Concept map GI bleed PDF

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Summary

full concept map for virtual simulation clinical, nursing diagnoses, vital signs, review of systems, medications used....

Description

Student Name: Date:

Clinical day: ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5

☐ On-Ground ☐ Virtual

Patient Information Initials: J.L DOB: 06/28/84 BP: 100/60 Pain level: 3 RR: 18 Chief complaint: weakness, dizziness Past Medical History: Crohn’s disease with intermittent gastritis Diagnostic Testing:  Fecal occult test -> positive  CBC -> in lab report *lab findings.  Endoscopy (colonoscopy) -> source of bleeding found

Admitted: 08/13/20 HR: 114 Temp: 100.2 SpO2: 98% Oxygen %: Room Air Admission diagnosis: Gastrointestinal bleed Allergies: Sulfa Laboratory findings:  Hgb: (8) decreased due to GI bleed  Hct: (24) decreased due to loss of RBCs as a result of the GI bleed  PTT: (21) due to a deficiency in blood clotting factors as evidenced by GI bleed and Crohn’s disease  INR: (0.7) decreased and means that the blood can coagulate faster and create a blood clot easier  CO2: (40) elevated due tachypnea related to blood loss

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BUN: (22) increased due to low blood flow to the kidneys due to tachypnea CL: (110) increased possibly due to high fever from internal blood loss

ROS: Patient reports feeling of light headedness and dizziness. Patient reports a history of  General: Reports daily stress. And that weight has increased due to poor diet habits and alcohol use. Reports feeling of weakness  Skin: no rashes, lesions or scars. Reports that skin is warm and pale.  HEENT: o Head: Reports lightheadedness and dizziness. No lesions, bumps or bruises. o Eyes: No vision problems. Does not wear glasses or contacts. No eye pain, or blurred vision. o Ears: No changes in hearing. No ringing. No aches, infections or discharge. o Nose: No drainage, stuffiness or sores. o Throat: No sore throat, no bleeding gums, no dentures. No problems with dry mouth. o Neck: No swollen glands. Never had a goiter. No reports of pain or stiffness.  Respiratory: No coughing. Patient reports shortness of breath. No recent X-ray. No hx of lung disease  Cardiovascular: No heart issues, no murmurs, no discomfort. Patient does report shortness of breath.  Gastrointestinal: Patient reports history of Crohn’s disease and abdomen feeling sore and crampy. Patient reports nausea. No reported issues with ileostomy site. Surgical Procedures: N/A Medical Diagnosis: Acute GI bleed. The common causes of a lower acute GI bleed are diverticular disease, colorecta cancer, colitis, Crohn’s disease, ulcers and hemorrhoids. With acute gastrointestinal bleeding, some manifestations include abdominal cramping, dizziness, fatigue, shortness of breath, paleness, dark or bright blood mixed with stool and weakness. Treatment is dependent upon the cause and location of the bleeding. The source of the bleeding can be stopped during a colonoscope, endoscope or sigmoidoscope procedure. To avoid or prevent a GI bleed, refrain from alcohol, and smoking.

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Medications Medication

Reason for therapy Analgesic- to treat moderate pain and fever

Adverse reactions & Contraindications Hemolytic anemia, renal dysfunction, rash, fever, hepatotoxicity. Caution to those with liver dysfunction.

Infliximab (Remicade)

Treats Crohn’s disease

Morphine (Roxanol)

Treat moderate to severe pain

Bone marrow depression, pruritis, exfoliative dermatitis, flushing, dizziness, anaphylactic shock Sedation, respiratory depression, apnea, shock cardiac arrest, constipation

(name, dose, route, frequency)

Acetaminophen (Tylenol) 650 mg PO Q4 hr PRN

Nursing implications (labs to check, etc)

-Monitor AST/ALT and CBC -Monitor vital signs -Monitor respirations -Observe skin

Monitor AST/ALT Monitor cardiac function Assess CBC and renal function Test for HIV and Hep B Monitor for CNS changes Monitor vital signs Monitor LOC Monitor drug- drug interactions Assess skin

Nursing Diagnoses List the top three nursing diagnoses for your client. Prioritize appropriately. Give information specific to your patient.

1. Risk for hypovolemic shock related to abnormal bleeding as evidenced by dizziness, hypotension and serosanguinous effluent in ostomy bag Assessment data: weakness, dizziness, abdominal tenderness, Planning/Interventions/Evaluation: obtain lab workup, initiate IV therapy fluids, administer blood product, monitor vital signs, monitor and observe output. Administer oxygen therapy. Education: encourage fluids, educate on diet and appropriate stress management. Goals: sustain normal blood pressure to patient’s baseline. Control source of bleeding. Oxygen saturation is increased to sustain body function. 2. Deficient fluid volume related to active fluid loss from internal bleeding as

evidenced by hypotension, tachycardia Assessment data: Weakness, tachycardia, and pale skin, blood pressure Planning/Interventions/Evaluation: Monitor and maintain fluid intake. Monitor orthostatic changes and vital signs. Monitor for signs of fluid overload. Education: increase fluid intake, inform to get up slowly. Dangle feet at side of bed before standing. Call for assistance. Goals: patient’s blood pressure is sustained back to baseline. Patient can demonstrate lifestyle changes to avoid dehydration. Patient describes signs and symptoms of current disease process. 3. Deficient knowledge related to inappropriate behavior related to diagnosed disease as evidenced by lifestyle Assessment data: determine source of psychosocial issue. Allow patient to speak freely about feelings and concerns pertaining to new ileostomy. Planning/Interventions/Evaluation: assess patient’s understanding of cause and treatment. Evaluate understanding of blood thinning substances like NSAIDS and alcohol.

Education: Refer to support groups. Teach ways non-pharmacological ways to manage stress. Teach about safe medication use and substances to avoid. Goals: patient verbalizes understanding of cause and management of GI bleed. Patient shows motivation to learn....