Question

Care Plan Map

Mr. TM is a 71year old admitted to room H-523 with a GI Bleed.

VS= B/P 100/60 TPR= 37°C 100- 20. Pulse Ox= 96% RA. Pain 7/10 c/o abdominal discomfort. Color pale, skin warm & dry.   Braden = 21. A & O x 4, PERRLA,

MAE x 4. Hand grip = & weak. Unsteady gait when ambulating. Needs assistance of 1. Denies numbness or tingling to extremities. Lungs clear vesicular sounds. No cough. PPP x 4 @ + 2, No edema, No JVD. CR < 3 sec. Abdomen hyperactive BS in all four quadrants. Abd soft; c/o abdominal tenderness to RUQ & LUQ upon palpation. No distention. Negative rebound. Black tarry stool ċ visible blood. Pt c/o diarrhea x 2 days. No c/o nausea. Foley catheter inserted to straight drain ċ clear amber urine. Falls precautions d/t weakness. History of GERD and depression.

Stat EGD completed., Results of biopsy pending. Pt. states he is afraid of results of biopsy. CXR is normal.

Lab results: Na+ 132   K+ 3.2 Cl- 97, Bicarb 23 BUN 10 Creatinine 0.9 Blood glucose 100 WBC= 6,200   Hbg = 7.8   Hct = 36%   Platelets = 224,000

Dr’s orders: Insert foley catheter. Type & cross match for 2 units PRBCs; BR ċ BRP.   SCDs while in bed. IV 0.9 % Normal Saline infuse @ 50 ml/hr to L-antecubital ṡ redness or swelling. I & O; NPO except for po meds; May give small sips of H2O with meds only.

esomeprazole magnesium 20 mg tab po daily

hydromorphone 1 mg IVP q4h prn pain

venlafaxine 75 mg po daily.

Client Initials _______ Date ________

Age _____ Gender _____ Room # _____   Admit Date __________

CODE Status __________ Allergies _____________________________________

Diet _________ Activity __________ Braden Score __________

Admitting Diagnoses/Chief Complaint:

Assessment Data:

Medications:

IV Sites/Fluids/Rate:

Past Medical /Surgical History:

Lab Values/Diagnostic Test Results:

Treatments:

Primary Nursing Diagnosis

Supporting Data:

STG:

Interventions with Rationale:

Evaluation:

              

Nursing Diagnosis #2

Supporting Data:

STG:

Interventions with Rationale:

Evaluation:

Nursing Diagnosis #3

Supporting Data:

STG:

Interventions with Rationale:

Evaluation:

EBP Citation:

Answer 1

Nursing diagnosis :

1)Acute pain related to increased bowel pattern,disease condition as evidenced by pain score,abdominal discomfort:

Supporting data

Abdominal discomfort ,pain on palpation

STG: to relieve from pain

Intervention with rationale:

• Assess the level of pain to know the status
• Administer analgesic to relieve pain
• Keep patient NPO to decrease bowel motility and reflux

Evaluation:decrease level if pain

2)Deficient fluid volume related to haemorrhage as evidenced by bleeding,decreased blood pressure,loss of sodium,increased bowel movement

Supporting data: black tarry stools,diarrhoea,weakness, pale,dry skin

STG: To cease patients bleeding ,loose stools,maintain fliud balance

Intervention with rational:

• Blood transfusion to increase hb level and recheck haemoglobin level in an hour
• maintain intake output chart to assess fluid balance
• Administer IV fluid at 50ml/ her to increase blood pressure and sodium level

Evaluation :

Increase in haemoglobin level,decreased fatigue

3)Ineffective coping mechanism related to anxiety as evidenced by patient fear,depression

Supporting data: anxiousand refusing to see the result of biopsy

STG: to cope with the current situation and ways to overcome it.

Interventions with rationale

• Explain all the procedure before performing to gain confidence and cooperation
• Encourage patient to speak out and clarify the doubts
• Provide diversional therapy

Evaluation

able to cope with the disease condition