Published
Mr. S, a 50 year old man, has been admitted to the Medical Surgical unit with a diagnosis of GI Bleed. He drove himself to the Emergency Department (ED) after vomiting bright red blood twice within 6 hours. He arrives on the unit alert and oriented X 3 but appears anxious. He is able to provide only a vague history but admits to drinking a "few " last weekend. He knows that he is "supposed to stop drinking" and takes "something for his stomach," but cannot recall the name of the medication. He reports intermittent dizziness and fatigue that has been worsening over the past 2 days. His skin is dry and pale. His abdomen is slightly distended. He reports pain (4 on a scale of 10) in the midepigastric area. Capillary refill is longer than 3 seconds, blood pressure 140/90mm Hg, pulse rate is 110 beats/min, resp rate is 24 breaths/min, and temperature 99 degrees F.
I was thinking that my nursing diagnosis for the patient is anemia related to GI bleed related to Peptic Ulcer Disease? Do you agree or have any other input?
I need a nursing diagnosis with interventions.
Thank you!
I am using risk for shock as my nursing diagnosis because of his blood loss, anxiety, tachycardia, and tachypnea. His temp will also continue to rise and will need to be monitored. Alcohol also acts as a blood thinner on the body and if he is taking something for his stomach, that could have additive effects causing stomach bleeding?Am I getting warmer? lol
LOOK AT HIM (figuratively speaking) you are stuck fitting him into what YOU think he needs and NOT what he really NEEDS....many new students make this mistake.
Look at the definition of shock....
Where does your patient fit in this diagnosis? Where is your proof?At risk for an inadequate blood flow to the body’s tissues which may lead to life-threatening cellular dysfunction[h=4]Risk Factors[/h] Advanced age (greater than 65 years); comorbidities (e.g., angina, prior stroke, peripheral vascular disease, diabetes, cancer, renal insufficiency); emergency procedures related to traumatic events; hypotension; hypovolemia; hypoxemia; hypoxia; infection; sepsis; systemic inflammatory response syndrome (SIRS)
Mr. S, a 50 year old man, has been admitted to the Medical Surgical unit with a diagnosis of GI Bleed. He drove himself to the Emergency Department (ED) after vomiting bright red blood twice within 6 hours. He arrives on the unit alert and oriented X 3 but appears anxious. He is able to provide only a vague history but admits to drinking a “few “ last weekend. He knows that he is “supposed to stop drinking” and takes “something for his stomach,” but cannot recall the name of the medication. He reports intermittent dizziness and fatigue that has been worsening over the past 2 days. His skin is dry and pale. His abdomen is slightly distended. He reports pain (4 on a scale of 10) in the midepigastric area. Capillary refill is longer than 3 seconds, blood pressure 140/90mm Hg, pulse rate is 110 beats/min, resp rate is 24 breaths/min, and temperature 99 degrees F
Looking at this assessment....what NURSING DIAGNOSIS would you think appropriate? It is NOT something he is at risk for because he is already symptomatic.
I am using risk for shock as my nursing diagnosis because of his blood loss, anxiety, tachycardia, and tachypnea. His temp will also continue to rise and will need to be monitored. Alcohol also acts as a blood thinner on the body and if he is taking something for his stomach, that could have additive effects causing stomach bleeding?Am I getting warmer? lol
There is no such thing in our business as a "blood thinner." Many people including, alas, physicians and nurses who know better, refer to anticoagulation medications (both antiplatelet and those acting on other parts of the clotting cascade) as "blood thinners." Unfortunately, and inaccurately, this puts people in mind of paint thinned by solvents or watered-down milk, or maybe thin, inadequate clothing. The problem then becomes that they are not aware of the actual physiological reason their medications are prescribed to reduce risk for embolic events, either stroke or deep vein thrombosis and pulmonary embolus. I have had patients tell me they are "always cold since taking that blood thinner." The risk of discontinuing the medication because the effects are inaccurately communicated is great, and very real. Anticoagulants do not "thin" the blood. They decrease blood clotting to decrease the chances of a clot in the heart from causing stroke or clot in a vein traveling to the lungs by preventing it from growing larger while the body's natural processes break it down for disposal. Side effects include easier bruising and bleeding. There, is that so hard?
Alcohol is not an anticoagulant; a couple of beers will not affect your clotting the same way a couple of aspirin or a slug of heparin will ... but if you drink a lot, what part of your body has a lot to do with clotting that also gets really annoyed at long-term alcohol intake?
Agree with Esme, though, that this is not his primary nursing problem.
You do not know his temp will continue to rise. Maybe it won't. Lots of people going into shock get cold. (Why??)
Again, the list in the current NANDA-I does not list anxiety, tachycardia, or tachypnea as a risk factor for shock; it doesn't list any specific medical diagnoses except sepsis, infection, and SIRS.
