Patient: Mr.York Clinical Issue: Hemorrhaging wound

Diagnosis

Assessing

Planning

Intervention

Evaluation

Vital signs:
BP: 90/52
HR: 128
RR: 26
O2: 93% on room air
T: 35.9
Pain: 10/10 back pain

Decreased responsiveness
Increased pallor
Dizziness
Slurring words
Skin cold to touch

Hgb: 80 g/L

Risk for hypoxia

Anemia

Risk for shock (hypotensive and tachycardic)

Report findings to physician

continue IV infusion of Normal Saline

Provide supplemental oxygen

Administer packed red blood cells

Apply supplemental oxygen to maintain oxygen saturation above 95%

Monitor the client's response to interventions

Repeat ADPIE as required

Assessment: Patient is deteriorating, less responsive, lethargic, increased back pain, bleeding wound on lower back
Diagnosis: Hemorrhaging
Planning: Control the bleeding and call the provider
Intervention: reinforce wound
Evaluation: repeat ADPIE as needed