Nursing 206 Care Plan M.P 1.5 year old male

Nursing Assessment Guide STUDENT NAME: Danielle Keasling Pt. Initials: L.L. Rm #: 311 Age: 62 Sex: Male Primary Medical Diagnosis (es): GI Bleed, Anemia, Acute Renal Failure, Hypothrombonemia, DVT Surgical Procedures (this admission; include date): None during this admission Chief complaint: “On Friday afternoon I went to the bathroom to have a bowel movement and I noticed that with my bowel movement I had a lot of fluid around it like diarrhea. So when I finished I checked and the toilet was all full of blood. I then came here because the kidney doctor told me that I could have bleeding in my intestines because my blood count was low. I came here right away because of that. I was really worried. Then from the ER they brought me up here. HISTORY OF PRESENT ILLNESS: Briefly summarize events (including time frame) leading up to admission. Presented to the Emergency room on 10/16/09, following an episode of lower abdominal pain followed by a bloody stool. He was admitted to the third floor for GI bleed and management of his s/s of GI bleed. He was scheduled to have a colonoscopy on 10/19/09 following a normal CT scan that was determined inconclusive of any pertinent findings. He was diagnosed following the colonoscopy on 10/19/09 with bleeding diverticuli and abdominal seroma. MEDICATION ORDERS: List ALL medication orders. Include dose, route, frequency & time of