It does list hypotension (not seen here ... yet), hypovolemia (hmmmmm-- what's your evidence for that? You have some good hints up above...), hypoxemia (nope ...but what has he tossed down the hopper that carries oxygen?), hypoxia (how is that different from hypoxemia????), infection (nope), sepsis (nope) and systemic inflammatory response syndrome (nope). So let's back off this and look at it from across the room, and try again.
Why are you stuck on risk of shock....for get shock.....you have NO EVIDENCE of this.Fluid volume deficit because of decreased venous filling, dry mucous membranes, tachycardia and changes in mental status (anxiety). My next diagnosis would be acute pain and then risk for shock? Or should I just stick with risk for fluid volume deficit?
LOOK at your NANDA there is a better one.....what does excessive drinking cause.....what organ does it affect....THINK....YOU KNOW This answer.
right but even before a diagnosis of cirrhosis.....what organ can show IMPAIRMENT? There is a specific diagnosis that addresses this.....you have no diagnostic evidence of cirrhoiss but his drinking habit place him at risk for .....liver impairment.
Care plans in school are to teach you what to look for in a patient. All the possible complications and implications in caring for your patient. Here are a few that I can see apply
Anxiety
Decreased Cardiac Output
Deficient Fluid Volume
Acute Pain
Ineffective Health Maintenance
Risk for impaired Liver Function
do you see why I choose these?
right but even before a diagnosis of cirrhosis.....what organ can show IMPAIRMENT? There is a specific diagnosis that addresses this.
Care plans in school are to teach you what to look for in a patient. All the possible complications and implications in caring for your patient. Here are a few that I can see apply
Anxiety
Decreased Cardiac Output
Deficient Fluid VolumeInadequate volume of blood pumped by the heart per minute to meet metabolic demands of the bodyDefining Characteristics
Altered Heart Rate/Rhythm
Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia
Altered Preload
Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain
Altered Afterload
Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings
Altered Contractility
Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds
Behavioral/Emotional
Anxiety; restlessness
Acute Pain
Ineffective Health Maintenance
Pattern of regulating and integrating into daily living a therapeutic regimen for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals[h=4]Defining Characteristics[/h] Failure to include treatment regimens in daily living; failure to take action to reduce risk factors; ineffective choices in daily living for meeting health goals; reports desire to manage the illness; reports difficulty with prescribed regimens
[h=4]Related Factors (r/t)[/h] Complexity of health care system; complexity of therapeutic regimen; decisional conflicts; deficient knowledge; economic difficulties; excessive demands made (e.g., individual, family); family conflict; family patterns of health care; inadequate number of cues to action; perceived barriers; perceived benefits; perceived seriousness; perceived susceptibility; powerlessness; regimen; social support deficit
Risk for impaired Liver Function
At risk for a decrease in liver function that may compromise health[h=4]Risk Factors[/h] Hepatotoxic medications (e.g., acetaminophen, statins); HIV co-infection; substance abuse (e.g., alcohol, cocaine); viral infection (e.g., hepatitis A, B, C, E, Epstein-Barr)
Thank you so much for your guidance! I had this problem with my last case study because I think too broad and I missed such a simple nursing diagnosis. Would it be too much to ask if after I write my case study that I send it to you just as guidance? I see that you have been a nurse for 35 years and clearly you are very knowledgable! I appreciate how you made me think through this and not just telling me the answer.. that's what I need!
it's all in learning what to look for....go simple not global. Eventually, if he keeps bleeding he will probably drop his blood pressure....however if you recognize it early and do some fluid replacement you will prevent this potentially catesrophic complication from occurring.
Post it here so many students can benefit. I am always here (except recently I've been sick) and so is GrnTea. Show us your effort and we will give you what you need
The other thing you see with chronic liver impairment is a gradual increase in size of the portal veins, which crawl around the top of the stomach and esophagus and become varicosed due to the high pressure in them, same as the varicosed veins in legs...esophageal varices. A varix (the singular) can bleed like holy hell and can be torn by hard vomiting. I'm not saying he has those, because we don't know, but if he does, the excrement will hit the impeller really, really hard.
Livers are also responsible for growing clotting factors (I will leave it to you to find out which ones-- I recommend Joyce LeFever Kee's classic Laboratory Studies and Diagnostic Tests with Nursing Implications, a great place to learn rationales and preps and stuff). Even if he has no esophageal varices, think things might be harder to deal with if he has disturbed coags?
Also, what happens to people when they are regular drinkers and then they are prevented from drinking? (What vital signs might such a person have? What else?)
All of these you want to look at when you are searching for nursing diagnoses.
BostonFNP, APRN
2 Articles; 5,582 Posts
What does a capillary refill > 3 seconds tell you?
Take away everything in that scenario except the nursing assessment and work from there.