Student Name: Tori Ann Yatogo
Date Submitted: 4-19-2013
History of Present Illness
66-yr old male w/past medical Hx of ESRD on HD
M/W/F. Hx of symptomatic bradycardia, restless leg syndrome, recurrent ascites w/multiple paracentesis.
Hospitalized from 3/21-3/26 for acute GI bleed from ulcers in stomach & large duodenum. Brought by wife w/hematochezia & generalized weakness. Intubated for airway protection. He was agitated & combative.
Hemoglobin as low as 3.0. OG showed coffee ground material.
Type of IV solution & Rate: none
Code status: FULL
Medical Dx: Upper GI bleed, Bleeding Ulcer
Surgical Procedure and date:
4/11 – Small Bowel Resection
Past Medical Hx:
Recent Hospitalization from GI Bleed
ESRD on HD M/W/F
HTN
Recurrent Ascities w/Paracentesis
Symptomatic
Bradycardia from
Hyperkalemia
Restless Leg Syndrome
Chronic Itching
Age: 66
Male or female: Male
Psychosoc: n/a
Cultural: Japanese
Spiritual: Christian
Marital Status: Married
Occupation: Ichida Law firm
Living condition: Mililani
Allergies: Ambien,
Fenofibrate, Lorazepam
Type of reaction:
Disorientation, agitation
Interdisciplinary referrals
Gastroenterology
General Surgery
Type of IV Access & Location: none
Diagnostic tests including test results (pre and post procedure nsg. implications later in CIS)
List all IV medications (research compatibility & infusion rate for each med.)
Med./dose none time Infusion rate Compat.
Treatment: (include PT, OT, precautions)
-Glucose check before meals
- Flowtron
- NO BP from LT arm
- Aspiration & Bleeding Precautions
- High risk for falls
- Weigh & Record daily 0500
- Up in Chair TID
- Up as tolerated PRN
- HOB elevated 30-45 degrees continuously
- May turn on side & elevate HOB 30 degrees
- PT, OT, Speech-Language Pathology
- Steri-Strips ¼ inch & Benzoin to bedside
3/22 – Ultra Sound: Liver
 Ascites present, No cirrhosis
4/2 – Ultra Sound: Paracentesis
 1.4 liters of light serosanguineous fluid removed, no complications
4/10 – EKG: abnormal, ↑ rate, nonspecific ST-T changes,
Prolonged OT
4/12 – KUB X-Ray
 NG tube placement at GE junction (d/c)
4/13 – X-Ray: Chest
 Pt extubated, RT central line removed, LT Central line
Stable
Discharge Planning:
-Pain management
-PT & OT (home care)
-Fall precautions
-Diet teaching (avoid spicy foods, alcohol, caffeine)
-Stress relief techniques
Type of Diet: Renal Diabetic Diet w/Snack
Fluid Restriction: none
Enc. Fluids: none
Activity (ability to walk – gait): Up as Tolerated
Type of activity: TID to Chair
Use of assistive device: Walker
O2: none
Weight/height: 148 lbs/ 5’4”
Daily Weight: 146 lbs
Elimination (continent/incontinent): Continent
Foley/condom cath/ st. cath: none
Last BM (constipation): 4/18

List all p.o. & s.c. Meds & prns
Med/dose/frequency time Indication
Insulin Regular Human
(Humulin R) / 100 units/mL
0700
1100
/ TID before meals under skin
No Insulin if <151
Antidiabetic. Control of hyperglycemia. Lowers blood glucose by increasing glucose uptake in muscle and fat & inhibiting hepatic glucose production.
Side effects
Hypoglycemia, lipodystrophy, pruritus, erythema, swelling.
Amlodipine / 1 tab (10mg) /
Naso-Gastric
Hold if SBP < 100
0900 Antihypertensive. Calcium channel blocker. Coronary vasodilation & decreases
BP.
