Problem-Based Care Planning with NCJMM Competencies
Student Name:
DEMOGRAPHICS-INTRO:
Client Initials
Allergies: (food, medication and environmental)
Doctors/Providers:
L.R.
Atorvastatin (Lipitor)
Dr. A. Nasir, MD
Advanced Directives:
Client Problem (s):
Primary Problem: Gastrointestinal hemorrhage as manifested by hematochezia, melena, anemia, low
None on file
hemoglobin and hematocrit, and thrombocytopenia.
Code Status: Full Code
Additional problems: abdominal discomfort and generalized weakness related to GI hemorrhage,
hypocalcemia, hypoalbuminemia, elevated neutrophil and monocyte counts, and low lymphocyte counts.
Age: 88
Day of Admission: 10/11/2022
Length of stay: 6 days
Past Medical History:
(Comorbid Health Conditions)
Atherosclerosis, sigmoid diverticulitis, hyperlipidemia, arthritis, and GERD
08/2022
Sam Houston State University
Problem-Based Care Planning with NCJMM Competencies
Other Safety Concerns:
Weight: 67.1 kg
Fall Risk
Height: 5’ 7”
Home Medications:
Multivitamin 1 tablet by mouth daily
(Dose of multi-vitamin not stated in chart)
Omeprazole 20 mg by mouth daily
Acetaminophen 325mg PO tablet q 6-8hrs by mouth daily PRN for pain
Ibuprofen 400mg tablet PO q6-8hrs PRN for pain
School of Nursing
Student Name:
NCJMM
PURPOSE OF CARE: In your own words, as if you were explaining to the client or family member, explain the pathophysiology related to why your patient is
receiving care.
The primary purpose of care for patient, L.R., is to treat and address the patient’s gastrointestinal hemorrhage that originates in the colonic region. As a result of
the diagnosed gastrointestinal hemorrhage, the patient is also receiving care that is directed towards treating the associated signs and symptoms as well as
consequences of the gastrointestinal hemorrhage such as hematochezia, melena, hypotension, anemia, and thrombocytopenia.
Gastrointestinal Hemorrhage
A gastrointestinal hemorrhage in simplified terms is bleeding that originates in the anywhere along the digestive tract. The digestive tract runs from the mouth
all the way to the anus where stool is excreted. In the patient’s case, the source of bleeding has been identified in the lower digestive tract, specifically in the
colon. The reason why the bleed has developed in the colon is due to excessive use of ibuprofen which has been used for pain relief due to a recent motor
vehicle accident. Although the ibuprofen may have helped to relieve pain from the motor vehicle accident, ibuprofen inhibits an enzyme in the body called COX1. The COX-1 enzyme allows the body to produce a substance called prostaglandin which helps to protect the digestive lining from damage. As a result of
excessive ibuprofen use, prostaglandins were prevented from being released, leaving the digestive tract lining with no protection, and as a result, the digestive
tract lining was damaged, and gastrointestinal hemorrhage occurred.
(Liley et al., 2023)
Hematochezia
The term hematochezia refers to fresh blood in the stools. The reason hematochezia, or blood in the stools is occurring is due to the gastrointestinal bleeding
that the patient has that originates in the lower digestive tract within the colon. The blood from this bleed moves through the remainder of the digestive tract
along with the stools and when the patient excretes the stools, the blood is noticed.
(National Library of Medicine, n.d.)
Melena
Melena is black or tarry stools. The reason why the black or tarry stools are being noticed is due to the gastrointestinal bleed that is occurring in the patient’s
lower digestive system within the colon. The blood within the digestive tract is mixing with digestive fluids within the digestive tract and so as a result, when the
stools are excreted, they appear black or tarry in color. Melena is a common finding for digestive tract bleeds, or gastrointestinal hemorrhages.
(National Library of Medicine, n.d.)
Anemia
Anemia refers to a condition of decreased red blood cells. Red blood cells are a component that makes up the blood and are responsible for carrying oxygen
throughout the body. The reason why anemia is occurring is because of the gastrointestinal hemorrhage, or the digestive tract bleed that is originating in the
colon. As a result of this bleeding, blood is being lost and this is causing the body to have decreased red blood cell counts as a result.
(Hubert & VanMeter, 2018)
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Thrombocytopenia
Thrombocytopenia is a condition that occurs when platelet counts in the blood fall below the normal range of 150,000-450,000 u/L. Platelets are a
component of the blood, and their main function is help in the prevention and stopping of bleeding. The reason why thrombocytopenia, or low platelet levels
have occurred is due the gastrointestinal hemorrhage, or bleed occurring the patient’s colon. Platelets are the component of the blood that assist in the
clotting process to stop bleeding. If platelets are being used faster than they can be regenerated, low platelet levels will result.
(Hubert & VanMeter, 2018)
In addition to the above conditions that the patient is receiving care for, there are other conditions that the patient has that may need to be treated or
considered as care is provided to the patient. These conditions include hypocalcemia, hypoalbuminemia, hypokalemia, and sigmoid diverticulitis.
Hypocalcemia/Hypoalbuminemia
Hypocalcemia is defined as low calcium levels or calcium levels that are below 9.0-10.5 mg/dL. Hypoalbuminemia is defined as low albumin levels or albumin
levels that are below 3.5-5.0 g/dL. Often, in someone who has low calcium levels, low albumin levels will also be seen.
