Topic 1: Use of the Nursing Process to Provide Patient Care Plan nursing care fo
ID: 238324 • Letter: T
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.
Explanation / Answer
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
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
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