Epoetin Alfa (Procrit) Inj for
ESRD / 10000 U IV (1mL)
M/W/F
0900
Anti-anemic: Stimulates erythropoesis. (production of red blood cells) Treats anemia in Pt.’s w/chronic kidney failure (ESRD).
Latanoprost / 1 drop for both eyes / after breakfast
Headache, peripheral edema, bradycardia, hypotension, flushing.
HTN, headache, seizures, MI, stroke,
CHF
Nsg. implications
Assess for S&S of hypoglycemia (anxiety; restlessness; tingling in hands/feet/lips; chills; cold sweats; confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger; headache; irritability; nausea; nervousness; tachycardia; tremor; weakness; unsteady gait) & hyperglycemia (confusion, drowsiness; flushed, dry skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; unusual thirst) during therapy.
Monitor BP & pulse during therapy. Monitor ECG during prolonged therapy.
Monitor I&Os & daily weight. Assess for signs of HF
(peripheral edema, rales/crackles, dyspnea, weight gain,
JVD).
Contraindicated in: Uncontrolled HTN
Monitor BP before & during therapy.
Monitor for S&S of anemia (fatigue, dyspnea, pallor)
May cause ↑ WBC & platelets.
Monitor renal function studies. ↑ in BUN, creatinine, uric acid, phosphorus & potassium may occur.
Intructions: refrigerate, do not shake
Black Box Warning
Store at room temperature.
Metoprolol Succinate / 1 tab (25 mg) / daily
24 hr sustained release, don’t crush or chew
Pantoprazole (Protonix) /
IV Push 10 mL (40 mg) /
Q12H
0900 Treats glaucoma & ocular
HTN. Prostaglandin analog that ↓ eye pressure by ↑ fluid flow out of eye.
0900 Beta-blocker: blocks Beta 1 receptors w/o affecting beta-2 receptors.
Decreases BP & HR to manage HTN.
Stinging, burning, itching, watering, swelling of eye, redness
Fatigue, insomnia, urinary frequency, bradycardia, HF, pulmonary edema
Monitor BP, ECG & pulse frequently periodically.
Monitor I&Os & daily weights. Assess for S&S of HF
(dyspnea, rales/crackles, weight gain, peripheral edema,
JVD).
Metoprolol: Monitor VS. If HR <40 bpm, especially if CO is also decreased, administer atropine 0.25–0.5 mg IV.
Assess Pt. for epigastric or abdominal pain & for occult blood in stool, emesis, or gastric aspirate.
Rotigotine (Neupro) / 1 patch (4 mg) / 24 hr transdermal patch
Sennosides/Sodium
Docusate (Senna-S) / 1 tab (8.6/50 mg) / BID
0900
2100
Proton-pump Inhibitor.
Antiulcer. Diminish acid in gastric lumen with less acid reflux. Healing of ulcers & esophagitis.
0900 Dopamine agonist. Tx
Parkinson’s disease. Brain natural substances to control movement, muscle control & balance.
0900
2100
Laxative. Stimulates peristalsis and treats constipation.
0900 Flush
Headache, abdominal pain, diarrhea, hyperglycemia, hypomagnesemia.
Rash, N&V, constipation, headache, fainting, increased sweating
Abdominal cramps, flatulence, nausea, excessive loss of water & electrolytes none
Store at room temp.
Reduce dose in pt.’s who experiences considerable abdominal cramping.
Contraindication: Fecal impaction, appendicitis
Flush all lumens before & after each use. Sodium Chloride Inj / 10-
20 mL / Q8H
Paricalcitol (Zemplar) Inj. /
0.4 mL (2 mcg) / MWF –
Hemo RN only
M/W/F
0900
Fat-Soluble Vitamins.
Promotes absorption of calcium & ↓ parathyroid hormone. Prevent & treat hyperparathyroidism in Pts w/Chronic Kidney Disease.
Headache, dry mouth, pruritus, weight loss.
Assess for bone pain & weakness.
