Question: What Would Be The First Three Nursing Diagnosis For A Conceptual Map With Evidence ?

Abdominal Assessment Scenario Mr. TM is a 71 year old admitted to room H-523 with a GI Bleed. VS=B/P 100/60 TPR=37°C 100-20. Pulse Ox= 96% RA. Pain 7/10 do abdominal discomfort. Color pale, skin warm & dry. Braden = 21. A&O x 4, PERRLA, MAE X 4. Hand grip = & weak. Unsteady gait when ambulating. Needs assistance of 1. Denies numbness or tingling to extremities. Lungs clear vesicular sounds. No cough. PPP x 4 @ +2, No edema, No JVD. CR <3 sec. Abdomen hyperactive BS in all four quadrants. Abd soft; Clo abdominal tenderness to RUQ & LUQ upon palpation. No distention. Negative rebound. Black tarry stool e visible blood. Pt clo diarrhea x 2 days. No clo nausea. Foley catheter inserted to straight drain c clear amber urine. Falls precautions dit weakness. History of GERD and depression Stat EGD completed. Results of biopsy pending. Pt. states he is afraid of results of biopsy. CXR is normal. I Lab results: Na+ 132 K+ 3.2 C- 97. Bicarb 23 BUN 10 Creatinine 0.9 Blood glucose 100 WBC= 6,200 Hbg = 7.8 Het = 36% Platelets = 224,000 Dr’s orders: Insert foley catheter. Type & cross match for 2 units PRBCS: BR CBRP. SCDs while in bed. IV 0.9% Normal Saline infuse @ 50 ml/hr to L-antecubital s redness or swelling. I & O; NPO except for po meds: May give small sips of H20 with meds only. esomeprazole magnesium 20 mg tab po daily hydromorphone 1 mg IVP 94h prn pain venlafaxine 75 mg po daily.