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
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