Observe carefully for hypocalcemia (paresthesia, muscle twitching, laryngospasm, colic, cardiac arrhythmias, &
Chvostek’s or Trousseau’s sign).

PRN
Acetaminophen (Tylenol) /
2 tabs (650 mg)
Q6H PRN: Pain & Fever Rash, renal failure, dyspnea, fatigue, insomnia, anxiety, headache, hypokalemia, constipation
Patients who are malnourished are at higher risk of developing hepatotoxicity w/ chronic use of this drug.
Pain: Assess type, location & intensity before & 30–60 min after.
Fever: Assess fever; note presence of associated signs
(diaphoresis, tachycardia & malaise).
Overdose antidote = acetylcysteine (Acetadote)
Monitor BP & pulse
May be administered concurrently with diuretics or beta blockers to permit lower doses and minimize side effects.
Hydralazine IVPB / 10 mg,
100 mL
Don’t infuse faster than
5mg/min
Mannitol (Osmitol) 20% IV,
50mL = 10g.
Albumin Human (Alburx) /
IV 25g (Hemo RN Only)
Q6H PRN: SBP over
160
Q30
MIN
PRN: Blood
Pressure (use 2 rd )
Diuretic
PRN: Blood
Pressure (use 3 rd )
Volume expander, blood products
Tachycardia, sodium retention, drug-induced
Lupus syndrome
Transient volume expansion, tachycardia,
N&V, dehydration
Headache, increased saliva, fluid overload, pulmonary edema
Assess VS, urine output.
Assess for signs of dehydration (skin turgor, fever, dry skin & mucous membrane, thirst)
Assess for anorexia, muscle weakness, numbness, tingling, confusion, excessive thirst.
Monitor VS & I&Os.
If fever, tachycardia or hypotension occurs, stop infusion & notify physician immediately.
Assess for signs of vascular overload (rales/crackles, dyspnea,
HTN, JBD)
Oxycodone/Acetaminophen
(Percocet) / 1-2 tabs (start w/1 tab)
Fentanyl Citrate Inj. 50 mcg
= 1mL IV
Pramoxine/Calamine
(caladryl) lotion / Topical
PRN: Pain (Give before Fentanyl)
Opioid Analgesic
Q2H PRN: Severe breakthrough Pain
Opioid analgesic
BID PRN: Itching
Anesthetic
Confusion, sedation, constipation, respiratory depression
Apnea, Laryngospasm, blurred vision, respiratory depression
Burning skin, edema, tenderness, irritation
Assess type, location, and intensity of pain prior to and 1 hr
(peak) after administration.
Assess BP, pulse & respirations.
Assess bowel function routinely. Prevention of constipation should be instituted w/ increased intake of fluids, bulk, & laxative
Monitor RR & BP frequently. Report significant changes immediately.
Assess type, location & intensity of pain before & 3-5 min after IV administration.
Assess type, location & intensity of pain before & a few minutes after administration of anesthetic.
Assess integrity of involved skin & mucous membranes before & periodically throughout course of therapy.
Flush all lumens before & after each use. Sodium Chloride Inj. 10-20 mL
PRN: Flush None
#1 Risk for falls related to recent fall during hospitalization.
Expected Outcome
Client will not experience any falls during his stay.
Nursing Interventions
1. Assess Pt.’s overall health status and LOC.
Patient Responses to interventions
Patient has full LOC. Pt was alert and oriented x4.
2. Keep room free of clutter. Keep primary ambulation path clear & as straight as possible.
3. Keep call light in reach & keep table with items frequently used close to bed.
4. Teach patient about risk factors for falls at home. (install handrails on stairs, get rid of loose throw rugs, install nonslip surfaces in shower, keep pathway clear, increase lighting, keep kitchens frequently used items in easy reach, wear shoes, alarm device)
Bed was in lowest position with both side rails up and the bed alarm on. Pt’s room was kept clean and clear. Able to move around at ease.
