Name : Muhammad Alvin Fuzail Iyaz

SID : P1337420621035
Class : 2A3 RKI

UPPER GI BLEEDING PROBLEM

WOC UPPER GASTROINTESTINAL BLEEDING
 Nursing diagnoses
Fluid volume deficit related to active fluid
loss
Goals and Outcome Criteria Intervention
After carrying out nursing care for ….. a. Fluid management
perfusion adequate peripheral tissue with 1. Keep accurate intake and record output
outcome criteria: 2. Monitor hydration status
3. Monitor laboratory results relevant to
a. Fluid balance fluid retention
4. Monitor for indications of excess/fluid
1. Blood pressure within normal limits retention
2. Pulse within normal limits 5. Give IV therapy
3. Good skin turgor 6. Give fluids appropriately
7. Distribute liquid for 24 hours
4. Balance intake output in 24 hours
8. Manage blood product availability
5. Moist mucous membrane 9. Prepare to administer blood products
6. No ascites b. Hypovolaemic management
7. No thirst 1. Monitor for signs of dehydration
8. No sunken eyes 2. Monitor for orthostatic hypotension
3. Monitor for sources of fluid loss such as
b. Electrolyte balance bleeding
4. Monitor intake and output
1. No decrease in serum sodium 5. Administer isotonic IV fluids as
2. No decrease in serum calcium prescribed
3. No decrease in serum chloride 6. Monitor skin integrity
4. No decrease in serum magnesium 7. Provide oral fluids to maintain the
integrity of the mucous membranes
c. Monitor vital signs
1. Monitor blood pressure, pulse,
temperature and respiratory status
2. Monitor pulse quality
3. Monitor heart rhythm and pressure
4. Monitor for cyanosis
5. Identify the cause of the change in ttv
6. Check the accuracy of the instrument
used
Acute pain related to biological injury
agent
After carrying out nursing care for ….. a. Pain management
perfusion adequate peripheral tissue with 1. Perform a comprehensive pain
outcome criteria: assessment that includes the location,
characteristics, frequency, quality,
a. Pain control intensity of pain
2. Use therapeutic communication to
1. Recognize when pain occurs know the experience of pain
2. Shows the factors that cause pain 3. Dig together the factors that aggravate
3. Demonstrates using reduction pain
4. Give information about pain such as the
measures without analgesics
cause
4. Report changes in pain symptoms 5. Teach the use of non-pharmacological
techniques such as relaxation
b. Pain level
6. Evaluate the effectiveness of pain
control measures
1. Report no pain
7. Support rest/sleep
2. No moaning and grimacing b. Anxiety reduction
3. No muscle tension 1. Use a calm approach
4. No pain facial expression 2. Provide information regarding diagnosis
and treatment
c. Anxiety level 3. Encourage the family to accompany the
patient
1. No distress 4. Help identify situations that trigger
2. No cold sweat anxiety
3. No sleep disturbance 5. Assess for verbal and non-verbal signs of
4. No feeling of restlessness discomfort
1. 5. No tense face c. Administration of analgesics
1. Check treatment orders
2. Check the history of drug allergies
3. Select and combine the appropriate
analgesic
4. Evaluate the effectiveness of analgesics
at regular intervals
5. Document response to analgesics and
there are side effects
Activity intolerance related to weakness After carrying out nursing care for ….. a. Activity therapy
perfusion adequate peripheral tissue with 1. Help the patient to choose activities and
outcome criteria: achieve goals through consistent
activities
a. Fatigue: disturbing effect 2. Help the patient obtain the necessary
resources for the activities performed
1. No malaise 3. Help patient and family identify
2. No lethargy weaknesses
3. There is no interference with physical 4. Instruct patient and family to maintain
function and health related to social,
activity
spiritual, and cognition
4. No routine interruptions 5. Instruct the patient and family to adapt
to the environment
b. Self Care : Daily activities
6. Help fulfill the patient's daily activities
7. Create a safe environment
1. Able to move and position oneself
8. Help the patient and family evaluate the
2. Able to eat independently patient's ability to carry out activities.
3. Able to dress b. Energy management
1. 4. Able to perform body and oral 1. Assess the patient's physiological status
hygiene for fatigue
2. Instruct the patient to express his ability
3. Choose an intervention that reduces
fatigue
4. Determine the type and number of
activities to be carried out
5. Monitor nutrient intake to find out
energy sources
6. Collaboration with nutritionists
regarding energy intake as needed
7. Increase the patient's bed rest and rest
time
8. Run passive/active ROM
9. Teach the patient to contact the health
worker if fatigue does not decrease
 Bibliography
HAPSARI, H. P. (2017, Juni 15). pustaka.poltekkes-pdg. ASUHAN KEPERAWATAN PADA PASIEN DENGAN HEMATEMESIS MELENA
EC SIROSIS HEPATIS DI IRNA NON BEDAH RUANG PENYAKIT DALAM RSUP DR. M. DJAMIL PADANG. POLTEKKES
KEMENKES PADANG.
http://pustaka.poltekkes-pdg.ac.id/repository/HARLINA_PRATIWI_HAPSARI_KTI_D-III_KEPERAWATAN_PADA.pdf

AGAPE SEO, R. (2019, Juli 25). repository.poltekeskupang. ASUHAN KEPERAWATAN PADA TN. D.B.E DENGAN HEMATEMESIS
MELENA DI RUANG TERATAI RSUD PROF. DR.W.Z JOHANNES KUPANG. POLITEKNIK KESEHATAN KEMENKES KUPANG.
http://repository.poltekeskupang.ac.id/1432/1/001.KTI%20R.A.SEO.pdf