Hypoalbuminemia is an indicator of malnutrition. Low albumin levels signify that the patient may be experiencing malnutrition as a result of dietary patterns
that do not support dietary needs.
Hypocalcemia in the patient’s case is likely due to malnutrition as well. In order for calcium to be absorbed, Vitamin D is needed. If the patient is not
consuming adequate vitamin D in the diet, calcium cannot be absorbed, and a calcium deficiency will result. A person who has low calcium levels may
experience nervousness and muscle cramps or tetany. These are signs that the nurse needs to monitor for as indicators of calcium status.
(Pagana et al., 2022)
Sigmoid diverticulitis
Sigmoid diverticulitis is a condition characterized by the inflammation of the diverticula located within the sigmoid colon. Diverticula are bulges that occur in
weakened areas of the intestinal wall due to increased pressure within the intestines. Often this condition occurs when low-residue diets are consumed over
a long period of time or as a result of chronic constipation, which is often seen in older adults When the diverticula become inflamed, it is termed
diverticulitis. The sigmoid colon is the last portion of the large intestines before reaching the rectum. When put all together, sigmoid diverticulitis is
inflammation of the diverticula located within the last portion of the large intestines before reaching the rectum. The reason why this condition is important
in the care of the patient is that it may have been a potential source of the gastrointestinal bleeding as when blood vessels within the diverticula rupture,
they can cause bleeding. Additionally, sigmoid diverticulitis is important in the case of this patient as it could be a possible source of infection given the
patient’s lab values.
(Hubert & VanMeter, 2018)
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ASSESS
RECOGNIZE CUES:
Objective Cues:
Vital Signs
Blood Pressure:135/66 (normal)
Heart Rate: 88 bpm (normal)
Temperature: 98.9 F (temporally)
Respiration rate: 18 breaths/min (normal)
SpO2: 97% on room air (normal)
Complete Blood Count/Differential Lab Values
WBC 10.26k/uL (normal)
RBC 2.96 m/uL (low)
HGB 8.9 g/dL (low)
HCT 26.9% (low)
Platelets: 149k/uL (low)
MCV 90.9 fL (normal)
MCH 30.1 pg (normal)
MPV 9.4 fL (normal)
Neutrophils: 72.8% (high)
Lymphocytes: 13.3% (low)
Monocytes: 10.8% (slightly elevated)
Eosinophils: 2.3% (normal)
Basophils: 0.3% (normal)
Coagulation Panel
PT: 14.5 (high)
INR: 1.2 (normal)
PTT: 22.3 (high)
ANALYZE
ANALYZE CUES: What is the disease process causing these assessment
findings. Provie rationale. No citation needed.
Gastrointestinal hemorrhage
Anemia (Low RBC, hemoglobin & hematocrit)
Anemia, low hemoglobin, and low hematocrit are all expected findings in
someone with a gastrointestinal hemorrhage. Anemia refers to low red blood
cell levels. Hemoglobin is a protein that is a part of red blood cells and
hematocrit refers to the percentage of red blood cells that compose the
blood. With a GI hemorrhage, blood is being lost. Since red blood cells are a
component of blood, their numbers will decrease, along with hemoglobin
counts as hemoglobin composes red blood cells. Additionally, hematocrit
counts decrease because there is a smaller percentage of red blood cells in
comparison to blood volume when bleeding occurs.
Thrombocytopenia
Low platelet counts are an expected finding in a patient who is having a
gastrointestinal bleed. Platelets are the component of the blood that assist in
the clotting process to stop bleeding. If platelets are being used faster than
they can be regenerated, low platelet levels will result.
Weakness/Sense of uneasiness
The weakness and sense of uneasiness that the patient is experiencing is likely
due to the related blood loss from the gastrointestinal bleed in the colon. The
blood loss has caused the patient to become anemic, which is likely
contributing to the overall weakness and sense of uneasiness for the patient.
Melena/Hematochezia
The black and tarry stools as well as red blood noticed in the stools are due to
the gastrointestinal hemorrhage. Melena is caused by the blood that is coming
the patient’s colon mixing with digestive fluids which creates black, tarry
stools that are being noticed by the patient. Hematochezia is just the fresh,
red blood that is noticed by the patient in the stools. Once the gastrointestinal
hemorrhage is treated, this will likely go away and be resolved.
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Chem Panel Values
Sodium: 135 mEq/L (normal)
Potassium: 3.8 mEq/L (normal)
Chloride 102 mEq/L (normal)
Magnesium: 1.8 mEq/dL
Calcium 8.6 mg/dL (low)
CO2: 26 mEq/L (normal)
BUN: 7mg/dL (low)
Creatinine: 0.65 mg/dL (low)
Blood Glucose: 148 mg/dL (high)
Albumin 3.1 mg/dL (low)
Assessment
Patient grimacing and pointing to abdomen as source of pain
Patient is restless and unable to find comfortable position
Black, tarry stools
Tenderness noted over infraumbilical area
Subjective Cues:
Patient reports:
Bright red and blood like stools 9 times last night
Having 1 episode of vomiting
Remains feeling nauseous
Overall feels weak and uneasy
Abdominal pain that is worsening with nothing making it better or worse
Tenderness /Pain over abdominal region
Tenderness and pain over the abdominal region are expected findings with
someone who as a gastrointestinal bleed. Gastrointestinal bleeds are very
painful, therefore, when the patient’s abdomen is palpated, it would be
expected that the patient reports some tenderness and pain in the associated
area.
