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Patient: Mr.York Clinical Issue:…
Patient: Mr.York Clinical Issue: Hemorrhaging wound
Diagnosis
Risk for hypoxia
Anemia
Risk for shock (hypotensive and tachycardic)
Assessing
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
Planning
Report findings to physician
continue IV infusion of Normal Saline
Provide supplemental oxygen
Intervention
Administer packed red blood cells
Apply supplemental oxygen to maintain oxygen saturation above 95%
Evaluation
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