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What nursing diagnoses should the nurse formulate for the patient? > Create a Nursing Care Plan for patient Jose. > Create FDAR chart for patient Jose. (F-ocus, D-ata, A-ction, R-esponse) Thank you!

What nursing diagnoses should the nurse formulate for the patient? > Create a Nursing Care Plan for patient Jose. > Create FDAR chart for patient Jose. (F-ocus, D-ata, A-ction, R-esponse) Thank you!

Phlebotomy Essentials
Phlebotomy Essentials
6th Edition
ISBN:9781451194524
Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)
Chapter1: Phlebotomy: Past And Present And The Healthcare Setting
Section: Chapter Questions
Problem 1SRQ
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QUESTIONS. 6. What nursing diagnoses should the nurse formulate for the patient? > Create a Nursing Care Plan for patient Jose. > Create FDAR chart for patient Jose. (F-ocus, D-ata, A-ction, R-esponse) Thank you!
Mr. Jose, 35 years of age, presented in Emergency Department due to nausea and vomiting. Upon interview by the nurse, client noticed with progressive abdominal distension, bearable on and off abdominal pain for two months duration and loss of weight over three weeks despite a good appetite. The patient has quit drinking alcohol for the past 2 months. His systemic inquiry was unremarkable. There was no significant past medical, surgical or allergic history. The admission vital signs include: BP, 88/50; P, 110; R, 26; and T, 37.3. Patient then, was transferred at intensive care unit. He is a tailor by profession and never married; He has two siblings who are healthy. On examination, he was dark in complexion and appeared well. He was not pale, or icteric. There was no clubbing or peripheral stigmata of chronic liver cell disease. There were no hepatic flaps or dependent edema. The abdomen was distended and firm, upon percussion there was no hepatic bruit or splenomegaly. His cardiovascular, respiratory, and neurological examinations were normal. The supplemental oxygen is on room air and the patient is placed on 2 L/min of oxygen per nasal cannula with supplemental oxygen. IV Fluid Started with PLRS 1 Lat 100 cc/hr. Routine laboratory investigations were done and revealed a hemoglobin of 14.9 g/dL with a MCV of 83 fL. The total leucocyte count was 10.06 X 109 /L with normal differentials and platelet count of313,000/mm3. Blood film showed acanthocytes and target cells which was suggestive of a liver pathology. Liver function tests showed an elevated alkaline phosphatase level of 319 U/L with normal alanine and the aspartate aminotransferases (AST= 21 IU/L, ALT-=26 IU/L) and a normal serum bilirubin concentration. The total serum protein was 6.5g/dL, with albumin levels of 3.3g/dL. The Gamma GT level was mildly elevated (58.5 U/L) Prothrombin time was 16.3 seconds with an INR of 1.43. Serum electrolytes and renal function tests were within normal limits. The inflammatory markers were normal.
Transcribed Image Text:Mr. Jose, 35 years of age, presented in Emergency Department due to nausea and vomiting. Upon interview by the nurse, client noticed with progressive abdominal distension, bearable on and off abdominal pain for two months duration and loss of weight over three weeks despite a good appetite. The patient has quit drinking alcohol for the past 2 months. His systemic inquiry was unremarkable. There was no significant past medical, surgical or allergic history. The admission vital signs include: BP, 88/50; P, 110; R, 26; and T, 37.3. Patient then, was transferred at intensive care unit. He is a tailor by profession and never married; He has two siblings who are healthy. On examination, he was dark in complexion and appeared well. He was not pale, or icteric. There was no clubbing or peripheral stigmata of chronic liver cell disease. There were no hepatic flaps or dependent edema. The abdomen was distended and firm, upon percussion there was no hepatic bruit or splenomegaly. His cardiovascular, respiratory, and neurological examinations were normal. The supplemental oxygen is on room air and the patient is placed on 2 L/min of oxygen per nasal cannula with supplemental oxygen. IV Fluid Started with PLRS 1 Lat 100 cc/hr. Routine laboratory investigations were done and revealed a hemoglobin of 14.9 g/dL with a MCV of 83 fL. The total leucocyte count was 10.06 X 109 /L with normal differentials and platelet count of313,000/mm3. Blood film showed acanthocytes and target cells which was suggestive of a liver pathology. Liver function tests showed an elevated alkaline phosphatase level of 319 U/L with normal alanine and the aspartate aminotransferases (AST= 21 IU/L, ALT-=26 IU/L) and a normal serum bilirubin concentration. The total serum protein was 6.5g/dL, with albumin levels of 3.3g/dL. The Gamma GT level was mildly elevated (58.5 U/L) Prothrombin time was 16.3 seconds with an INR of 1.43. Serum electrolytes and renal function tests were within normal limits. The inflammatory markers were normal.