Restlessness/Grimacing
The grimacing and restlessness are an expected finding in the patient. The
patient is grimacing because of the pain that is being experienced related to
the gastrointestinal bleed. The restlessness that is being seen in the patient is
also due to pain of the gastrointestinal hemorrhage and is a result of not being
able to get comfortable.
Monocytosis
Elevated monocyte levels are finding that may be found with gastrointestinal
hemorrhage due to the stress it places on the body. When stress occurs in the
body often epinephrine is released. Increased levels of epinephrine have been
associated with increased white blood cell counts and could be a potential
reason why monocyte counts have increased. Additionally, the patient’s does
have a history of sigmoid diverticulitis, and these diverticula could have been
infected, increasing WBC counts, including monocyte counts.
Elevated Neutrophil Counts
Elevated neutrophils are a finding that is often consistent with infection. The
patient being cared for has a history of sigmoid diverticulitis. Diverticula can
be a source of infection. When infection occurs, WBC counts will increase.
Neutrophils are a type of white blood cells, therefore, if infection is present, it
would be expected that their numbers increase.
Coagulation Disorder
Elevated PT and PTT levels
The results from the patient’s coagulation panel showed increased PT and PTT
levels. Increased PT and PTT are indicative of a possible clotting problem and
signify that the blood is taking longer to clot than usual. This could put the
patient at an increased risk for bleeding. Possible causes could be related to a
vitamin K deficiency or inadequate proteins in the blood that would be
needed for blood clotting to occur at a normal rate.
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Malnutrition/Nutrition Related
Hypocalcemia
Hypocalcemia is likely due to malnutrition in this patient. The most common
reason for this is likely due to the patient’s diet not being sufficient to meet
calcium needs. First, the patient may not be consuming enough Vitamin D in
the diet. Vitamin D is needed to absorb calcium; therefore, if there isn’t
enough vitamin D in the diet, calcium cannot be absorbed, and low calcium
levels may result. Secondly, the patient may be getting enough Vitamin D, but
if calcium isn’t be consumed in adequate amounts in the diet, then low
calcium levels could also occur this way.
Hypoalbuminemia
Low albumin levels are often a sign of malnutrition. The reason why albumin is
low in those who have malnutrition is due to inadequate protein and/or
calorie intake. Older adults are at a higher risk for nutritional deficiencies, and
this is likely the case for this patient as the patient’s diet may not be adequate
to meet protein and/or calories needs to support normal albumin levels.
Elevated BGL
The elevated blood glucose levels could be due to a number of factors. First, it
could be that the patient has just eaten. If the patient has just eaten, insulin
would not have had adequate time to absorb glucose into the cells to return
blood glucose levels to a normal level. The elevated blood glucose levels could
also be due to the patient possibly having some form of pre-diabetes or
diabetes that has not be diagnosed yet.
Lymphocytopenia
There are a couple of different reasons the patient could have low lymphocyte
cells. The first reason could be related to the patient’s malnutrition possibly.
Those who consume inadequate amounts of protein in the diet over a
prolonged period of time can have lymphocytopenia. It appears based on
other lab values that the patient may be experiencing malnutrition. Additional
reasons for lymphocytopenia would be the patient having an autoimmune
disease, HIV, leukemia, or lupus but the patient did not indicate having any of
these conditions. This finding will likely require additional testing to determine
the exact source if it is not malnutrition that is the cause.
Low Creatinine/BUN
Low creatinine and BUN levels are most likely nutrition related. Based on the
patient’s other lab work, it appears that the patient may be malnourished.
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Problem-Based Care Planning with NCJMM Competencies
School of Nursing
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Often diets that are low in protein can result in low creatinine and BUN levels
if sustained over a long period of time.
ANALYZE & PRIORITIZE
PRIORITIZE HYPOTHESIS
The nurse will need to quickly ASSESS the patient situation, ANALYZE relevant cues, and PRIORITIZE HYPOTHESIS based on priority concerns. These priority
concerns are called problems and can be NANDAs or Texas Concept that focus on signs and symptoms It should not be based on a medical diagnosis.
Create a list of all possible patient problems/problems in order of priority. List the highest priority first. Provide a rationale for priority Problems 1 and 2.
Problem #1: Fluid Volume Deficit
A patient who has had a gastrointestinal hemorrhage is at major risk for deficient fluid volume. When there is inadequate fluid volume, the patient is placed at
an increased risk for a number of complications. The patient already due to blood loss associated with the gastrointestinal hemorrhage has developed anemia,
low hematocrit levels, low hemoglobin levels, and low platelet levels. It is vital that treatment be provided to this patient to prevent further complications such
orthostatic hypertension leading to falls, decreased tissue perfusion due to anemia and low hemoglobin counts that will compromise optimal organ functioning,
and continued red blood cell, hemoglobin, hematocrit, and platelet counts that decrease.
