Richard J. Daley College
Nursing 101 Data Collection for Care Plan

Section I – Demographic Data:
Patient Initials: K. J. Sex: Female MSWD: Married
Age: 44 No. of children: 1 Occupation: Disabled

Section II- Admission Data
1. Date admitted: 10/19/2007
2. Admitting diagnosis: Hematomesis, melanotic stools, cirrhosis, hepatorenal syndrome.
3. Allegries: Codiene
4. Signs and symptoms on admission: jaundice appearance, lethargic, oriented x 1, vomiting bright red blood, has had black stools.
5. Summary of History and Physical on admission: Patient has a history of hepatitis C, alcohol abuse, cirrhosis, GI bleed, pancreatitis. Patient was lethargic, with mental status changes. Patients appearance is jaundice, stomach
When this happens, an electrolyte imbalance, or disorder, results. This patient was having mental status changes, weakness, fatigue, which often happens with hypokalemia.
Nursing Responsibilities:
Expalain to the patient why the specimens are being collected. Tell the patient that no fasting or diets are required for this test. Collect specimen label approprietely and submit to lab. Notify the attending physician for this patient’s with abnormal results.
Section V- Theraupetic Treatments:
Treatment- A naso-gastric tube was inserted.
Patient at admission had hematemesis which is an indication of internal bleeding.
Rationale-This was placed to monitor how much blood was being lost.
Results: The naso-gastric