Stan Checketts Nursing Care Plan PDF

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Stan Checketts Nursing Care Plan: VSIM...

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Pace University Lienhard School of Nursing Nursing Care Plan Name: Pt's Initials: S.C. Age: 52 Gender: Male Diagnosis: bowel obstruction and severe loss of fluids Date: 2/21/21 Assessment Pathophysiology Goals Nursing Diagnosis Nursing Interventions

Chief Complaint: severe abdominal pain, vomiting, nausea,

Subjective: Severe abdominal pain Dizziness Hasn’t urinated since yesterday

Objective: Vomiting Dry mucous membranes Visible abdominal distension and tender to touch Skin was cold and there was a decreased skin turgor Hyperactive bowel sounds

Patient came to the hospital with complaints of severe abdominal pain, nausea and vomiting. His abdominal was distended, poor skin turgor and dry mucous membranes. Doctor ordered a nasogastric tube to low intermittent suction.

Patient was diagnosed with a small bowel obstruction and was given normal saline fluid bolus 500 ml over 30 minutes to

Decompression of the bowel through an NG tube Administration of IV fluids Assessing and measuring the NG output Assessing for fluid and electrolyte imbalance Monitoring nutritional status, and assessing for manifestations consistent with resolution

a. Deficient fluid volume r/t inadequa te fluid volume intake a. Deficient

Fluid replacement Administration of pain and antiemetic medications Maintaining the function of the NG tube

Rationale

Evaluation

The patient is very dehydrated and experiencing hypovolemic shock, so it is important to replace the lost fluids, and prevent further vomiting

Short- term goal: to get the nausea under control. Evaluation: patient was given antiemetics and NG tube to stop nausea and vomiting

Assessing and measuring output of NG tube

Short- term goal: administer fluids Evaluation: patient was given saline bolus

Assessing for fluid and electrolyte imbalance Monitoring nutritional status Assessing for signs of resolution (normal bowel sounds, decreased abdominal distension, improvement in abdominal pain and tenderness, passage of flatus

To make sure the bowel obstruction is resolving, and to ensure improvement

Long- term goal: patient will have improved bowel sounds. Evaluation: patient is being monitored for improvement Long- term goal: monitor patients’ nutritional status Evaluation: Patient hasn’t ate any food yet, but

replace fluids. Initial assessment Heart Rate: 131 BP: 108/77 RR: 29

Buprenorphin e 0.3 mg slow IV push every 6 hours for pain as needed.

SpO2: 90 Temp: 99F

Last assessment of Vital signs: Heart Rate: 116 BP: 106/76 RR: 28 SpO2: 93

Ondansetron for nausea: 48 mg IV every 6 hours as needed

The patient was also experiencing hypovolemic shock due to vomiting

fluid volume r/t inadequa te fluid volume intake Deficient Fluid volume r/t inadequate fluid volume intake

Temp: 99F Fall risk due to dehydration HPI Allergies: Demerol Patient had a hernia repair many years ago as well as an appendicectomy

Acute pain due to bowel obstruction as evidenced by patient’s complaint of abdominal pain

or stool

improvement is being seen

NPO NPO is important because of the vomiting and in case surgery was needed

EP 1/2019; Nursing Care Plan single sheet...