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
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
Monitor intake and output
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
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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