(Makic et al., 2020)
Other Problems:
Decreased cardiac output related to blood loss
The patient has a gastrointestinal hemorrhage and with this hemorrhage, the patient is experiencing blood loss. As a result of the blood loss, cardiac output can
be decreased. If cardiac output is decreased significantly, then there is less blood to be circulated throughout the body to provide oxygen and essential nutrients
to the organs of the body. It is imperative that the bleeding be stopped to prevent inadequate perfusion to the organs of the body.
(Makic et al., 2020)
Infection as evidence by elevated neutrophil and monocyte counts
The patient has certain white blood cell counts that have increased. It is known that the patient has a history of sigmoid diverticulitis. It is very possible that the
reason why there are increasing white blood cells indicated in the patient’s recent labs is due to an infection of the diverticula.
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Risk for injury related to restlessness, pain, and weakness.
I am concerned that the patient may cause injury to themselves. The patient has a gastrointestinal hemorrhage and because of the blood loss is experiencing
weakness likely due to being anemic. The patient is frequently trying to stand up and get out of bed. If the patient were to get up out of bed without assistance,
the patient has a very high risk for falling which could cause injury to the patient and a number of complications in the patient’s care.
(Makic et al., 2020)
Impaired Nutrition: less than body requirement
Based on the patient’s lab work, it appears that the patient may be malnourished as calcium and albumin levels are low. It is important that this problem be
addressed in order to prevent further deficiencies as well as additional health related issues if these deficiencies are not addressed. For example, continuing to
have inadequate calcium in the diet could place the patient at an increased risk for osteoporosis and even fractures.
(Makic et al., 2020)
Impaired comfort related to gastrointestinal hemorrhage
The patient’s gastrointestinal hemorrhage is causing the patient a lot of pain and as a result, the patient is very restless and cannot seem to get comfortable.
Additionally, the patient’s abdomen is extremely tender, and the patient is grimacing due to the pain. It is important to address the patient’s pain in order to
provide the patient comfort and prevent addition complications in care as a result of untreated pain.
(Makic et al., 2020)
Fatigue related to loss of blood volume and decreased oxygen carrying capacity
The patient’s gastrointestinal hemorrhage has caused the patient to lose a moderate amount of blood. As a result, the patient’s blood volume has been
compromised leading to anemia, thrombocytopenia, as well as low hematocrit and hemoglobin levels. With the anemia, the patient has decreased red blood
cells, and therefore, directly has decreased oxygen carrying capacity as proper hemoglobin levels have also been compromised. The reduced number of red
blood cells and the associated lower hemoglobin levels are likely causing the patient to feel especially weak and more tired than usual.
(Makic et al., 2020)
Knowledge Deficit related inappropriate ibuprofen use
The suspected reason why the patient has experienced a gastrointestinal hemorrhage is due to increased and prolonged use of ibuprofen as a result of a recent
care accident. It is important that the knowledge deficit regarding the consequences of increased ibuprofen intake and their associated side effects be
addressed to decrease likelihood of additional gastrointestinal bleeds.
(Makic et al., 2020)
PRIORITY LABS/DIAGNOSTIC CUES:
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List priority labs/diagnostics and how they are associated to the problem identified above
CBC
It is essential that a complete blood count be done on the patient. The patient is experiencing a gastrointestinal bleed and as a result has already developed
anemia, low hemoglobin levels, low hematocrit levels, as well as platelet levels. The complete blood count will allow for red blood cell, hemoglobin, hematocrit,
and platelet counts to continue to be monitored in relation to the patient’s diagnosed anemia. A CBC will be important as it can be an indicator of whether
bleeding is continuing to occur if the above blood components continue to decrease or if the patient’s condition is beginning to stabilize as evidence by
increasing levels of the components listed above.
PT/PTT levels
Partial thromboplastin and plasma thrombin time are necessary lab tests that need to be performed on this patient. It is important to repeat these labs again as
the patient’s initial labs show increased PT and PTT levels. It is possible that the patient could have a clotting factor deficiency which may complicate the
patient’s current condition. If blood is taking longer to clot than normal, this could lead to prolonged bleeding, further contributing to a fluid volume deficit due
to lost blood volume.
Orthostatic
Orthostatic need to be performed for this patient. The patient has experienced blood loss because of the gastrointestinal hemorrhage and as a result, the body
may not be able to compensate as easily with changes in patient position. As a result, the patient may be at an increased risk for falls, therefore, it is important
to perform orthostatic to determine if the patient has orthostatic hypotension.
Electrocardiography
An electrocardiography is important in the case of this patient. Since the patient has experienced blood loss related to the gastrointestinal hemorrhage,
decreased blood volume may be available to adequately perfuse the body organs such as the heart. An electrocardiography would be able to watch for signs of
ischemia or infarction related to decreased blood volume perfusing the myocardium by looking at the heart rhythm.
Hemoccult
The patient has already been diagnosed with a gastrointestinal bleed, but continuous monitoring of this bleed as manifested by blood in the stools is necessary.
One way to determine whether blood is still present in the patient’s stools is to periodically perform a hemoccult. A hemoccult will be able to determine
whether the patient is continuing to have blood in the stools even when it may not be noticeable to the naked eye. Continued blood in the stools as evidenced
by a positive hemoccult would be indicative of bleeding that is still present in the gastrointestinal tract.
