UNRS 312 MANAGEMENT OF ADULTS NURSING CASE STUDY & CARE PLAN TEMPLATE (GI-BLEED).

UNRS 312 MANAGEMENT OF ADULTS NURSING CASE STUDY & CARE PLAN TEMPLATE (GI-BLEED). Running head: CASE STUDY 1 Case Study Azusa Pacific University UNRS 312 Management of Adults AZUSA PACIFIC UNIVERSITY SCHOOL OF NURSING CASE STUDY 2 UNRS 312 MANAGEMENT OF ADULTS NURSING CASE STUDY & CARE PLAN TEMPLATE Student Name: Sarah Park Date: DIRECTIONS: Points are earned on accuracy, thoroughness, and completeness of findings. All sections must be addressed to receive credit. Type all areas, text boxes will expand to accommodate information entered. Please see rubric for complete grading information. Omissions will result in failure of the assignment. Passing is ≥85%. IDENTIFYING DATA Patient initials: S.H. Age: 88 Gender: Male Race: Caucasian Marital Status: Married Occupation: Retired Insurance: Blue Shield Family Composition: Head of household Home/ Living Situation: Primary caregiver for wife Allergies (include allergen and reaction to allergen): Doxycycline, Penicillin’s, Augmentin Admit date: Hospital day #: 14 Post-operative day #: 10 Dates of Care: 10/29/18- 11/12/18 Physician(s) (include physician specialty): Rustern, Saliar T M.D. Internist ADMITTING DATA Medical diagnosis (admitting): Upper gastrointestinal bleed, ventral hernia. CASE STUDY 3 History of Present Illness (HPI): Patient was brought to the hospital by ambulance on 10/29/18 with left lower quadrant abdominal pain for one day with coffee-ground emesis. He rated his pain 10/10 on the numeric pain scale. Patient described the pain as diffuse that became worse when eating. Patient stated he was diaphoretic, hypertensive, and tachycardic as told by EMS. He denied any chest pain, shortness of breath, weakness, or headaches. ER found a small bowel obstruction and a ventral hernia. Past Medical (Comorbidities) and Surgical History: Patient with history of severe aortic stenosis status post TAVR. Anemia. Cardiac pacemaker placed 10/2018. Chronic depression. Diabetes Mellitus type 2. Hyperlipidemia. Hypertension. Multiple abdominal surgeries including cholecystectomy, laparotomy for bowel obstruction. Coronary angiogram. Social History: Denies any smoking or alcohol use. Patient is independent with all ADLS and IADLS. He states he drives, does hobbies, housework, laundry, meal preparation, and yardwork. Lives in a singlestory home with wife whom he is the primary caregiver for and does receive assistance from another caregiver twice a week. Hospital Course (Acute Care & Rehab): Patient has been in the hospital since 10/29/18 and received occupational therapy 11/10/18-11/11/18. Patient was able to participate in ADL training and functional transfers with tolerance. He required assistance for perineal care due to difficulty reaching the back. Patient progressed well towards the therapy goals. PATHOPHYSIOLOGY Pathophysiology of admitting diagnosis (must include reference): Upper gastrointestinal bleeding is when bleeding occurs in the esophagus, stomach, or duodenum. The characteristics include bright red blood, or dark grainy digested blood that resembles coffee grounds. The most common cause of bleeding is from varices in either the esophagus, peptic ulcers, or malformations of the arteriovenous. Changes in blood pressure and heart rate are the most common signs of loss of blood in the gastrointestinal tract. The peripheral arteries and arterioles begin to constrict to stop the flow of blood to the vital organs. If there is a lot of blood loss, the patient will experience a decrease in blood pressure, feeling of lightheadedness, loss of vision, and tachycardia to maintain the cardiac output for tissue perfusion. Hypovolemic shock and organ failure can occur and result in death with severe blood loss. Understanding Pathophysiology, Sixth Edition, 2017, Elsevier Inc., Sue E. Huether, Kathryn L. McCance CASE STUDY 4 Correlation of admitting diagnosis to social history, comorbidities, or past surgical history (must include reference): Patient with history of bowel obstruction. He does the main duties inside and outside of the home, including yardwork and is the primary caregiver for his wife, which may have caused the hernia. 10% of hernias are ventral that affect the small bowel. A small bowel obstruction is often caused by postoperative adhesions, tumors, and hernias. Abdominal distension occurs when there is difficulty with absorption and an increase in the accumulation of secreted fluid and gas inside the lumen near the obstruction. This causes difficulty in the intestines with absorbing water and electrolytes. Dehydration increase in hematocrit levels, tachycardia, and hypotension can occur, which can lead to hypovolemic shock and metabolic alkalosis. If pressure from the distention is severe, it can alter circulation and cause ischemia, necrosis, perforation, peritonitis, and bowel necrosis. Understanding Pathophysiology, Sixth Edition, 2017, Elsevier Inc., Sue E. Huether, Kathryn L. McCance LABORATORY TESTS: Include admission (baseline) and most current lab results. Delete rows of lab tests not performed. Test Norma l range Date: 11-05- 18 High, Low, or Norma l Curren t Date: 11-12- 18 High, Low, or Norma l Trend (Impro ving, Worse ning, Stable) Rationale for ABNORMAL Results SPECIFIC to Your Patient’s Diagnoses, Comorbidities, or Complications: CBC & DIFF: WBC 4-10 K/uL 7.5 K/uL Norma l 4.7 K/uL Norma l Stable CASE STUDY 5 RBC 3.0- 5.30 K/uL 3.08 K/uL Low 2.81 Low Worse ning Patient with history of anemia. HGB 13.4- 17.4 gm/dL 9.7 gm/dL Low 8.8 gm/dL Low Worse ning Patient with history of anemia. HCT 40- 54% 27.7% Low 25.6% Low Worse ning Patient with history of anemia. Platelets 150- 440 K/uL 89 K/uL Low 119 K/uL Low Worse ning Patient with history of anemia. Neutrophils 2-8 K/uL 4.3 K/uL Norma l 2.1 K/uL Norma l Stable Lymphocyte s 1-4 K/uL 1.7 K/uL Norma l 1.6 K/uL Norma l Stable Monocytes 0.2-0.8 K/uL 1.1 K/uL High 0.9 K/uL Norma l Improv ing Eosinophils <0.5 K/uL 0.2 K/uL Norma l 0.1 K/uL Norma l Stable Basophils <0.01- 0.1 K/uL 0.0 K/uL Norma l 0.0 K/uL Norma l Stable.