MR. WATERS
1. Problem: Risk for Bleeding related to Active fluid volume loss/hemorrhage as evidence by epistaxis.
Action Plan: Administer Vitamin K Subq
Rationale: Vitamin K is the antidote for Coumadin, but the treatments must be done carefully. If too much vitamin K is given, this can reverse the effect of Coumadin to the point that it is no longer effective for preventing blood clots. If too little is given, the risk of bleeding will persist. A careful balance in which both the vitamin K and Coumadin do not outweigh each other.
Goals: Bleeding will cease. Blood pressure will increase. Heart rate will decrease.

2. Problem: Risk for falls related to HTN as evidence by syncope episode
Action Plan: Remove all clutter from room, instill fall precautions (yellow socks, sign, yellow wrist band), enable bed alarm, instruct patient to not get out of bed, keep call light in reach for patient.
Rationale: Will have more room to walk and less likely to fall, signs and precautionary measures show others that patient is a fall risk, patient is instructed to not get out of bed without using the call light for assistance to prevent any falls that’s why the call light is placed in reach and bed alarm is enabled just in case, for my own precautionary measures.
Goals: Patient will be free of falls

3. Problem: Fatigue related to CAD as evidence by irritability of pt and pt states “I just want to sleep.”
Action Plan: Have pt discuss his realistic activity goals, plan care to allow individual adequate rest periods, schedule activities for periods when client has the most energy, instruct patient to have a nightly routine before bed and try not to alter that routine.
Rationale: Pt will be less irritable if has adequate sleep, the more energy the patient has from having the periods of the rest the more at ease and calm he will feel.
Goals: Lessen fatigue, to encourage pt participation, to encourage patient’s cooperation, to help the patient calm and night and not fatigue so quickly throughout the day.

4. Problem: Ineffective Tissue Perfusion related to impaired circulation as evidence by HTN.
Action Plan: Maintain bed rest, elevate the head position in bed, Assess blood pressure at admission in both arms, sleeping, sitting with arterial pressure monitoring if it is available. Measure the input and discharge. Ambulation within pts means and avoids fatigue in patients. Monitor electrolytes, creatinine according to medical advice. Maintain fluids and medications according to medical advice.
Goals: The circulation of the body is not impaired. Pt will demonstrate an improved tissue perfusion as indicated by: blood pressure within acceptable limits, no complaints of headache, dizziness, and lab values within normal range.

5. Problem: Risk for infection related to hemorrhage as evidence by active bleed and open areas.
Action Plan: Stop the bleeding with Vitamin K. Monitor daily lab value. Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature.
Goals: Pt will remain free from symptoms of infection. Pt understands symptoms of infection of which to be aware. Pt will demonstrate appropriate care of infection-prone site. Pt will maintain white blood cell count and differential within normal limits. Pt will demonstrate appropriate hygienic measures such as hand washing, oral care, and perineal care.

This situation with Mr. Waters could have all been avoided if the nurse had performed all her duties as expected. The nurse should have never given the drugs to Mr. Waters because she wasn’t the one who opened them which means she wasn’t able to check her 5 rights. This can cause a huge issue. Also the nurse administered his Lipitor medication with all the other medications. Cholesterol medications are not supposed to be given with any other medication. It acts as a glue and binds all medications together thus making some not work as