Peritoneal fluid examination showed 40 cells/mm3 and a very high protein level of 8g/dL with negative acid-fast bacilli (AFB). Peritoneal fluid cytology was negative He had negative hepatitis B and C serology. Retroviral screening, Mantoux test and sputum AFB were negative. Ultrasonography of the abdomen revealed a hepatomegaly of 18.2cm with an enlarged caudate lobe and an architecture characteristic of chronic parenchymal liver disease. There was moderate ascites and bilateral pleural effusions. There was evidence of early portal hypertension. The initial colour doppler studies failed to show any abnormalities. Liver biopsy revealed effaced architecture with the liver parenchyma was separated into nodules by thick fibrous septae. Hepatocytes showed ballooning and degeneration. There was no steatosis, bile stasis, necro-inflammation or interphase hepatitis. These findings were compatible with established liver cirrhosis. The health provider places orders for the following: Kеep Spo2> 92% Кеep HOB > 30 degrees Insert 2 large bore Parenteral IV lines (PIV's) 500 mL NS IV bolus STAT 100 mL/hr NS IV continuous infusion Hydrocodone/Acetaminophen 5-500 mg 1-2 tabs q4h PRN moderate to severe pain Diphenhydramine 25 mg PO q8h PRN itching Ondansetron 4 mg IV q6h PRN nausea Lactulose 20 mg PO qồh After 24 hours upon admission patient experienced vomiting 2 times of fresh blood moderate in amount. Repeat laboratory done, result patient's hemoglobin is 7 g/dL, the hematocrit is 12%, and the platelets are 75,000. The patient has a prolonged PT and PTT. EGD was requested, which later revealed esophageal varices. The physician placed a right subclavian triple lumen catheter and there is NS infusing at 100 mL/hr. The iCú nurse administered vitamin K. Additional orders on the chart from the gastroenterologist include the following: Octreotide (Sandostatin) 5-mcg bolus followed with continuous infusion 500 mcg in 250 mL D5NS at 25 mcg/hr. Type and cross of 6 units of PRBCS STAT and transfuse 2 units of PRBCS over 2 hours each and administer furosemide (Lasix) 20 mg IVP in between each unit. Repeat CBC 1 hour after the transfusion is completed.
Transcribed Image Text:Peritoneal fluid examination showed 40 cells/mm3 and a very high protein level of 8g/dL with negative acid-fast bacilli (AFB). Peritoneal fluid cytology was negative He had negative hepatitis B and C serology. Retroviral screening, Mantoux test and sputum AFB were negative. Ultrasonography of the abdomen revealed a hepatomegaly of 18.2cm with an enlarged caudate lobe and an architecture characteristic of chronic parenchymal liver disease. There was moderate ascites and bilateral pleural effusions. There was evidence of early portal hypertension. The initial colour doppler studies failed to show any abnormalities. Liver biopsy revealed effaced architecture with the liver parenchyma was separated into nodules by thick fibrous septae. Hepatocytes showed ballooning and degeneration. There was no steatosis, bile stasis, necro-inflammation or interphase hepatitis. These findings were compatible with established liver cirrhosis. The health provider places orders for the following: Kеep Spo2> 92% Кеep HOB > 30 degrees Insert 2 large bore Parenteral IV lines (PIV's) 500 mL NS IV bolus STAT 100 mL/hr NS IV continuous infusion Hydrocodone/Acetaminophen 5-500 mg 1-2 tabs q4h PRN moderate to severe pain Diphenhydramine 25 mg PO q8h PRN itching Ondansetron 4 mg IV q6h PRN nausea Lactulose 20 mg PO qồh After 24 hours upon admission patient experienced vomiting 2 times of fresh blood moderate in amount. Repeat laboratory done, result patient's hemoglobin is 7 g/dL, the hematocrit is 12%, and the platelets are 75,000. The patient has a prolonged PT and PTT. EGD was requested, which later revealed esophageal varices. The physician placed a right subclavian triple lumen catheter and there is NS infusing at 100 mL/hr. The iCú nurse administered vitamin K. Additional orders on the chart from the gastroenterologist include the following: Octreotide (Sandostatin) 5-mcg bolus followed with continuous infusion 500 mcg in 250 mL D5NS at 25 mcg/hr. Type and cross of 6 units of PRBCS STAT and transfuse 2 units of PRBCS over 2 hours each and administer furosemide (Lasix) 20 mg IVP in between each unit. Repeat CBC 1 hour after the transfusion is completed.
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