Question

Pt was admitted to the hospital for rectal bleeding in November 2nd. He has hx of NIDDM, HTN, Diverticulitis and CKD (stage IV). Pt was last seen in the ED on 10/29/20 for complaints of rectal bleeding. He was discharged w/ dx of lower gastrointestinal bleeding, hyperkalemia. On 11/2/2020 the pt presented to the ED via POV alone for complaints of bloody stools. Onset in the evening. Pt stated he had no recurrence of bloody stools since last ED until that evening. He had one episode of bright red blood in stools. Report last colonoscopy was 2014 by GI Dr. J and believed bleeding was due to divertoculitis.

He was Afebrile, VSS today. He did not move his bowels throughout my shift and did not complain any pain. He is not currently taking anticoagulants. He denies fever, chiils, abdominal pain, nausea, and vomiting. He's on a renal diet and tolerating well.

Labs:

WBC: 8.5

RBC: 3.57 L

Hgb: 10.8 L

Hct: 32.5 L

Plt: 157

PT 12.4

INR 0.97

APPT: 26

Na: 132 L

Anion Gap 6 L

Creatinine: 1.93 H

Immature Gran: 0.07 H

Lymphocytes: 15.0 L

EST GFR AfAM: 39 L

EST GFR NonAf: 33 L

Medications are:

Novolog Flx Pen SQ AC SCH

Protonix tab 40 mg PO daily SCH

- What are the nursing diagnosis?

- What are the three top problems for this patient? Include "related to" and "as evidenced by".

- What are the goals presented for priority problems are listed with measurable outcomes?

- What are the interventions (at least one education intervention) Relationships apparent between interventions and each goal/outcome and problem. Be concise and clear, achievable, relates to the stated diagnosis and client outcome.

- Evaluation: States how client outcome was met, what might have helped or hinder attainment of the outcome, analyzes the care given. If needed, revisions in the care plan done; interventions, assessment, state if should have done something differently in retrospect.

Answer 1

Diagnosis:

1. Fluid volume deficit related to blood volume loss secondary to lower GI bleeding as evidenced by blood in stools.

Outcome: Patient will have an absence of rectal bleeding and improved HB level.

Interventions:

Assess vital signs particularly BP level.

Monitor the input and output level of the patient.

Sart IV therapy as perscribed.

Transfuse blood as per advice

Evaluation: The BP is within normal limit.

2. Impaired Renal Tissue Perfusion related to Glomerular Malfunction as evidenced by as evidenced by Increase in Lab results

Outcome:

• Patient will demonstrate participation in his/her recommended treatment program.

Interventions:

Monitor and record vital signs.

Note characteristic of urine: measure urine specific gravity.

Monitor BP, ascertain patient’s usual range.

Provide diet restriction as indicated, while providing adequate calories.

Administer medication as ordered.

Evaluation: Patient demonstrates behavior changes to prevent complications.

3. Activity Intolerance related to Generalized weakness as evidenced by Reports of fatigue on exertion.

Outcome: The patient will attain increased tolerance for activity.

Interventions:

Assess the extent of weakness, fatigue, ability to participate in active and passive activities.

Schedule care and provide rest periods following an activity; allow the patient to set own limits in the amount of exertion tolerated.

explain the patient when to rest and when to stop an activity .

Evaluation: Patient verbalises reduced fatigue while performing ADL.

Patient education:

Educate regarding Exercise which promotes normal bowel function and reduces pressure inside the colon

Educate patient to avoid Smoking as it is worsens the diverticulitis.

Educate pateint regarding prognosis or long term effects of CKD

Educate the patient to maintain positive attitude; suggest use of relaxation technique such as guided imagery as appropriate.