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.

- Labs: (discussed how the labs relates to the patient’s specific condition).

Answer 1