Medsurg- Care Plan PDF

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NUR 322 Nursing Care of the Adult Clinical

NURSING PROCESS CARE PLAN Student Kayla Rowell Date 11/2/2020 NURSING DIAGNOSIS: Acute pain r/t pressure from distended abdomen AEB patient rating pain at a 9/10 on pain scale and states abdominal cramping PRIORITY # 1 ASSESSMENT Subjective and Objective Data Subjective Objective Patient stating a 9 pain level using 0-10 numerical pain rating scale “painful gurgling feeling” “cramping abdominal pain”

Morphine sulfate (3mg) prescribed and administered PRN when pain level greater than 7/10 Distended abdomen Elevated HR of 105 bpm BP- 145/73

PLANNING 1 Client Goal (Goal must be timed and measurable) SMART Patient will use a selfreport pain tool (the numeric 0-10 pain scale) to identify current pain intensity level and establish a comfortfunction goal of below a 3, throughout nurse’s shift.

Interventions (3 Nursing Interventions with Rationale and Reference for each) 1. Nurse will assess if the patient is able to provide a self-report of pain intensity, and if so, assess pain intensity level using a valid and reliable self-report pain tool, such as the 0 to 10 numerical pain rating scale. [Self-report is considered the single most reliable indicator of pain presence and intensity, and singledimension pain ratings are valid and reliable as measures of pain intensity level] (Ackley et al,. 2020, p.677)

O2 sat- 93% 2. Respirations- 20 Small bowel obstruction Large bruise covering the LLQ of abdomen Facial grimacing

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Nurse will administer analgesics around the clock for continuous pain (expected to be present approximately 50% of the day, such as postoperative pain) and as needed (PRN) for intermittent or breakthrough pain. [If pain is present most of the day, the use of PRN medications alone will lead to periods of undermedication and poor pain

IMPLEMENTATION Actual Completion of Nursing Interventions 1.

Nurse assessed the patient’s pain level by using the 0 to 10 numerical pain rating scale. Patient stated pain level as a 9/10. Patient expressed wanting her pain scale to be below a 3.

2.

Nurse administered 3mg IV push of morphine sulfate PRN q4/hr for patient’s intermittent abdominal pain, when patient’s pain level was above a 7/10.

EVALUATION Goal Evaluation (met, not met, partially met and explanation) Yes, patient used the 0-10 numerical pain rating scale to report pain level. Established a comfort-function goal of below a 3. Patient’s pain was a 2/10 after administering analgesic.

NUR 322 Nursing Care of the Adult Clinical

control and periods of excessive medication and adverse effects] (Ackley et al,. 2020, p.678) 3.

Nurse will regularly reassess the patient for the presence of pain and response to pain management interventions, including effectiveness and the presence of adverse effects related to pain management interventions. [Systematic tracking of pain is an important factor in improving pain management and making adjustments to the pain management regimen] (Ackley et al,. 2020, p.678) * Cite all interventions/rationales per APA format

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3.

Nurse regularly reassessed the patient for presence of pain and response to pain management interventions. After receiving an analgesic (morphine sulfate), patient rates pain level as a 2/10.

NUR 322 Nursing Care of the Adult Clinical

NURSING DIAGNOSIS: Nausea r/t bowel obstruction AEB patient reports of nausea and has actively vomiting PRIORITY # 2 ASSESSMENT Subjective and Objective Data Subjective Objective Patient stating, “I am extremely nauseous” Abdominal pain Patient states, “my mouth is watering a lot, I feel like I am going to throw up”

Ondansetron (Zofran) 4mg prescribed and administered PRN q6hr for nausea NG tube placement on low intermitted suctioning Patient vomiting Gastric distention and irritation Morphine sulfate 3mg prescribed and administered for colicky abdominal pain (can cause nausea) CT scan (10/27) showing a small bowel obstruction

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PLANNING Interventions (3 Nursing Interventions with Rationale and Reference for each)

1 Client Goal (Goal must be timed and measurable) SMART Patient will state complete relief of nausea, throughout the nurse’s shift.

IMPLEMENTATION Actual Completion of Nursing Interventions

1.

Nurse will assess and document each episode of nausea and/or vomiting separately and the effectiveness of interventions. Consider an assessment tool for consistency of evaluation. [A systematic approach can provide consistency, accuracy, and measurement needed to direct care. It is important to recognize that nausea is a subjective experience] (Ackley et al,. 2020, p.640)

1.

Nurse assessed patient for nausea and/or vomiting and documented each episode separately and the effectiveness of interventions.

2.

2.