Colonoscopy
A colonoscopy would be important in the case of this patient. A colonoscopy has already been performed to determine the location of the gastrointestinal
hemorrhage, but a repeat colonoscopy would be beneficial when bleeding is suspected to have stopped to verify that the gastrointestinal hemorrhage has
resolved.
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CT of the abdomen and pelvis
A CT of the abdomen and pelvis would also be an important diagnostic test to be performed in the case of this patient. A CT of the abdomen and pelvis has
already been performed to detect hemorrhages of the gastrointestinal tract and its associated location. A repeat CT of the abdomen and pelvis would be
beneficial to determine whether the bleed is resolving or has stopped.
MEDICATIONS & PARENTERAL THERAPIES CUES:
List medications in order of priority. Answer the following question for each medication.
Dextrose 5%- 0.45% NaCl at 75mL/hr IV
a) Why is this patient on this medication? The patient is on this medication to improve fluid volume status related to the blood loss from the
gastrointestinal hemorrhage.
b) Special considerations? The nurse should monitor the patient’s IV site for signs of extravasation. Also, since the solution has dextrose, BGL should be
monitored as the patient’s recent labs showed increased BGL, so BGL need to be carefully monitored.
c) Any Critical Assessment? When to hold? The nurse needs to monitor the client’s fluid volume status. This can be done by looking at mucous membrane
moisture, skin turgor, as well as the blood pressure.
d) Critical patient teaching? Teach the patient that this medication is being used for the purpose of replacing lost fluids due to the gastrointestinal bleed
that has occurred.
(Kizior & Hodgson, 2022)
Morphine 2mg IV PRN (pain greater than 7/10)
e) Why is this patient on this medication? The patient is on this medication because of the severe pain associated with the gastrointestinal hemorrhage
originating in the patient’s colon. Additionally, the patient reports pain in his body because of a recent motor vehicle accident that occurred recently.
f) Special considerations? Can be addictive. This medication can cause orthostatic hypotension, constipation, and respiratory depression. Medication
should not be administered if the patient has taken an MAOI within the last 14 days or patient has severe respiratory depression.
g) Any Critical Assessment? When to hold? Vital signs need to be closely monitored with special attention to blood pressure and respiration rate. Hold the
dose with hypotension (BP < 90/60) and respiration rate that is less than 12 breaths per minute.
h) Critical patient teaching? Ask for assistance before ambulating or getting out of bed, change positions slowly, increase fluid intake to decrease
constipation risk, and should not be used long term as there is the risk for addiction.
(Kizior & Hodgson, 2022)
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Naloxone 0.2 mg IV (PRN)
a) Why is this patient on this medication? The patient has this medication on standby in case of severe respiratory depression that would require narcotic
reversal due to the morphine being administered.
b) Special considerations? Too rapid reversal could lead to agitation, nausea, vomiting, tremors, increased BP, or tachycardia.
c) Any Critical Assessment? When to hold? Naloxone would need to be administered when opioid induced sleep occurs, or respiratory rate becomes so
low that reversal is required which is a respiratory rate less than 8 breaths/minute.
d) Critical patient teaching? Teach patient that this is the medication that is used to reverse the effects of morphine that is being taken as part of pain
management.
(Kizior & Hodgson, 2022)
Cefepime 1 g in 100 mL in NaCl IVPB at 200 mL/hr every 12 hours
a) Why is this patient on this medication? The patient is on this medication for empirical reasons for treatment of a possible infection as certain white
blood cell counts are increased according to the patient’s labs. It is suspected that an intra-abdominal infection may be present and could be infection
of the diverticula as the patient does have a history of diverticulitis.
a) Special considerations? Needs to be used with caution in elderly or those who have a gastrointestinal disease which the patient in this case does.
Additionally, if a specimen culture is required, the culture needs to be obtained before medication administration is started.
b) Any Critical Assessment? When to hold? Need to monitor the patients CBC for improvement or worsening of the possible infection and renal function
before administering the medication. The nurse needs to also be alert for signs of oral thrush that will present as white patches that can be wiped off in
the mouth or on the tongue. The medication will need to be held if the patient shows any signs of adverse drug reactions such as a rash, difficulty
breathing, confusion, or difficulty swallowing.
c) Critical patient teaching? Need to teach the patient that the medication might cause thrush and related signs and symptoms of thrush need to be
reported to provider, as well as that the medication can cause nausea, diarrhea, or possibly abdominal cramping.
(Kizior & Hodgson, 2022)
Metronidazole in 0.9% NaCl (100 mL) IVPB 500mg at 100ml/hr every 8 hours
b) Why is this patient on this medication? Metronidazole is often given alongside cefepime in relation to empiric treatment of intra-abdominal infections.
