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!
