Problem
A 15-year-old female presents to the ED with complaints of fatigue, stomach pain, and vomiting for 3 days. The patient reports that his emesis appears brown and granular, similar to coffee grounds, and her stool is red and tarry.
Upon assessment, the patient appears pale and lethargic. she complains of 8/10 stomach pain and says that the pain is worse when his stomach is empty. Her heart rate is 107 BPM, blood pressure is 91/43 mmHg, respiratory rate is 22 breaths per minute, and oxygen saturation is 96% on room air. The patient is alert and oriented and lung sounds are clear.
The patient's CBC reveals low hemoglobin and hematocrit of 7.2 g/dL and 24.2% respectively. A stool sample is sent and the stool guaiac test is positive for occult blood. In addition, stool culture detects Helicobacter pylori. An endoscopy is performed, confirming the presence of a stomach ulcer.
The patient is admitted to the hospital with an Upper GI Bleed.
For the problem statements, you need to ask, "What issue could kill this patient if not addressed"? The problem needs to be a current issue, not something that has already been addressed, like surgery. The interventions need to be NURSING interventions. Nurses cannot perform surgeries, order medications or labs, etc.