The patient exact cause of the gastrointestinal hemorrhage has not been precisely identified and could have been due to diverticulitis in the case of this
patient; therefore, this medication is being given empirically until official caused is determined.
c) Special considerations? Needs to be used with caution in elderly patients. If a specimen culture is required, the culture needs to be obtained before
medication administration is started.
d) Any Critical Assessment? When to hold? Need to monitor the patients CBC levels, urine/stool outputs and their consistency and color, neurological
status for dizziness, as well as signs of superinfections as evidence by a fever and thrush in the oral cavity. This medication will need to be held if the
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patient develops adverse reactions to the medication (see below section).
e) Critical patient teaching? Need to teach the patient that the medication may cause lack of appetite, nausea, dry mouth or metallic taste in the mouth,
diarrhea, constipation, dizziness, or reddish-brown urine. Patient needs to report any of the above side effects to the provider so monitoring can be
done, or medication adjustments can
(Kizior & Hodgson, 2022)
Pantoprazole EC tablet 40 mg by mouth at 0600 and 1700
a) Why is this patient on this medication? Used for prophylaxis of stress ulcers due to being in the hospital. Stress ulcer development would further
complicate the patient’s health status. Additionally, the patient has a history of GERD so this medication is also used for this purpose.
b) Special considerations? May increase the patient’s risk for fractures as well as GI infections. The medication is best given at least 30 minutes before
meals. Additionally, taking this medication may increase the patient’s risk for development of C. diff in rare cases.
c) Any Critical Assessment? When to hold? Taking this medication can increase the risk for C. diff so nurse needs to monitor for the associated symptoms
such as abdominal pain, diarrhea, and fever. The medication would need to be held if the patient C. diff related symptoms such as watery diarrhea
abdominal pain and cramping, as well like reactions to the medication such as rash, difficulty swallowing, SOB, or hives.
d) Critical patient teaching? Teach the patient that the medication is best taken before meals and that if begin to experience diarrhea, fever, or abdominal
pain, it needs to be reported to the provider immediately.
(Kizior & Hodgson, 2022)
Acetaminophen PO 650 mg every 6 hours for pain
a) Why is this patient on this medication? The patient has this medication on file as needed for pain that is associated with the gastrointestinal bleed as the
well the pain that may be resulting from the patient’s recent motor vehicle accident.
b) Special considerations? Should not be administered to those who have significant renal or liver impairment. Caution needs to be taken when given this
patient this medication since he does have mild hypovolemia.
c) Any Critical Assessment? When to hold? Need to assess the patient’s pain level before administration and then after administration within an hour.
Additionally, nurse needs to monitor for signs of acetaminophen toxicity. The medication would need to be held if patient is not reporting pain or signs
of acetaminophen toxicity develop.
d) Critical patient teaching? This medication should not be taken with any form or amount of alcohol as well as food may decrease its absorption rate.
Medication needs to be taken with a full glass of water. Important to notify the provider if begin experiencing anorexia, nausea, or fatigue as this could
be a sign of acetaminophen toxicity.
(Kizior & Hodgson, 2022)
PLAN
GENERATE SOLUTIONS: What is the goal for the patient? Create Specific, Measurable, Achievable, Realistic, and Timely (SMART) Outcomes
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NCJMM
Problem #1- Fluid Volume Deficit
Short-Term Goal: The patient will show sign of stabilizing fluid volume status as
evidenced by blood pressure and heart rate returning to within normal range by
the end of shift today.
Long-Term Goal: By the time of discharge, the patient fluid volume status will
return to homeostasis as evidence by decrease report of dizziness and fatigue,
adequate intake and output measurements, absence of bloody stools, as well as
stabilized hemoglobin and hematocrit levels.
IMPLEMENT
TAKE ACTION(S): What interventions will the nurse implement when caring for this patient? INCLUDE THE EVIDENCE/RATIONALE.
List interventions in order of priority. Include Collaborative and nurse-initiated interventions.
NURSING SKILLS:
Provide at least two (2) for each problem with a rationale as to why you do the
nursing skill
Problem #1: Fluid Volume Deficit
1. First, the nurse will offer patient water or other forms of oral fluids
as ice chips, juice, or coffee, as well as snacks to improve volume
status per client’s dietary restriction as tolerated. Second, the nurse
will administer prescribed fluids: Dextrose 5%- 0.45% NaCl at
75mL/hr to help improve blood volume status.
Additionally, if the patient’s hemoglobin level falls below 7, the nurse will
administer blood products per the physician orders. All of the above
measures will help to increase and replenish the patient’s fluid volume
that has been lost as result of the gastrointestinal hemorrhage.
HEALTH TEACHING/HEALTH PROMOTION:
Provide at least one for each problem
Problem #1 Fluid Volume Deficit
Education is crucial in the case of this patient. The patient as well as the
patient’s family should be taught ways to counteract the fluid volume deficit
that has resulted due to the gastrointestinal bleed. One way to do this would
be to increase fluid intake. This could include orally through water, but also
juice, coffee, milk, or through foods that have high-water content such as
cucumbers, watermelon, berries, or tomatoes. Overall, it is important to
emphasize that the intake needs to occur in small, frequent amounts over a
period of time to normalize fluid volume status again.
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Sam Houston State University
Problem-Based Care Planning with NCJMM Competencies
School of Nursing
Student Name:
NCJMM
(Makic et al., 2020, p. 408)
2. There are a couple of areas the nurse is going to need to monitor
for a patient who has compromised fluid volume status. First, the
nurse needs to monitor the patient’s vital signs. It is important to
especially monitor the patient’s heart rate, blood pressure, and
respirations. When patients initially become fluid volume depleted,
they may become tachycardic, tachypneic, and hypotensive. As fluid
volume continues to be depleted, the patient’s vital signs will show
hypotension and decreased pulse rate. These vitals need to be
monitored at least every 4 hours if the patient is stable or at
increased frequencies with a worsening status.
