Question

J.S. is a 52 year old female who is presenting in the ER with frequent bloody stools.

J.S. has a history of ulcerative colitis, DM II, CAD, HTN, & hypercholesterolemia.

Patient presents pale, short of breath and fatigued.

Vitals:

T- 99.6

RR- 18

HR- 98

BP-146/76

O2Sat- 93% on room air

Develop a care plan for J.S.

what are two nursing diagnoses

What diagnostics need to be completed?

what is some Education for patient.

What will your assessment include?

Current Medications:

Accuchecks AC/HS Regular insulin sliding scale

Aspirin 325mg PO Daily

Atenolol 25mg PO daily

Simvastatin 20mg PO HS

Answer 1

1. in this case two best nursing diagnosis can be

- Ineffective breathing pattern related to hypoxia(lack of oxygen supply to body cells) as evidence by short of breath and fatigue.

- Fatigue-related to hypoxia and anemia as evidenced by Tiredness and lack of energy.

2.

The patient presented in the ER with frequent bloody stools, pale skin, and fatigue. It may a case of anemia due to blood loss from ulcerative colitis through stool.

So, Blood hemoglobin levels should be investigated first.

3.

In this case, the patient needs some education about

- You should avoid spicy and oily foods in our diet.

- You should take PPI (Proton pump inhibitors) to control the acid secretion of your stomach

- You should avoid NSAID pain killers

- Limit dairy products in your diet.

- Avoid alcohol and caffeine foods because it can worsen the condition.

- You have to avoid aspirin because aspirin is a blood thinner which increases the bleeding.

4. Assessment should includes

History of patients (Dietary habits includes smoking and alcohol intake)

Investigations - (Complete blood count, endoscopy, CT Scan)