Dana Hupczey Nursing 204 Physical Safety

Skin: warm, dry, intact. No lesions, no petechiae, no ecchymosis, no ulcers, mucous membranes pink moist Body Temperature: warm 0700-98.0 1400-98.2 Hair: brown, even distribution, no alopecia Head: normocephalic, facial movements symmetrical Neck: no vein distention, trachea midline, full ROM Eyes: symmetrical, sclera white, pink conjunctiva, PEARL Ears: canals clear, no redness, no discharge Nose: no nasal flaring, no drainage, septum intact with no deviation Lips,mouth,throat: oral mucosa pink moist no lesions, swallow and gag reflex intact Breasts: symmetrical, no masses, no nipple discharge Abdomen: Distended, soft, rounded, painful upon palpitation, bowel sounds present all quadrants Restraining Devices: none Nameband: on Allergies: NKA Pain: 0900- c/o states pain 8 on 1-10 scale, medicated with Dilaudid 2mg IVP, reassessed at 1000-states pain at 6 on scale 1-10. 1230c/o lower back and upper gastric pain states pain 7 on 110 scale, medicated with Tramadol (Ultram) 25mg, reassessed at 1330- states pain at 4 on scale 1-10 with moderate relief IV: IV infusing NSS 100ml/hr without evidence of trauma, dressing intact Labs/Diagnostics: PT 11.2 PTT 32 INR 1.12 Platelets 224Medications: Potassium Chloride ER 40meq daily for low potassium, Propranolol (Inderal) 20mg BID for HTN , Spironolactone (Aldactone) 100mg daily for fluid retention rt cirrhosis, Metolazone (Zaroxolyn) 25mg daily for fluid retention, Furosemide (Lasix) 40mg daily for fluid retention, Insulin Glargine (Lantus) 65units AM+HS for DM2, Omeprazole (Prilosec) 40mg daily for acid reduction, Insulin Lispro (HumaLOG) sliding scale for DM2, Nortriptyline (Pamelor) 25mg BID for depression, Dilaudid 2mg IVP for severe pain, Tramadol (Ultram) 25mg prn for moderate pain, K-Rider 100ml/hr 3x stat for low potassium, Ampicillin-sulbactam in NSS 1.5g IVPB 50ml q6h over 30minutes for infection.

UGI Bleed Acute Cholecystitis Oxygenation Vital Signs: 0700- 98.0 72 18 109/56 92%RA 1400 98.2- 80 -18 -105/60 94%RA Skin: warm, pale, dry Chest:symmetrical,nontender, no deformities. Lung sounds decreased bilaterally, breathing regular and unlabored O2/PulseOx/Spirometry: room air, pulse ox 0700 92% encouraged to take deep breathes, 18 1400 94% assisted with use of incentive spirometry, 18 Cough: noneSecretions:noneBlanching/Clubbing: no clubbing, cap refill within normal range at <3secs Danger signs: none Labs/Diagnostics: Duplex of liver 2/18 cystic duct obstruction Upper GI Endoscopy 2/15 no active bleeding, mild Schatzki ring External Gallbladder tube placement 2/19 CBC 2/19 WBC 13.09 (4.8-10.8) infection, RBC 4.5 (4.2-5.4), HGB 14 (12-16) HCT 40 (37-47) Medications: Dilaudid 2mg IVP for severe
pain, Tramadol (Ultram) 25mg prn for moderate pain, K-Rider 100ml/hr 3x stat for low potassium, Ampicillin-sulbactam in NSS 1.5g IVPB 50ml q6h over 30minutes for infection, Propranolol (Inderal) 20mg BID for HTN, Metolazone (Zaroxolyn) 25mg daily for fluid retention, Furosemide (Lasix) 40mg daily for fluid retention

Mrs Noss T.K. Activity, Rest, Sleep Posture/Gait/Curvatures: posture straight, gait steady, no sign of curvatures Extremities: +5 muscle strength bilaterally upper and lower extremities, full ROM. +2 edema lower extremities bilaterally Contractures: none ADLs: Ax1 with all ADLs Assistive Devices: nonskid footwear Sleep Patterns: Undisturbed, 8 hours per night Pain:
0900- c/o states pain 8 on 1-10 scale, medicated with Dilaudid 2mg IVP, reassessed at 1000-states pain at 6 on scale 1-10. 1230- c/o lower back and upper gastric pain states pain 7 on 1-10 scale, medicated with Tramadol (Ultram) 25mg, reassessed at 1330states pain at 4 on scale 1-10 with moderate relief Medication: see

medications under physical safety

Dana Hupczey Nursing 204 Elimination Bowel: Distended, soft, rounded, painful upon palpitation, bowel sounds x4, last BM at admission Bladder: voids in urinal, yellow urine, output 500 mL Vomitus: none Gastric Suctioning: none Menses: none Diagnostics/Labs: Urinalysis specific gravity 1.019 (1.005-1.013), pH 6.0 (5-8), protein-glucose-ketonebilirubin-blood negative Medications: Soluable Fiber oral powder 1 packet daily for constipation, Docusate Sodium (Colace) 100mg BID for constipation, see medications under physical safety

