reduction in the level of blood and this is shown by an elevation in the heart rate of the patient as well as the reduction in the blood pressure. However, since the blood pressure and the vital signs are within normal range and the patient has no clear signs of pallor or bleeding upon referral, the main information indicating the presence of internal bleeding are the 2 bright red stools which were stated by the patient. Furthermore, the patient has a history of GERD and diverticulosis which places him at risk of GI bleeding (Miller et al., 1994). The first approach would be to ensure that the patient is hemodyamically stable. From my experience I would first attain the blood stat type and begin volume enhancing IV fluid therapy. The pulse of the patient is below 100 pulsations per minute which indicates that the blood loss is not excessive (Hearnshaw et al., 2011). I would also check if the patient has normal bowel movement. Despite the fact that the patient does not want to stay in the hospital he will have to be admitted for a limited period of time determined by the MD. It is important to assure the patient and his family the necessity of this admission and facilitate for visits from his wife. Interventions would be based on the MD’s instructions which will include supportive therapy for maintaining normal volumes of the patient’s blood as well as administering the prescribed medications. Constant monitoring of the patient is also necessary to determine the need for analgesia and ensuring that he is comfortable. The patient’s vitals will be constantly monitored to detect any significant changes early. In addition it is also important to monitor the electrolyte and fluid status of the patient. In cases such as GI bleeding it is also important to monitor the psychological status of the patient to ensure that he is not over anxious about his diagnosis. There is also a need to educate the patient on his diagnosis and inform him on the different causal factors as well as the drug therapies that are involved (Urden et al., 2014). References Hearnshaw, S. A., Logan, R. F., Lowe, D., Travis, S. P., Murphy, M. F., & Palmer, K. R. (2011). Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut, 60(10), 1327-1335. Herdman, T. H. (Ed.). (2011). Nursing Diagnoses: Definitions and Classification 2012-14. John Wiley & Sons. Miller, L. S., Barbarevech, C., & Friedman, L. S. (1994). Less frequent causes of lower gastrointestinal bleeding. Gastroenterology Clinics of North America, 23(1), 21-52. Urden, L. D., Stacy, K. M., & Lough, M. E. (2014). Critical care nursing: diagnosis and management. Elsevier Health Sciences. 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