Sei sulla pagina 1di 6

Patient Initials: A. G.

Age: 87 Diet: Clear liquid diet Bath/shower: Bed bath Activity Level: ambulate with assistance Nurse on duty: Nahomy D CNA on duty: Catrena DNR status: Full Code Allergies: Sulfa drugs, Meperidine Diagnosis: (Include Patient history) A.G. is an 87 yr old woman who arrived at the hospital with a 3 day history of intermittent abdominal pain, abdominal bloating, and n/v. She speaks very little English and lives with her grandson. Small Bowel Obstruction (SBO) secondary to adhesions History: colectomy for colon cancer 6 yrs ago, ventral hernia repair 2 yrs ago. No history of CAD, DM, or pulmonary disease. Pathophysiology: (define the disease process) SBO- any obstruction that results in failure of the contents of the intestine to progress through the lumen of the bowel. Obstruction of the small bowel may cause severe pain, vomiting of fecal matter, dehydration, and eventually a drop in blood pressure. Adhesion: in the abdominal cavity, usually involving the intestines, caused by inflammation or trauma. If adhesion causes great pain or intestinal obstruction, they are removed surgically. Treatments and Therapies/Nursing Interventions: Ibuprofen for Arthritis, 3 days of NGT for suction, Cl O2/NC, measure and record total I & O every shift for vomiting, consider alternative therapy such as ginger and peppermints for nausea. Vital Signs: Temp. 97.8 References: Lab and Diagnostic Test, 8th Edition, pg 204, 212, 352, 357 Coxs Clinical Applications of Nursing Diagnosis, 5th Edition, Newfield, Hinz, Tilley, Sridaromont, Maramba, pg. 161, 189, 240 Tabers Cyclopedic Medical Dictionary, Edition 20, F. A. Davis Company, pg 49, 1616 Daviss Drug Guide for Nurses, 11th Edition, Judith Hopfer Deglin, April Hazard Vallerand, pg 640, 996, 1017, 1372 Pulse: 75 BP: 118/90 Respirations: 20

Medications (For this clinical experience, please pick 5 medications related to your patients diagnosis and complete the form below) Medication Name (trade and generic name) Phenergan/ promethazine Dilaudid/ hydromorphone Dosage Is this a safe dose? Frequency Route (How do you give it?) IV Classification and Primary Action of Medication (Why is this patient receiving this drug?) Therapeutic: antiemetics Pharmacologic: phenothiazines For nausea Therapeutic: allergy, cold, and cough remedies (antitussives), opioid analgesics Pharmacologic: opioid agonists For pain Mineral and electrolyte replacement. Maintain acid base balance, isotonicity Nursing Implications/Side Effects (What should the nurse do prior to giving any medication and especially this medication?) Assess patient for nausea & vomiting before and after admin. Assess BP, pulse, & respirations before and periodically during administration. Assess type, location, and intensity of pain prior to and 5 min following IV admin. Assess for signs and symptoms of hypokalemia (weakness and fatigue), abdominal pain, vomiting, nausea

25mg

Yes

Q4hr prn

2mg

Yes

Q4hr prn

IV

KCL IV D5 1/2NS/ Potassium supplements

20meq

Yes

Q4hr prn

IV

Labs Lab name/test (ex. Chemistry, hematology/Na+, K+, Hct, Hgb) Protein albumin Glucose Creatinine BUN Co2 CL Potassium (k) Sodium (Na) Normal values (What is the reference range?) 6.8 3.0 126 1 19 25 108 3.7 136 Lab Value (What is the patient result?) 4.9 g/dL 2.1 g/dL 65 mg/dL 2.2 mg/dL 38 mg/dL 31 mmo/L 97mmol/L 2.5 mmol/L 130 mmol/L Significance of the Lab result (What are the nursing implications?) Losing protein Assess with skin turgor Malnutrition Assess for peripheral edema lower extremities Instruct the client to take insulin or oral hypoglycemic agent Dehydration Increased creatinine Increased BUN Increase CO2 Dehydration Decreased potassium Vertigo/dizziness Confusion

NANDA Nursing Diagnosis Nausea r/t (SBO), adhesion AEB vomiting

NOC Expected Outcomes Will self report no nausea within 2 days

NIC Interventions 1. Try small frequent feedings, drink fluids between meals 2. Consider alternative therapies such as ginger, peppermint, or cinnamon 3. Avoid greasy fatty meals 1. Record amount, color and consistency of feces following each bowel movement. Question the client regarding bowel movements at least once per shift. 2. Monitor and record symptoms associated with passage of bowel movements, straining, pain, or headache, any rectal bleeding or tissues 3. Assist the client with implementation of stress reduction techniques at least once per shift 1.

2. 3. 1.

Acute pain r/t risk for constipation

Will return as nearly as possible to usual bowel elimination habits by two days

2. 3.

Rationale for Interventions Reduces the amount of food in the stomach and avoids the feeling of fullness Alternative treatment to calm the stomach Greasy foods promote nausea Basic assessment of problem severity as well as monitoring effectiveness of therapy Allows early detection of additional problems Promotes relaxation and can increase feces passage through the intestines

Evaluation Resident is free from nausea and eating well

Patient is back to usual bowel elimination habits

Risk for fluid volume deficiency r/t nausea and vomiting AEB vomiting

Intake and output will balance within 200mL by today

1. Take vital sign every 2 hours on the hour and include apical pulse 2. Measure and record total I & O every shift 3. Weigh daily at the same time. Teach the patient to weigh each day with the same clothing

1. Essential to Intake and output balanced monitoring of cardiovascular response to illness state and replacement therapy 2. Determines extent of fluid loss need for replacement or progress of replacement therapy 3. Monitoring for fluid replacement. Allows consistent comparison of weight

Nurses Notes

Potrebbero piacerti anche