UGI Bleed Acute Cholecystitis Nutrition Height: 511 Weight: 235.4 Appetite/Diet: NPO, strong appetite with cravings for food. Non-compliant with NPO status Condition of hair/nails: Dark, even distribution I&O: IV 1500ml, voiding 500ml Diagnostics/Labs: 2/19 Glucose 0800 143 1000-134 1200-61 1230 157 1400 145 1600-137 2/19 Chloride 3.6 (3.55.1), CO2 102 (98-107), Anion Gap 31 (22-29), Calcium 10.6 (7-16) Medications: Potassium
Chloride ER 40meq daily for low potassium, Spironolactone (Aldactone) 100mg daily for fluid retention rt cirrhosis, Metolazone (Zaroxolyn) 25mg daily for fluid retention, Furosemide (Lasix) 40mg daily for fluid retention, Insulin Glargine (Lantus) 65units AM+HS for DM2, Omeprazole (Prilosec) 40mg daily for acid reduction, Insulin Lispro (HumaLOG) sliding scale for DM2, Dilaudid 2mg IVP for severe pain, Tramadol (Ultram) 25mg prn for moderate pain, K-Rider 100ml/hr 3x stat for low potassium

Mrs Noss T.K. Psychosocial Well-being LOC/Communication: alert and oriented x3, non-receptive to communication, yells freely Social History: 58 white male, married, discontinued tobacco use 2011, alcoholic last drink 12/31/12 Family/visitors: No visitors, lives with wife Psychiatric history: client has history of depression Code level: full code Diagnostics / Labs: Home Care consult 2/19 Medications: see medications under physical safety Nortriptyline (Pamelor) 25mg BID for depression

Dana Hupczey Nursing 204

UGI Bleed Acute Cholecystitis

Mrs Noss T.K.

Nursing Diagnosis: Acute Pain related to gallbladder inflammation as evidenced by verbal report of pain, discomfort, generalized weakness and Goal Client will report relief of pain at <5 on scale of 1-10 and ambulate 15ft during my tour of duty 0700-1600 on 02/19/13.
Implementations

1. Assess pain characteristics each shift. Reassess each time pain occurs/is reported. a) Quality b)Severity (1-10 scale) c) Anatomical location d) Onset e) Duration f) Aggravating factors g) Relieving factors 2. Teach client about using nonpharmacological pain management strategies. a) cold application b) heat application c) massage therapy d) relaxation techniques and imagery e) distraction 3. Administer and document analgesics as ordered every shift. 4. Maintain NPO status each shift. 5. Increase activity gradually by a) mutually setting goals for activity schedule b) collaborating with health care team including physical therapy, occupational therapy, and exercise physiologist c) allowing for rest periods d) allowing patient to set pace e) increasing tolerance by increasing mobilization time every day 6. Promote energy conservation every shift by a) scheduling rest periods during activity and at intervals throughout the day b) resting 3 minutes for every 5 minutes of activity c) stopping for perceived increase in heart rate, dyspnea, or chest pain 7. Provide active and passive ROM exercises to unaffected area every two hours as ordered. 8. Assist with use of respiratory devices and treatments every shift (deep breathing exercises, incentive spirometry, prescribed inhalers).

Rationales
1. Gathering information about the pain can provide information about the extent of the pain. (Mosby 127) 2. Knowledge about how to implement nonpharmalogical strategies can help the client gain maximum benefits from the interventions. (Mosby 128) 3. The distribution of ordered analgesics helps to maintain an acceptable level of pain. (Doenges 590). 4. NPO status decreases stimulation of gallbladder. (Holloway 663) 5. Activity should be planned based on the patients knowledge of activity demands, values, beliefs, and perceived ability. Tolerance develops by adjusting frequency, duration, and intensity until desired activity level is achieved. Frequency is increased first followed by intensity and duration. (Holloway 663) 6. Interventions should be directed at delaying the onset of fatigue and optimum muscle efficiency. Symptoms of activity intolerance are alleviated with rest. (Holloway 663) 7. ROM promotes muscle tone, circulation, and a feeling of well-being. They also prevent contractures. (Holloway 607) 8. Various therapies may be required to acquire and maintain adequate airways, improve respiratory function and gas exchange. (Doenges 82)

lack of ambulation.

Evaluation: Goal met: Client reported pain at a level of 4 and ambulated 25 feet during my tour of duty 0700-1600 on 2/19/13.

