Student name:Charlene Springstead Instructor: Nakamura Patient Education / Discharge Planning: (Barriers to education, learning goals, learning outcomes) (Home Vs Facility, servicesneeded after discharge, adaptive equipment needed for home.) Erikson’s Developmental Stage Related to Pt & APA citations Cultural Considerations: Ethnicity, Occupation, Religion, Family Support, Financial Considerations. History of Present Illness (OLDCART): (Onset, Location, Duration, Character, Aggravating, Relieving, Temporal) Pathophysiology of Admitting Dx with APA references: Previous Medical History: (How does the current diagnosis affect the pre-existing medical conditions) Previous Surgical History: Patient Information Name: MUV Age: 71 years old Gender: Male DPOA: N/A Living Will: N/AHt: 175.26 cm Wt: 104.32 kg Chief Complaint Admitting Diagnosis: Diagnostic Tests / Lab Result w/ Dates and Normal Ranges (Prioritize tests that prove the admitting diagnosis exists/is correct) Plan of Care: Abdominal pain and rectal bleeding Gastrointestinal Bleeding Patient is currently in the Integrity vs. Despair stage of psychosocial development. During this stage, life starts to slow down. The individual is typically retired and they start to reflect over their accomplishments throughout life. If they feel that they have led a productive life, they achieve integrity. However, if they feel that their life was unproductive and that they did not achieve their goals, they will feel despair. These individuals may feel very depressed. If the patient succeeds this stage, they will develop the virtue of wisdom. This allows them to feel closure at the end of life and allows them the ability to accept death (McLeod, 2013). -Total left hip arthroplasty -Bilateral glaucoma surgeryAt about 0300 hours on 11/30 patient started to feel severe abdominal pain, especially on the left lower quadrant and had loose bowel movements followed by black stools. Pain is sharp and constant with a pain level 8/10. Patient claims that he has been having dark stool with signs of blood recurring for the last couple of days. Aggravating factors for his pain include sitting up or when pressure is applied to the area and the relieving factor is his pain medication. Patient has a known history of colon polyps and diverticulosis, which has been seen on previous colonoscopies. He claims that he has no diarrhea. When he was admitted at the ER on 12/1, he had a slight fever. Gastrointestinal bleeding is typically caused by a number of disorders of the gastrointestinal tract. Some of these conditions include peptic ulcers, IBD, diverticulosis, colon polyps, cancerous tumors, and hemorrhoids. When gastrointestinal bleeding occurs, blood appears in the stools or vomit. When in the stool, it may be hidden or it may make the stool look bright red or black & tarry, depending on which part of the GI tract the bleeding is coming from. Bleeding that occurs in the colon tends to be a brighter red and that of the stomach tends to be dark and tarry, as it has gone through the digestion