Explained purpose of call light. Call light in reach, Pt able to communicate need for getting up. kept phone, backscratcher and water in close reach.
Pt acknowledges risk factors. Will be taking certain precautions when discharged (getting rid of loose throw rugs, keep pathway clear).
Evaluation:
Pt did not have any injuries related to previous fall. Pt had no falls during shift. He was cooperative with hospital policy and responsive to some preventative teaching measures for the home.

Nursing Diagnosis (choose 3 nursing diagnoses of highest priority - also include assessment, interventions and teaching)
Gulanick, PhD, APRN, FAAN, M., & Myers, RN, MSN, J. L. (2011).
Missouri: Elsevier Mosby.
Expected outcome:
Pt verbalizes & demonstrates selection of foods or meals that will achieve a cessation of weight loss.
Nursing Interventions Patient Responses to interventions
1. Assess for changes in body weight. Obtain a nutritional history. Monitor serum albumin levels.
2. Teach about the importance of eating a balanced diet w/meals at regular intervals. (eating small meals, frequent intervals)
Pt lost 2 lbs in his 6 day stay. Usually eats healthy foods and exercises.
Serum albumin levels are low normal.
Pt stated he usually eats small frequent meals. He likes to snack in between meals
3. Encourage Pt to limit intake of coffee and other caffeinated beverages (↑ acid production). Soft, bland, nonacidic foods cause less gastric irritation.
4. Instruct importance of abstaining from excessive alcohol. (↑ irritation & pain) Spicy foods, pepper, raw fruits & vegetables ma cause irritation.
Pt was requesting coffee until taught how it could cause irritation to his stomach ulcers. He seemed surprised and later requested for hot tea.
Pt accepted teachings. He seemed reluctant at first but later recognized how he ate a lot of spicy foods before being brought to the hospital.
Evaluation:
Pt acknowledged a lot of factors of his lifestyle that could be contributing to his ulcers. Stated he will try to be more aware of his diet and will relax more since he just recently retired. Pt was receptive to teachings and agreed to implement some changes.
#3 Acute pain related to increased gastric secretions, decreased mucosal protection manifested by weight loss, nausea & vomiting and pain rated as 7/10.
Expected Outcome
Pt reports satisfactory pain control at a level less than 3-4 on a 0 to 10 scale.
Nursing Interventions
1. Assess Pt’s pain including location, characteristics, precipitating factors, onset, duration, frequency, quality, intensity & severity.
2. Eliminate additional stressors or sources of discomfort whenever possible. Provide rest periods to facilitate comfort, sleep and relaxation.
3. Administer prescribed drug therapy: PPIs, Prostaglandin analogues, antacids, sucralfate.
Patient Responses to interventions
Pt stated abdominal pain 6 out of 10. It was specifically to his surgical incision, open to air w/steri-strips, well approximated with no exudate present. He stated it was a continuous aching pain.
Pt on bed rest and was able to nap after breakfast. Allowed dim lighting and efficient care to allow time for rest.
Administered Tylenol 650 mg for pain. Also gave PPI (Protonix) to decrease acid and allow healing.
4. Teach use of nonpharmacological pain relief strategies.
Guided imagery, relaxation, distraction, music therapy, acupressure.
Pt distracted self with TV. Able to talk to wife on phone about feelings. I spent time with patient and allowed him to reminisce on his lawyer and army days.
Evaluation:
Pt stated he felt a lot better after the Tylenol. He did rate his pain 5 out of 10 but seemed more relaxed. Used non-pharmacologic mechanisms to decreases pain.