Dana Hupczey Nursing 204

UGI Bleed Acute Cholecystitis

Mrs Noss T.K.

Nursing Diagnosis: Knowledge deficit related to primary diagnosis (Cirrhosis) as evidenced by lack of interest in learning. Goal Client will verbalize understanding of condition, disease process, and appropriate changes in lifestyle and behaviors, including eating patterns, food quality/quantity, and exercise program during my tour of duty on 2/19/13 from 0700-1600. Implementations 1. Assess risk or presence of conditions associated with Cirrhosis. 2. Determine clients ability, readiness, and barriers to learning. 3. Identify motivating factors for the client, specifically the abstention of alcohol in relation to disease process. 4. Provide mutual goal setting and contracts. 5. Provide written information or guidelines and self-learning tools for client to refer to. 6. Help client cope with anxiety or other strong emotions. 7. Include family members/support system in learning process. Rationales
1. The assessment of preexisting conditions and risk factors helps to ascertain treatments or interventions that may be needed.(Doenges 571) 2. Individual may not be physically, emotionally, or mentally capable at the time and may present specific barriers. (Doenges 496) 3. Motivating factors that are put into perspective for the client can provide the client with the push needed to stick with a specific plan of care and keep the disease process at bay. (Doenges 497) 4. Setting goals provides a model for the client to follow and clarifies expectations. (Doenges 498) 5. These methods reinforce the learning process and allow the client to proceed at own pace. (Doenges 498) 6. Emotions and anxiety may interfere with the clients ability to learn (Doenges 499) 7. The support system/family plays an important role in patient teaching and compliance. These members can aid the patient in further understanding and positive reinforcement. (Doenges 499)

Evaluation: Goal not met- Client was unwilling to change any behaviors in relation to eating patterns, food quality/quantity, and exercise programs

and was unable to verbalize understanding of disease process during my tour of duty 2/19/13 from 0700-1600.

Dana Hupczey Nursing 204

UGI Bleed Acute Cholecystitis

Mrs Noss T.K.

Nursing Diagnosis: Risk for Infection related to increased environmental exposure and invasive procedures as evidenced by external biliary drainage tube. Goal Client will remain free from symptoms of infection during my tour of duty on 2/18/13 from 0700-1600 Implementations Rationales 1. Monitor client every shift for signs of infection 1. The constant monitoring for signs and symptoms of infection will including reduce instances of infection and complications. (Doenges 468) a) redness 2. Each of these represents a break in the bodys normal first lines of b) swelling defense, the skin. (Doenges 468) c) increased pain 3. The early detection of signs and symptoms of infection leads to d) elevated temperature aggressive measures which reduces the complications associated with 2. Assess for presence, existence of, and history of risk infection. (Doenges 468). factors such as open wounds and abrasions, in-dwelling 4. Sepsis is a severe complication of infection and can lead to shock and catheters, wound drainage tubes, and venous/arterial death. It is systemic and affects the entire body. The prevention of this is access devices every shift. key in relation to infection. (Doenges 468). 3. Observe for localized signs of infection at insertion 5. Rising white blood count (WBC) indicates bodys efforts to combat sites of invasive lines, sutures, surgical incisions, and pathogens (normal is 4000-11000). Very low WBC indicates the risk for wounds every shift (redness, inflammation, drainage) infection because client does not have sufficient WBCs to fight 4. Note signs and symptoms of sepsis which includes infection. (Doenges 468). fever, chills, diaphoresis, altered level of consciousness, 6. Clients with poor nutritional status may be anergic, or unable to and positive blood cultures every shift. muster a cellular immune response to pathogens and are therefore more 5. Monitor CBC, urinalysis, and labs, focusing on white susceptible to infection. (Doenges 468) blood count every shift. 7. Handwashing is a first-line defense against healthcare-associated 6. Assess nutritional status, including weight and serum infections and infection in general. (Doenges 468). albumin every shift. 8. This reduces the risk of cross contamination and the spread of 7. Teach proper hand hygiene to client and family infectious material. (Doenges 468) members and stress importance of it every shift. 9. This aids in the movement of respiratory secretions and prevention of 8. Emphasize proper use of personal protective aspiration/respiratory infections. Early ambulation also improves skin equipment (PPE) by staff, client, and visitors, as integrity by promoting movement and prevents contractures. (Doenges indicated by agency policy every shift. 468) 9. Encourage early ambulation, deep breathing, 10. Overall good hygiene reduces the risk of infection by preventing coughing, frequent position changes and ROM exercises microbes and other pathogens from existing on bodily surfaces. every 4 hours or as ordered. (Doenges 470) 10. Teach client importance of maintaining proper hygiene including oral care, perineal care, and overall bodily washing every shift. Evaluation: Goal met Client remained free from symptoms of infection during my tour of duty on 2/18/2013 from 0700-1600.