Need nursing dx for 86y/o that presents to ER with head lac with satuated dressings and EMT’s unable to stop?
Head lac unable to stop blood, pt. has hx of HTN, Arteriosclerotic heart disease, atrial fibrillation, eczematous dermatitis of legs, recurrent UTI Vital signs are BP 150/98 (H), pulse 120 rapid, Resp 24 fast. pO2 is 98%normal he weighs 130 pds. at 5 ft. 10in. He is bleeding profusely 3inch gash over right ear coming in spurts that match his pulse. He is anxious, restless, and combative but alert and orient to place and person. What is his main problem? What will kill him on my shift? Blood volume deficit? Fluid volume Deficit? Need primary NANDA? Any help is appreciated!
Your patient has an arterial bleed. Primary concern is going to be to stop the bleeding. Will take a while to bleed out (even though it looks bad), but a liter of fluids may be warranted. Extremely unlikely that he will die on your shift as a result of this hemorrhage unless all staff present are incompetent and cannot stop the bleeding. (And I’m talking really retarded here if this is his only bleed.)
Other considerations will revolve around identifying the cause of the injury (why he was injured, besides how) and determining if his currently mental status is normal for him or altered. If altered, then determine why and treat.
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