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