What priority assessments should the nurse perform? What are the anticipated findings?

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.


 

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