John Adams is 55 years of age and is male patient who is admitted to the intensive care unit with the diagnosis of acute esophageal varices bleed. The patient has a long-standing history of alcoholism and cirrhosis of the liver. Six months ago, the patient received an EGD, which diagnosed the esophageal varices. The patient has quit drinking alcohol for the past six months and has been active in Alcoholics Anonymous. The patient has a history of coronary artery disease and angina. The patient has been taking nadolol (Corgard) and isosorbide (Isordil). The admission vital signs include: BP 88/50, P 110, R 26, and T 99°F. The O₂ saturation is 88% on room air and the patient is placed on 2 liters per minute of oxygen per nasal cannula with O₂ saturation of 94%. The patient’s hemoglobin is 6 g/dL, the hematocrit is 12%, and the platelets are 75,000. The patient has a prolonged PT and PTT. The liver profile shows a mild elevation of the aspartate amino-transferase (AST) and the aminotransferase (ALT). The BUN and serum creatinine are also elevated. The patient has in place from the emergency department a nasal gastric tube to low wall suction. The emergency department physician placed a right subclavian triple lumen catheter and there is NS infusing at 100 mL per hour. The emergency department nurse administered vitamin K. Additional orders on the chart from the gastroenterologist include:

 

Based on the given information what would be the Nursing Diagnosis (NANDA)?

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Status NEW Posted 08 Nov 2017 05:11 AM My Price 7.00

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