Case Study - GI

A 45 year old male comes in from the ER with complaints of abdominal pain that started yesterday morning. He also complains of frequent dark tarry stool that has lasted for 3 days and coffee ground looking emesis that just started yesterday. He states he feels dizzy and very weak. The pt looks pale and diaphoretic. His mucous membranes are dry. Current vital signs are: Temp 98.8, BP 99/62, HR 111, O2 Sat 98% and pain rating of 8 on 1-10 scale. Patients medications include Aspirin 325 mg PO daily, Lisinopril 2.5 mg PO Daily, Liptior 10 mg PO at bedtime, and Coumadin 5 mg Daily. Lab work shows the following: Hgb 7.4, Hct 35%, INR 6.7.

Fluid Volume Deficit related to hemorrhage as evidence by dry mucous membranes, BP 99/62, HR 111, Hgb 7.4, coffee ground looking emesis, abdominal pain, INR 6.7, and frequent dark tarry stools.

SUBJECTIVE DATA:

Abdominal pain that started yesterday morning, , frequent dark tarry stools that has lasted for 3 days, coffee ground looking emesis that started yesterday, feels dizzy and very weak.

OBJECTIVE DATA:

Pt looks pale, diaphoretic, mucous membranes are dry, VS BP 99/62, HR 111,  pain rating of 8 on 1-10 scale, Hgb 7.4, INR 6.7.

1. Pt’s HGB will be greater or equal to 14 as evidence by lab values within 48 hours.
2. Pt’s input will be equal to output as evidence by shift I & O reports within 72 hours.
3. Pt’s mucous membranes will appear moist as evidence nursing documentation within 48 hours

Potential Nursing Interventions:

1. Pt will be transfused 2 units of Packed Red Blood Cells per MD order and HGB will be rechecked 1 hour after transfusion has completed.
2. Nursing will measure and accurately record patients input and output hourly.
3. Pt will be started on Normal Saline IV at 150 cc/hr  for 24 hours per MD order and mucous membranes will be reassessed within 24 hours