CHEM 25
Glucose, fasting
BUN
Creatinine
BUN/Creatinine
Sodium
Potassium
Chloride
TCO
2
Magnesium
Phosphorus
Calcium
Albumin
Total protein
Globulin
A/G ratio
Bilirubin, total
Bilirubin, direct
Bilirubin, indirect
Uric acid
Osmolality (Calc)
CPK
Digoxin Tx
BNP
Troponin I
Troponin T
LDH
AST (SGOT)
ALT (SGPT)
GGTP sLab Test
CBC
WBC
RBC
Hemoglobin
Hematocrit
Reticulocytes
MCV
MCH
MCHC
RDW
Platelet. Count
MPV
Differential
Bands
Segmented
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Neuts (Segs)
(absolute)
Lymph (absolute)
Mono (absolute)
Eos (absolute)
Baso (absolute)
PT
PTT
INR
Lab Test
20-45
3-7
1-3
0.5-1
54-62
11.4-14.2
25-35
0.9-1.2
Normal
Range/ Unit of measure
4-11
4-6
14-18
40-50%
0.5-2
76-100
25-35
31-35
11.5-14.5
150-400
7.4-10.4
0-6
44-76
Date/ Result
4/16
9.70
10.1
31.1
91.2
29.6
32.5
17.2
235
81.0
Date/ Result
4/17
9.87
3.54
10.4
32.4
91.5
29.4
32.1
17.4
284
77.3
Date/ Result
4/18
10.13
10.8
34.1
91.9
29.1
31.7
17.5
360
76.7
Rationale for abnormalities specific to your client
Bleeding ulcers & ESRD
Bleeding ulcers & ESRD
Possible liver disease (Ascites)
Infection?
6.6
7.5
0.5
7.8
6.3
1.0
6.4
10.3
5.2
1.0
Normal (according to Queen’s)
Normal (according to Queen’s)
Normal (according to Queen’s)
Normal
Range/ Unit of measure
65-100
6-23
0.6-1.4
10-20:1
135-145
3.5-5
98-107
23-27
1.8-3.0
2.5-4.5
8.5-10.2
3.5-5
6.5-8.2
2.3-3.5
0.3-1
<0.4
2.5-7.8
275-299
0-5
<100
0.6-2.8
<0.1
100-190
<35
10-35
15-80
Date/ Result
4/16
1.8
8.5
2.7
113
39
5.0
136
3.7
99
28
2.3
Date/ Result
4/17
3.6
9.0
3.0
88
58
6.9
134
4.4
95
24
2.5
Date/ Result
4/18
3.8
9.1
3.2
81
35
5.3
135
4.3
97
26
2.3
Rationale for abnormalities specific to your client
ESRD
ESRD
Imbalanced nutrition (GI bleed)

Lab Test
Alkaline phosphatase,
Amylase
Lipase
Cholesterol
Triglycerides
Homocysteine
Others:
Lactic Acid
ABG pH
PaCO2
Pao2
O2 saturation
HCO3
BE
Urinalysis
Color
Appearance
Specific gravity pH
Leukocytes
Nitrites
Protein
Glucose
Ketones
Urobilinogen
Bilirubin
Erythrocytes
UA microscopic
WBC
RBC
Epithelial cells
Occult blood
Bacteria
Mucus
Casts
Crystals
Yeast
Comments
Cultures and sensitivities
Organism
Sensitivity for ordered antibiotic
Sensitivity for ordered antibiotic
Sensitivity for ordered antibiotic
Other tests
Blood culture
Reference:
Yellow
Hazy
1.020
>8.5
Neg
Neg
100
100 (Trace)
Neg
0.2
Neg
3-5
Normal
Range/ Unit of measure
44-147
Date/ Result
4/8
Date/ Result Date/ Result Rationale for abnormalities specific to your client
None
None
None
30-100
<160
<200
80-150
3-7
7.35-7.45
35-45
75-105
96-100
21-28
+-3
Yellow
Clear
1.050-1.030
4.6-8
Neg.
Neg.
50-80
Neg.
<5
1-4
None
≤2
80-100
0-5
<3
ESRD
ESRD
ESRD
ESRD
ESRD
Neg.