Additionally, it is vital that teaching occur about the use of ibuprofen. The
reason why the patient developed a gastrointestinal bleed is because the
excessive use of ibuprofen to help relieve the pain associated with a recent
motor vehicle accident. It would be important to teach the patient the risk
factors of ibuprofen in causing gastrointestinal bleeding, but also some safer
alternatives to pain management for the future. Alternative pain management
would include warm/cold compresses or the use of Tylenol instead of
ibuprofen.
Second, the nurse needs to monitor the patient’s weight for any sudden
decreases which could indicate further fluid volume deficit. A change of
more than 2 lbs. would be worrisome. Third, a nurse needs to monitor
the patient’s intake and outputs as well as recent lab values (RBC,
hemoglobin, hematocrit, platelet counts, as wel as PT and PTT values).
Optimally, urine output should be greater than 0.5mL/kg/hr with
adequate fluid volume status. When assessing the labs, a nurse should
look for decreasing trends in RBC, hemoglobin, hematocrit, and platelet
counts as indicators of continued bleeding, or increasing trends of these
CBC components as an indicator of stabilizing bleeding status. Lastly, a
nurse should monitor patient stools for blood as indicator of whether
bleeding is still occurring.
All the above measures help the nurse to monitor whether the patient is
continuing to lose fluid volume as related to the gastrointestinal
hemorrhage or fluid volume is beginning to stabilize with nursing and
physician prescribed measures.
(Makic et al., 2020, p. 407)
3. It is important the nurse assess the patient in regard to fluid volume
status. One way that the nurse will assess the client’s fluid volume
status is by checking skin turgor and mucous membranes. The
nurse should see elastic skin turgor and moist mucous membranes
as indicators of proper fluid volume status.
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08/2022
Sam Houston State University
Problem-Based Care Planning with NCJMM Competencies
School of Nursing
Student Name:
NCJMM
If the nurse does not, this could indicate the patient has compromised
fluid volume status and blood is continuing to be lost.
(Makic et al., 2020, pp. 407-409)
COLLABORATION WITH OTHERS:
Consider how other members of the health care team play a role in meeting your client’s outcomes and
restoring their health.
Gastroenterologist
The gastroenterologist is very important in the case of the patient with the gastrointestinal hemorrhage. A gastroenterologist is a specially trained individual in
conditions and disease relating to the gastrointestinal tract. The gastroenterologist will play a crucial role in helping to determine the cause of the medical
diagnosis, as well as how to treat the related condition. The gastroenterologist is crucial in monitoring the status of the patient’s bleed through orders for
colonoscopies and CTs of the abdomen and pelvis. Additionally, with the expertise of the gastroenterologist, criteria will be developed to determine when the
patient can be safely discharged.
Internal Medicine Doctor
The internal medicine doctor also plays a key role in the care of the patient with the gastrointestinal bleed. The internal medicine doctor frequently rounds on
the patient to monitor the client’s overall status looking and noting both improvements and decline in patient status. Based on client assessment, internal
medicine doctor may place orders and modify the care plan for the patient as needed. Additionally, if the client required a referral, it is the internal medicine
doctor would do this. Lastly, the internal medicine doctor manages any additional conditions that clients had unrelated to the admitting diagnosis. In the case of
my patient, it was hyperlipidemia. The internal medicine doctor also works with other members of the patient’s care team to determine criteria for discharge.
Registered Nurse
The registered nurse plays a key role in the care of the patient who had a gastrointestinal hemorrhage. First, the nurse is the individual who frequently checks on
the patient and assess the patient’s status. If any abnormalities or changes in client status are noted, the nurse notifies all needed individuals and documents this
in the patient’s chart for continuity of care purposes. Additionally, the nurse ensures the orders placed for the patient are carried out by the appropriate health
care team members, as well as administers medications for the patient for treatment of admitting diagnosis as well as other established conditions. Overall, the
nurse helps to monitor the patient, ensure all care measures are provided, and ensures client comfort and satisfaction.
Nutritionist/dietician
The dietician helps to assist the client in determining appropriate dietary choices. The patient has hyperlipidemia, a history of diverticulitis, and is possibly
malnourished. The dietician is able to counsel the patient on the appropriate dietary choices in regard to these conditions. Additionally, since the patient did have
some electrolyte abnormalities, the dietician will also be able to help the patient learn how to increase these electrolytes in the diet to prevent any associated or
long-term complications.
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08/2022
Sam Houston State University
Problem-Based Care Planning with NCJMM Competencies
School of Nursing
Student Name:
NCJMM
PCA
The PCA was crucial in helping to meet the patient’s basic needs. The PCA helps in meeting the basic patient’s hygiene needs as well as mobility needs. By meeting
these basic needs, it provided the patient much comfort and this overall contributes to the healing and well-being of the patient while in the hospital.
Social Work
Social work is also helpful in the case of managing the patient who had a gastrointestinal bleed. The social workers help in all areas of the patient’s hospital stay.
When a client is admitted, social work will often perform an initial screening and evaluation of the patient for needed resources and assistance. Throughout the
patient’s stay, social work follows the patient in helping to obtain resources the patient may need as well as working with other care staff on client discharge.
When a client is discharge, social work often ensures that any additional resources the client may need will be available, as well as insurance related concerns.
