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Dx. UGIB Patient Bed No.17 Patient name: MR.Somchai Punpao - Coggle…
Dx. UGIB
Patient Bed No.17
Patient name: MR.Somchai Punpao
2.Electrolyte imbalance due to hypercalcemia
S: -
O: 1.K high 5,5 mmoL
2.Patient's mouth and skin was dry.
3.Patient has weakness and confusion.
4.Diagnosis UGIB
Nursing Goals
1.To prevent complication of hypercalcemia.
Evaluation Criteria
1.Patient not has sign and symptom of hypercalcemia such as fatigue, bone pain, headaches,nausea,vomitting,depression and weakness.
2.K level was stable rang.
(3.4-4.5 mmoL.)
Nursing Activities with reasons
1.Assess sign and symptoms of hypercalcemia such as fatigue, bone pain, headaches,nausea,vomitting,depression and weakness for prevent complication may occur to patient.
2.Observ I/O for prevent dehydration happen to patient.
3.Monitor EKG for prevent irregular heartbeat.
4.Reassess electrolyte laboratory result.
Patient Activities
1.Patient got assess sign and symptomps of hypercalcemia such as fatigue, bone pain, headaches,nausea,vomitting,depression and weakness
2.Patient got NPO and not has output.
3.Patient got EKG monitor.
4.Patient got Complete Blood Count.
Evaluation
1.Patient still has dry mount,dry skin and confusion.
3.K level was stable rang.
Analysis for nursing Diagnostic Fluid Imbalance can arise from hypercalcemia are susceptible to dehydration and electrolyte abnormal can happen from GI bleed and amount of water in body was change may occur the symptoms such as fatigue, bone pain, headaches,nausea,vomitting,depression and weakness.
3.Paliative care
S: -
O: 1.Prolonged disease.
2.U/D Cancer oropharynx GI mat c Brain mat.
3.The disease can not treat for back to normal.
4.Patient has bed ridden.
Nursing Goals
1.To promote quality of life.
Evaluation Criteria
1.Patient has good quality before end of life.
Nursing Activities with reasons
1.Assess sleep pattern including sleep deprivation, emotion distress, side effect of medication and progression of disease process.
2.Encorage nutrition intake and use of supplements as appropriate.
3.Document cardiopulmonary response, dyspnea,arrhythmias and diaphoresis can provide guideline for participation.
4.Monitor breath ,air hunger and hypoxia increase fatigue ability to function.
5.Provide supplemental oxygen as indicated and monitor response to increase oxygenation.
6.Change position every 2 hours for prevent bed sore.
7.Promote nutrition giving TPN kabiven peripheral.
8.Observ EKG for prevent VF.
Patient Activities
1.Patient got assess sleep pattern including sleep deprivation, emotion distress, side effect of medication and progression of disease process.
2.patient got TPN kabiven peripheral.
3.Patient got change position every 2 hours.
4.Patient got monitor breath ,air hunger and hypoxia.
5.Patient got EKG monitor.
Evaluation
1.Patient has good quality of life.
Analysis for nursing Diagnostic
Palliative care is specialized medical care that focuses on providing patients relief from pain and other symptoms of a serious illness, no matter the diagnosis or stage of disease. Palliative care teams aim to improve the quality of life for both patients and their families.
Patient Information
Name-Sure name Mr.Somchai Punpao
Age 68 years Sex male Marital status Married Religious Buddhism Occupation Retired Education level Bachelor degree
First Diagnosis : UGIB
Second Diagnosis : UGIB
Chief complaint : 8 hours PTA Patient has hematemesis 10 times not has Selena and fever.
Present illness : Patient has cancer at oropharynx last 3 years ago and got complete radiation therapy 8 hours PTA Patient has hematemesis 10 times not has Selena and fever.
Past illness history : CA oropharynx C GI mat c Brain mat at both frontal lobe.
Laboratory
Patient has Hct (30%-33%) less than normal rang(Hct 40-54%) cause of cancer spread to bone marrow, such as leukemia and lymphoma and UGIB to loss a lot of blood
can trate by got blood transfusion or medicine to stop bleeding
Patient has K(5,5 mmoL) more than normal level(3.4-4.5 mmoL.).the laboratory result when too much calcium enters the extracellular fluid or when there is insufficient calcium excretion from the kidneys.In this case the doctor order to give elixir and IV fluid.
1.Risk for hypovolumic shock due to UGIB
S: -
O: 1.Patient has hematemesis 10 times PTA.
2.Hct drop 33% to 30%
3.NG lavage : coffee ground.
4.Dx.UGIB
Nursing Goals
1.To prevent hypovolemic shock.
Evaluation Criteria
1.Patient not has sign and symptoms of hypovolemic shock such as cool,confusion,decrease or no urine output,weakness,rapid breathing.sweating or moist skin and unconciousness.
2.CBC : normal
Hct 40-54%
Hb 12-16.0 g/dl.
3.Oxygen sat more than 95%
4.No coffee ground.
Nursing Activities with reasons
1.Assess sign and symptoms of hypovolemic shock such as cool,confusion,decrease or no urine output,weakness,rapid breathing.sweating or moist skin and unconciousness.
2.Monitor Vital sign.
3.Correct serial Hct every 6 hours. if drop more than 3% notify doctor.
4.Give medicine IV drip follow the medical order to stop bleeding at GI tract.
5.Recheck NG lavage: still have coffee ground or not.
6.NPO for reinsure patient has hematemesis or not.
Patient Activities
1.Patient got assess sign and symptoms of hypovolemic shock such as cool,confusion,decrease or no urine output,weakness,rapid breathing.sweating or moist skin and unconciousness.
2.Patient got correct erial Hct every 6 hours.
3.Patient got NG lavage.
4.Patient got NPO.
Evaluation
1.Patient not has sign and symptoms of hypovolemic shock.
2.CBC was normal.
3.Patient not has hematemesis and coffee ground.
4.Oxygen sat 98%
Analysis for nursing Diagnostic
Patient has risk for hypovolemic shock from UGIB patient has underlying CA oraphalyx, The UGIB happen in upper GI tract it damage to mucosal injury, the sign and symptoms including hematemesis,melena,epigastric pain and when patient loss a lot of volume the blood circulation was poor,it can increase patient to hypovolemic shock.