Nursing Care Plan

Richard J. Daley College

Nursing 101 Data Collection for Care Plan

Section I – Demographic Data:

Patient Initials: K. J. Sex: Female MSWD: Married

Age: 44 No. of children: 1 Occupation: Disabled

Section II- Admission Data

1. Date admitted: 10/19/2007

2. Admitting diagnosis: Hematomesis, melanotic stools, cirrhosis, hepatorenal syndrome.

3. Allegries: Codiene

4. Signs and symptoms on admission: jaundice appearance, lethargic, oriented x 1, vomiting bright red blood, has had black stools.

5. Summary of History and Physical on admission: Patient has a history of hepatitis C, alcohol abuse, cirrhosis, GI bleed, pancreatitis. Patient was lethargic, with mental status changes. Patients appearance is jaundice, stomach distended and tender to palpation.

6. History of Surgical Procedures with dates: Not Known

Section III-Progress Report of Patient:

Patient was brought to Mercy Hospital ER by her husband who found patient lying naked on the doorway. She has multiple home medications including lactulose. History of hepatitis C, pancreatitis, cirrhosis, and alcohol abuse. Patient is allergic to codeine. She is suspected to have hepaticportal hypertension. She is on protonix, multi-vitamins, folic acid, thiamine and lactulose at home. Patients appearance is jaundice, lethargic with altered mental status. Patient only oriented to place. Pupils dilated and weakly reactive to light, deep sclera icterus, conjunctivae pallor. Neck is reported to be supple; no JVD, or LAD. Pt is in no respiratory distress. Her abdomen appears to be distended and it is tender to palpation. Blood Pressure 83/33, pulse of 53, respiratory rate of 24, and temp of 36.8 C. Medical team suspects she is having a GI bleed and an NG tube will be inserted to observe the amounts of blood and monitor if she is actively bleeding. Patient will be transferred to the MICU form ER. In MICU a central line was placed and an EGD was performed to rule out any active bleeding as well as esophageal varices.

On 10/22/2007 patient was transferred from ICU9 to Unit floor 925. Her diagnosis is hepatorenal syndrome. She currently is not bleeding and her NG tube has been discontinued. Electrolytes and Blood work will be monitored closely and corrected appropriately. Patient was found to have electrolyte abnormalities low Na, K, acidosis, anemia and coagulopathy. She was transfused 4 units of RBC and 4 FFP, with vitamin K. Potassium improved from 2.6 to 3.3. The EGD showed several varices gastropathy and portal hypertension. Her hemoglobin is stable at 9.6. Comfort care is being discussed since she is in end stage liver failure. Doctors also state she is not a candidate for liver transplant given the fact that she was still abusing alcohol prior to admission.

Section IV- Lab and Diagnostic Test Results

COMPLETE BLOOD COUNT

DATE

Units WBC

k/cmm RBC

mil/

cmm HGB

Gm/dl HCT

% MCV

fL MCH

Pg MCHC

% RDW

% PLATELET

COUNT

K/cmm MPV

fL

10/19/07 24.41H 1.6 L 6.2 L 16.7L 102.1H 37.7H 36.9 H 18.3 H 161.0 8.7

10/20/07 14.16H 2.4 L 8.1 L 22.4L 93.5 34.0H 36.3 17.4 H 101.0 L 8.2

10/21/07 14.62H 3.0 L 10.1L 27.4L 91.9 33.8 36.7 H 17.6 H 107.0L 7.3 L

10/22/07 15.47H 2.8 L 9.6 L 26.2L 92.5 34.0 36.8 H 18.0 H 97.0 L 7.1 L

10/23/07 14.58H 3.1 L 10.3L 28.2L 92.2 33.8H 36.6 H 18.4 H 111.0 L 7.5

10/24/07 16.41H 2.9 L 10.1L 26.7L 92.5 34.9H 35.9 18.4 H 100.0 L 7.5

10/25/07 18.10H 3.2 L 10.9L 29.9L 92.3 33.8H 36.6 H 18.3 H 122.0 L 7.7

Rationale:

A CBC is performed because it provides information about the hematologic system and many other