Allergies: _________________nka____________________________ The MEDICAL DIAGNOSIS that brought the client to the hospital is: RUQ pain, intercostal pain,
PATHOPHYSIOLOGY of diagnosed disease: (From text)
Hardened deposits of digestive fluids form in the callbladder and make their way into the common bile duct, blocking juices from flowing and inflammation in the ABD
SYMPTOMS typically seen with this diagnosis include (as identified in your text): Fever abd inflammation jaundice abd pain
CLIENTS SYMPTOMS of the diagnosed disease include: Jaundice of the eyes RUQ pain Distended, tender Abd
NUTRITIONAL ASSESSMENT: Height (actual or estimated): __70 inches______ Weight (actual or estimated): 83 kg_______
Does this client have characteristics of a well-nourished person? Yes __X_ No _____ Explain your answer. Client has healthy BMI and looks well nourished
PSYCHOSOCIAL STAGE OF DEVELOPMENT
What is the clients developmental stage? Middle adulthood
Has he/she met the necessary accomplishments? Yes __X__ No _____ Explain. Pt. has wife, children, and grandchildren. He talks about the fun he has with the grandkids.
How is this illness affecting the clients ability to meet these necessary accomplishments? Severe pain prevents completion of ADLs and ability to enjoy the fruits of his labors
NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS Indicate below the 2 priority nursing diagnoses that are most relevant for your client. #1 NURSING DIAGNOSIS (problem r/t) Acute pain r/t obstruction of bile flow DEFINING CHARACTERISTICS (S/S) that support this diagnosis: ABD pain, distended abdomen
OBJECTIVE/CLIENT OUTCOME for this diagnosis: Pt. report that pain mgmt. is effective in maintaining comfort level
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1.Assess pt. for pain routinely and medicate accordingly
2.discuss clients fear of addiction
3.Explain that pain mgmt. approach is temporary and talk about alternative methods of pain control
#2 NURSING DIAGNOSIS (problem r/t) Imbalanced nutrition-less than requirements r/t nausea/vomiting DEFINING CHARACTERISTICS (S/S) that support this diagnosis: Nausea/vomiting, anorexia
OBJECTIVE/CLIENT OUTCOME for this diagnosis: Consume adequate nutrition
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1.monitor intake and record percentage of meals eaten
2.consult nutrition specialist for pt. education
3.offer easy to eat or easy to digest foods.
COMPLICATIONS: If this clients condition were to worsen, what would be the most likely reason and why? Worsening abd pain and jaundice r/t bile buildup or possible infection
How would you know this is happening? Pt. reported pain, worsening jaundice, fever
What will you do if this happens? Check vital signs, consult dr. about situation and assume a blood draw will be ordered
PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS
MEDS/IVs/TX/DIET (Include dose, route, frequency) REASON PRESCRIBED (Drug Classification, What is it treating?) NURSING IMPLICATIONS FROM TEXT (Checking for adverse reactions, preparation & administration concerns) CLIENT DATA FROM YOUR ASSESSMENT (What data is important to know before & after giving) Atenolol 50 mg PO BID
HTN Check bp pulse Monitor EKG Monitor serum electrolytes Causes bronchospasms, hypotension, and fatigue Clonidine 0.3 mg PO QHS
HTN Check bp, pulse No abrupt stopping Assess for HF Zosyn 3.375 GmIVPB Q6
Antibiotic Hypersensitivity Interaction with blood thinners ABN LFTs Lowers WBC Nausea Dilaudid 1mg IVP q3
Pain control
Constipation Dependence CNS depression Check BP and Pulse, Respirations Assess pain Monitor for change of consciousness
Zofran
antiemetic Blurred vision Sob Tachycardia Interacts with tramadol and antipsychotics
Analysis of Diagnostic Tests
DIRECTIONS:
1. List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical treatments (i.e. medications) and provide the patient values for each test. Explain why they are pertinent for this patient.
2. List any screening diagnostic and laboratory tests that are not within normal limits. Explain why these tests are increased or decreased in relation to your patient's medical condition.
Diagnostic/Lab Test Patient Values Analysis of Values
HCO3 20 low COPD, smoker Calcium
8.3 low Malnutrition r/t abd pain ALB
3.0 low Liver dysfunction r/t obstruction of bile duct Bili