Question

Topic 1: Use of the Nursing Process to Provide Patient Care

Plan nursing care for the following patient:

Carla Hernandez is a 15-year-old adolescent whose parents immigrated to the United States from Mexico when she was 3. She was admitted to the medical /surgical unit with a diagnosis of peptic ulcer disease. She has a two day history of vomiting blood and dark, tarry stools. She rates her pain as an 8 out of 10 on a 0-10 scale and states the pain is worse at night. During her admission assessment she states, “I’m dying. My stomach is killing me, and my throat is on fire.” Past medical history includes: gastroesophageal reflux disease (GERD), bulimia nervosa, purging type, pernicious anemia, and asthma. She states she has not had an “asthma attack” for 6 years, although she occasionally wheezes when her GERD flares up. Home medications include omeprazole (Prilosec) 20 mg PO once per day, cyanocobalamin (Vitamin B12) 2000 mcg PO daily, levonogestrel/ ethinyl estradiol (Allesse) PO one tablet daily for birth control, and fluoxetine (Prozac) 40 mg PO daily.

Admitting vital signs are as follows: temperature 98.4 F, oral, pulse 112, respirations 22, and blood pressure 94/57.

Admitting orders are as follows:

Admit to medical unit

Full Code

Allergies: eggs, peanuts, codeine

Activity as tolerated

Vital signs and pulse oximetry Q4H

If SpO2 <90%, then begin 2L O2 per nasal cannula and call MD

Daily weights

Monitor intake and output

Bland diet

Patient is to remain upright for 3 hours after eating

Push oral fluids as tolerated

0.9% normal saline at 100 mL/ hr

Omeprazole (Prilosec) 20 mg PO BID

Famotidine (Pepcid) 20 mg IV BID

Hydrocodone/ acetaminophen (Vicodin) 5mg/ 325mg 1-2 tablets PO Q4-6H prn pain

Fluoxetine (Prozac) 40 mg PO daily

Cyanocobalamin (Vitamin B12) 2000 mcg PO daily

Levonogestrel/ ethinyl estradiol (Allesse) PO one tablet daily for birth control

Urinalysis, Urine hCG

CBC with differential, BMP now and in AM

Surgery consult re: bleeding ulcer

Psychiatric consult

Dietary consult

What priority assessments should the nurse perform? What are the anticipated findings?
What are the top three priority nursing diagnoses for this patient and family?
For the diagnoses you identified, create a list describing subjective and objective assessment data associated with the diagnosis, a plan of care, and the methods that will be used to evaluate care given.

Answer 1

Nursing Care plan

Subjective and Objective data	Nursing Diagnosis	Objective	Intervention	Rationale	Evaluation
Subjective: none Objective: Patient has hematemesis	Deficient fluid volume related to hematemesis secondary to peptic ulcer as evidenced by hypotension and increased heart rate	After 6 hours of nursing intervention patient will maintain fluid volume at a functional level	Monitor Hb Monitor heart rate and blood pressure Administer fluids Administer antiemetics Administer pantoprazole	To assess the need for blood transfusion Provides baseline data To increase the fluid volume Anti emetics reduces vomiting Pantoprazole reduces GI bleeding	Effectiveness Was the client’s condition able to be corrected? Was the client’s fluid volume be able to be evaluated? Was the client able to follow the regular diet? Efficiency Are interventions carried out at right time? Accessibility Were the interventions are done? Appropriateness Were the interventions appropriate to the client? Adequacy Were the interventions can adequately meet the client needs?
Subjective: Patient says” I am dying, my stomach is killing me, my throat is on fire” Objective: Pain scale rating of 8 out of 10	Acute pain related to effect of GI secretions on gastric lining As evidenced by pain scale rating of 8 out of 10	Patient will demonstrate effective pain control with a pain scale reading of below 4 I 0-10 scale	Assess the characteristics of pain Provide compulsory rest periods Administer analgesics Reassure the client	Provides baseline data of care Exhaustion will increase pain To reduce pain and improve comfort Improves patients confidence in health care team	Check the goals are met or unmet
Subjective: Patient says” I’m dying, my stomach is killing me” Objective data: Restlessness, facial tension	Anxiety related to acute illness as evidenced by patients verbalization	After nursing interventions patient will appear relaxed and cope with anxiety	Review coping skills used in past Give accurate information about the situation Allow ventilation of feelings	Act as baseline for current situation It aids patient to accept the reality Helps to understand the client and plan accordingly	Check the goals are met or unmet