Question

Please help it’s due tomorrow and I have so many quizzes I’m so sorry!

1. What is the nursing diagnosis?

2. What is the inference?

Develop your care plan Ricardo is a 45 year old engineer admitted due to epigastric pain, loss of appetite,melena. Upon assessment he feels weak, showing signs of anemia such as Hgb 90 mg/dL and pallor He is scheduled for an endoscopy 9am the following day to assess for presence of ulcers He is nervous for the upcoming surgery his BP is 160/100 and avoids eye contact

Answer 1

1)Pain (acute) in the abdomen related to bleeding as evidenced by malena secondary to ulcer

• Desired outcome / goal: to relieve pain
• Assessment
  • Subjective :epigastric Pain,loss of appetite
  • Objective :malena
• Nursing intervention /rational
  • Assess the level of pain (intensity, duration,frequency, site) to get the baseline data
  • Administer medication as per order to relieve pain
  • Provide comfort devices to soothe the patient
  • Monitor and record bowel movements to make clinical decisions

Anemia/Fatigue related to decrease in haemoglobin level as evidenced by blood reports,malena,pallor

• Desired outcome :to achieve a normal normal haemoglobin level
• Assessment
  • Subjective data:fatigue
  • Objective data:malena,lab report
• Nursing intervention /rationale
  • Monitor vital signs because patient may have decrease in blood pressure
  • assists the patient in daily activities to prevent fall sue to fatigue
  • Monitor oxygen saturation, decrease in Haemoglobin may lead to hypoxia
  • Monitoring blood counts to prevent any consequences
  • Administer medications as per order to correct the underlying cause
  • Administer antifibrinolyticx in case of any bleeding

Imbalanced nutrition less than body requirement as evidenced by loss of appetite

• Goal/Desired outcomes:to correct any deficiencies
• Assessment
  • Subjective data:loss of appetite,
  • Objective data:weakness, pallid
• Nursing intervention /rationale
  • Provide foods preferred by the patient yo encourage eating
  • Administer appetite stimulant to increase appetite
  • Provide IV fluids as per order to balance the loss
  • Provide liquid diet and soft dietfor easy digestion
  • Avoid foods which are gastric irritants

Anxiety related to procedure as evidenced by nervousness, rise in blood pressure ,poor eye contact

• Desired outcome: to relieve anxiety
• Assessment
  • Subjective :nervous ,pain
  • Objective :raise in BP,poor eye contact,nervousness
• Nursing intervention /rationale
  • Explain all the procedures to win confidence and cooperation
  • Encourage to express, verbalize his fear, doubts to know the coping strategies
  • Provide diversional therapy to relieve stress
  • Encourage patient to be optimistic by giving positive reinforcements
  • Provide calm and quite environment

2)The signs and symptoms are suggestive of peptic ulcer,or irritable bowel disease.