Nurse administered 4mg of IV Zofran, an appropriate antiemetic, according to the emetic cause which was bowel obstruction. No side effects occurred and the medication was administered every 6 hours per patient request.

Nurse will administer appropriate antiemetics, according to emetic cause, by most effective route, considering the side effects of the medication, with attention to and coverage for the time frames in which the nausea is anticipated. [Antiemetic medications are effective at different receptor sites and treat different causes of N&V. A combination of agents may be more effective than single agents] (Ackley et al,. 2020, p.641)

EVALUATION Goal Evaluation (met, not met, partially met and explanation) Yes, patient stated complete relief of nausea during the nurse’s shift, after receiving antiemetics along with using acupressure.

NUR 322 Nursing Care of the Adult Clinical

3.

Nurse will consider nonpharmacological interventions such as acupressure, acupuncture, music therapy, distraction, and slow, deliberate movements. [Nonpharmacological interventions can augment pharmacological interventions because they predominantly affect the higher cortical centers that trigger N&V. Nonpharmacological interventions are often low cost, relatively easy to use, and have few adverse events. The nonpharmacological interventions most likely to be effective include progressive muscle relaxation, hypnosis for anticipatory chemotherapy-induced N&V (CINV), and managing client expectations. Effectiveness has not been established for several other nonpharmacological interventions, primarily because of study limitations, lack of effect in small studies, and inconsistent results] (Ackley et al,. 2020, p.641) * Cite all interventions/rationales per APA format

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3.

Nurse educated patient on the nonpharmacological intervention, acupressure. Nurse demonstrated the technique of applying gentle pressure on P6 and LI4 pressure points to relieve symptoms of nausea.

NUR 322 Nursing Care of the Adult Clinical

NURSING DIAGNOSIS: Risk for electrolyte imbalance r/t nasogastric suctioning PRIORITY # 3 ASSESSMENT Subjective and Objective Data Subjective Objective Patient states, “I’m feeling nauseous” Patient states, “I feel tired and fatigued”

NPO diet ordered Gastrointestinal losses from vomiting and NG tube (low intermitted suctioning) Low potassium serum levels (3.4) Calcium serum levels (8.5) Magnesium serum levels (1.8) Potassium chloride administered Continuous Lactated Ringers solution administered IV Vomiting Increased HR of 110 bpm

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PLANNING Interventions (3 Nursing Interventions with Rationale and Reference for each)

1 Client Goal (Goal must be timed and measurable) SMART Patient will maintain normal serum potassium, sodium, calcium, magnesium and phosphorus levels during nurse’s shift.

1.

Nurse will monitor vital signs at least three times a day, or more frequently as needed and will notify health care provider of significant deviation from baseline. [Electrolyte imbalance can lead to clinical manifestations such as respiratory failure, arrhythmias, edema, muscle weakness, and altered mental status]

IMPLEMENTATION Actual Completion of Nursing Interventions 1.

Nurse monitored patients vital signs three times during the nurse’s shift. Vitals were baseline for the patient so health care provider did not need to be notified.

0800: T- 98.0, P- 79, BP- 132/60, O2sat- 96 1200: T- 98.2, P- 84, BP- 135/65, O2sat- 93

(Ackley et al,. 2020, p.360)

1600: T- 97.9, P- 90, BP- 139/68, O2sat- 94

2.

2.

Nurse will monitor intake and output and daily weights using a consistent scale. [Weight gain is a sensitive and consistent sign of fluid volume excess] (Ackley et al,. 2020, p.361) Nurse will administer parenteral fluids as ordered and monitor their effects. [Rapid resuscitation with fluids can cause adverse effects such as electrolyte imbalance, increased bleeding, and coagulopathies] (Ackley et al,. 2020, p.361)

Nurse monitored intake and output and daily weights using a consistent scale.

Total intake: 985 mL Total output: 860 mL Net: -125 mL Weight: 58.6 kg/129.2 lbs

3.

3.

Nurse administered parenteral fluids as ordered and monitored their effects. No adverse reactions when administered.

Lactated Ringers- 1000 mL, 110 mL/hr

EVALUATION Goal Evaluation (met, not met, partially met and explanation) Yes, the goal was met. Patient maintained normal serum potassium, sodium, calcium, magnesium and phosphorus levels during the nurse’s shift.

NUR 322 Nursing Care of the Adult Clinical

Potassium Chloride- 10 mEq/50 mL * Cite all interventions/rationales per APA format

References Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidencebased guide to planning care. (12th ed.). Elsevier. [VitalSource Bookshelf]. Retrieved from https://bookshelf.vitalsource.com/books/9780323551120

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