Physical Therapy
The client with the gastrointestinal bleed was seen by physical therapy. It was determined that the client would need an assistive device when ambulating. Physical
therapy helped to promote client safety by identifying the need for a walker so that the client could ambulate safety while in the hospital with assistance of care
staff.
Pharmacist
The pharmacist also played a key role in the care of the patient with a gastrointestinal bleed. The pharmacist helped to ensure that all medications the client
needed were appropriate given the patient’s condition, safe given the prescribed dosage, and any cases where the medication may interact with another
medication or be contraindicated for use in the client’s situation.
EVALUATE
EVALUATE OUTCOMES: Evaluate the actual client outcomes in the situation and compare them with expected outcomes. Determine what client assessment
findings indicate improvement, decline, or no change in the client’s condition. Decide if the selected nursing actions were effective, ineffective, or made no
difference.
Problem #1: Deficient fluid volume related to blood loss from gastrointestinal hemorrhage
Short-Term Goal- met, not met, or making progress- The patient will show stabilizing fluid volume status as evidence by normotensive blood pressure and
controlled heart rate, as well as elastic skin turgor and moist mucous membranes.
Interventions:
The goal for the client to show stabilizing fluid volume status as evidence by normotensive blood pressure and controlled heart rate, as well as elastic skin turgor
and moist mucous membranes. The assessment finding that told me this is that the client had increased skin turgor that returned within 2 seconds and no skin
16
08/2022
Sam Houston State University
Problem-Based Care Planning with NCJMM Competencies
School of Nursing
Student Name:
NCJMM
tenting noted, as well as the mucous membranes were moist. Additionally, patient BP was 141/66 and HR 88. I feel that the interventions that the nurse and I
took in giving the client IV fluids as well as frequent, small amounts of oral liquids in addition to educating the patient about how to increase fluids volume status
where helpful in improving the client’s overall fluid volume status based on the assessment findings obtained prior to the end of the shift.
Long-Term Goal met, not met, or making progress: The patient will show stabilized blood volume status as evidence by decrease report of dizziness and fatigue,
adequate intake and output measure, no further blood in stools, as well as stabilized hemoglobin and hematocrit levels by time of discharge.
Interventions: The goal for the patient to show stabilized blood volume status as evidence by decrease report of dizziness and fatigue, adequate intake and output
measure, no further blood in stools, as well as stabilized hemoglobin and hematocrit levels by time of discharge is making progress. Overall, the patient’s blood
and fluid volume status are improving, but not all components of the long-term goal above have been met yet. The patient has shown increasing intake and
output measures and no further blood present in the stool, but still reports dizziness and hemoglobin and hematocrit levels still remain low. I believe that the
nursing actions of giving the patient fluids did help to contribute to making progress towards the above long-term goal, but ultimately, the patient needs more
time to meet this goal. It may be helpful to have nutritional services come and take to the patient regarding ways that the above lab components could be
increased through dietary measures.
REFLECTION OF CARE: What changes need to occur in the care based upon the evaluation?
Reflecting on the care that has been provided to the patient and evaluating the client’s status, the patient’s overall status has improved since admission, but
continued measures are still needed for the patient to fully recover from the gastrointestinal hemorrhage. First, it will be important that the patient continue to
still receive small, frequent fluids to replenish fluid volume due to blood loss, as well as skin turgor, vital signs, weight, intake, and outputs, as well as labs continue
to be monitored as indicators of resolving gastrointestinal hemorrhage and improvement in client health status. I do believe it is important to also sit down with
the patient as well as the patient’s family before discharge once again explain to verify understanding of how the ibuprofen use contributed to the gastrointestinal
bleed. The reason the gastrointestinal bleed occurred is due to a knowledge deficit in not being aware that prolonged and excessive used of ibuprofen can induce
gastrointestinal bleeding. If the client is understands the associated risks, the likelihood of have a gastrointestinal bleed again due to excessive ibuprofen use will
be significantly reduced.
08/2022
Sam Houston State University
Problem-Based Care Planning with NCJMM Competencies
School of Nursing
Student Name:
NCJMM
References
Hubert, R.J. & VanMeter, K. (2018). Gould’s pathophysiology for the healthcare professional (6th ed.).
Saunders. Kizior, R.J. & Hodgson, K.J. (2022). Saunder’s Nursing Drug Handbook. Saunders.
Liley, L.L., Collins, S.R., & Snyder, J.S. (2023). Pharmacology and the nursing process (10th ed.). Mosby.
Makic, M.B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: an evidence-based guide to planning care. Mosby.
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McCarthy, M. & Zhang, L. (2021). Hemangioma. Pathology Outlines. Retrieved October 3, 2022, from
https://www.pathologyoutlines.com/topic/livertumorhemangioma.html
MedlinePlus. (n.d.). Black or tarry stools. National Library of Medicine. Retrieved October 3, 2022, from
https://medlineplus.gov/ency/article/003130.htm
MedlinePlus. (n.d.). Rectal bleeding. National Library of Medicine. Retrieved October 3, 2022, from
https://medlineplus.gov/ency/article/007741.htm
Pagana, K.D., Pagana, T.J., & Pagana, T.N. (2022). Manual of diagnostic and laboratory tests. Mosby.
08/2022
Sam Houston State University
School of Nursing
NCJMM