 After assessment, identify important physical assessment findings in the above diagram & below
Neurological/Mental Status
A&O x4: oriented to person, place, time and situation
Pupils: 3.5 mm non-reactive to light Sensory deficits: Color blind
Speech: Clear Sensation: full
Motor & strength: Full strength in upper & lower extremities
Respiratory System
Depth, rate, rhythm: normal depth, rate, rhythm Cough: weak, non-productive
Uses of accessory muscles/cyanosis : none Sputum color, amount: none
Breath sounds: Clear in RUL & LUL, decreased in RLL & LLL Use of O2: none
Pulse oximeter: 99%
Chest tube: none
Smoking: Hx 1 pack/wk
Cardiovascular System
Pulses: bilaterally palpable radial & dorsal pedis Edema: none
Heart sounds: Normal S1 & S2
Capillary refill: less than 3 sec
Chest pain: none
Other
Gastrointestinal System
Abdomen: Soft, non-tender Last BM: Today
Bowel sounds: present Ostomy: none
NGT(suction, feeding): none
Musculoskeletal System
Other:
Bones: Fx/dislocation: none
Affected extremity CMS (pulses, temperature, edema, movement, sensation) check: n/a
Use of cast, splint, neck collar, brace or traction (identify): none
Genitourinary System
Pain or burning sensation with urination: none Urine: normal frequency, unmeasured
Foley, continent, incontinent, ostomy: continent Dialysis: M/W/F
Skin & Wounds
Color, turgor: warm, dry, good skin turgor
Bruises/rash: dark scars present on both legs (from rash)
Describe wounds (size, location): abdomen incision, intact, no exudates, no edema
Dressing: open to air, steri-strips
Wound vac: none
IV site (peripheral, PICC, TLC): none
Other

Disease Process – Schematic (how did this disease happen which led to clinical Manifestations)
Breakdown in protective epithelial lining of stomach & duodenum.
Vagus nerve is increased & pyloric cells release gastrin.
Aspirin, NAIDS, alcohol, bile acids strip away surface mucus & cause degeneration of epithelial cell membranes.
Diffusion of acid into gastric epithelial wall.
Gastrin acts on parietal cells to release hydrochloric acid (HCl) & results in inappropriately high levels of HCl in duodenum.
Ulcer penetrates through mucosa, submucosa, tunica muscularis to the serous layer.
Gastric Ulcers
-Burning, gaseous pressure in high LT epigastrium
-Pain 1-2 hrs after meal
-occasional N&V, weight loss
Duodenal Ulcers
-Adequate Rest
-Proton Pump Inhibitors: block acid secretions
-Histamine (H2) –Receptor Blockers
-Antibiotic Therapy
-Antacids
-Cytoprotective Drug Therapy
-Only for complications of PUD (hemorrhage,
-Burning, cramping, pressure-like pain in midepigastrium
-Pain 2-4 hrs after eating
-Pain relief w/food & antacids perforation, gastric outlet obstruction)
-Acute exacerbation: NPO for a few days, NG tube for suction. IV fluid replacement. VS. Regular mouth care.
-Physical & emotional rest for ulcer healing. (quiet & restful environment)
-Pain management, nutritional therapy (avoid foods that cause gastric irritation)
-Use of mild sedative or tranquilizer has beneficial effects
-Observe for complications (hemorrhage, perforation, gastric outlet obstruction)
- Smoking cessation, alcohol abstinence, avoidance of aspirin & NSAIDs, stress reduction. Avoid foods that exacerbate symptoms (spicy foods – pepper, caffeinated beverages & alcohol)
Reference:
Copstead-Kirkhorn, L., & Banasik, J. (2009). Pathophysiology. (4 th ed.). St Louis: Elsevier.
Lewis, S., Dirksen, S., Heitkemper, M., Bucher, L., Camera, I. (2011). Medical-surgical nursing: Assessment and management of clinical problems, (8 th ed.). St
Louis:Elsevier.