Patient Assignment Clair is a 71-year-old female who presented to…

Question Answered step-by-step Patient Assignment Clair is a 71-year-old female who presented to… Patient AssignmentClair is a 71-year-old female who presented to the emergency department (ED) 6 hours ago with nausea, hematemesis, and epigastric pain. She was admitted to the hospital with a diagnosis of acute GI bleed and made NPO. A 16-gauge IV site was placed in her left forearm. 1000 mL of 0.9 NS was initiated at 100 mL/hr per primary care provider (PCP) order. An NG tube was placed and attached to intermittent low wall suction. 400 mL of red-tinged drainage was visible in the NG collection container within 30 minutes of insertion. She has had one melena stool since her admission. Clair is a full code with an allergy to penicillin (PCN) and a Braden score of 20.Initial Assessment·      Vitals: 37.5° C (98.6° F), BP 106/54, P 114 and regular, R 22 and shallow. O2 saturation is 96% on RA.·      Reports a pain level of 6/10 in her epigastric area that is cramping and intermittent, “coming in waves.”·      A/O x4, PERRLA, moves all extremities·      Clair states, “I have been nauseated occasionally for the last few weeks on and off. Then this morning I started having severe cramping and vomiting that would not stop. I decided to come into the emergency room when I noticed the blood and the pain got too bad.”·      Lung sounds are clear bilaterally·      Abdomen is soft, extremely tender on light palpation with rebound tenderness and hyperactive bowel sounds in the LUQ, RUQ, and LLQ, and normal in the RLQ.·      Dorsalis pedis pulses are 2+ bilaterally without any dependent edema present.·      IV site: LFA 16 g without redness, tenderness, or swelling. 1000 mL 0.9 NS running at 100 mL/hr on infusion pump.Based on the above information answer the following questions:1.    List a minimum of three pieces of objective data from the initial assessment that support Clair’s admitting diagnosis of acute GI bleed.2.    Define the terms hematemesis, coffee-ground emesis, hematochezia, and melena. Briefly explain when each one might be present in a GI bleed.3.    Identify at least three underlying causes for upper GI bleed.4.    List a minimum of four assessment questions that you as the nurse need to ask Clair during her admission interview on the medical-surgical unit to get a better idea of what may have caused the bleeding.5.    The PCP asks you to check Clair for orthostatic hypotension. Explain what orthostatic hypotension is and what is the rationale for assessing it in Clair?6.    During your interview and assessment of Clair, she shares that she has been taking ibuprofen 600 mg three times a day for the past 3 months because of pain in her left knee following a tennis injury. Explain the significance of this assessment finding to your understanding of Clair’s current condition.7.    The PCP orders hydromorphone 0.2 mg/mL PCA. Why is this medication being ordered for Clair? What is the drug classification of Hydromorphone? What does PCA stand for and how does it work?8.    What patient assessments should be completed before initiating a PCA infusion of hydromorphone on every patient? Place an asterisk next to the highest-priority assessment.9.    Write two nursing diagnoses for Clair at this point in her care and identify short-term goals for each.10. Clair is scheduled for an esophagogastroduodenoscopy (EGD) in 2 hours. Briefly explain the purpose of an EGD.11. List essential post-EGD nursing interventions for all patients undergoing this procedure.Assessment UpdateEGD results note a small tear in the mucosal lining of the stomach and the presence of H. pylori bacteria indicating the presence of peptic ulcer disease (PUD). The tear was cauterized, and Clair’s NG tube was discontinued following the procedure. She is allowed to progress to a soft diet and oral medication and instructed to discontinue use of any NSAIDs without consultation with her PCP. Clair is ordered omeprazole 20 mg bid PO for 4 weeks, clarithyromycin 500 mg bid PO for 14 days, and amoxicillin 1 g bid PO for 14 days. Discharge planning within 48 hours is initiated.12. For each medication, note the drug classification and rationale for prescribing it for Clair.13. Before administering Clair’s first dose of amoxicillin, you call to clarify the order with the PCP. What is your rationale for doing this, and what is the likely outcome of your call? 14. Because Clair was diagnosed with peptic ulcer disease, she requires nutritional guidance. A referral to what member of the health care team would be helpful in providing this information. List at least four considerations that this health care team member will share with Clair to avoid potential exacerbation of her condition.15. Identify a third nursing diagnosis and short-term goal (STG) based on Clair’s new medical diagnosis of PUD. Health Science Science Nursing Share QuestionEmailCopy link Comments (0)