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Date of Care _10/24/2014__

Faculty Initials
Texas Womans University College of Nursing
N3005 Preclinical Information and Care Plan
BAIN CLINICAL GROUP
PAGES 1-3 TO BE COMPLETED PRIOR TO PATIENT CARE

Student Name _Thi Thu Thao Ho__


Diet _Regular__

Unit _Med/Surg__

Code status: Full OR DNR

Rm # __874

Age _44__

PT INITIALS _HR__

ALLERGIES _NKDA__

M/F__M___ Nurse/Precepted by: _Samantha Liu___

Admitting Diagnosis _____Postoperative fever and abdominal pain____________________


Surgical Interventions during this hospitalization with date _Laparotomy exploratory, repair of perforated gastric ulcer on 10/3/2014
History of Present Illness: the pt is a 44 yo male who was recently admitted by Dr. Meyers and underwent laparotomy with primary
closure of perforated gastric ulcer on 10/3/2014. He was discharged on 10/10/2014. Came in with the above chief complaint. The pt was
seen by Dr. Meyers 5 days ago in the office, and abdominal drain was removed 2 days after the drain removal, the pt was noted to be
having fever which was maxed to 102 F yesterday (10/20/2014). He was complaining of abdominal pain. No nausea, no vomiting. No
diarrhea. But, having some chills. The pt was complaining of worsening pain when he lies down. No chest pain. No shortness of breath.
No cough
Past Medical History: Gastric ulcer with perforation

Past Surgical History: Laparotomy exploratory, repair of perforated gastric ulcer, Grahams patch on 10/3/2014

Pathophysiology of the Patients admitting disease process and Surgical procedures (if applicable): (Describe the disease process and
clinical signs and symptoms you would assess for). List your references.
A peptic ulcer is an open sore or raw area in the lining of the stomach or intestine. Most ulcers occur in the first layer of the
inner lining. A hole that goes all the way through the stomach or duodenum is called a perforation. A perforation is a
medical emergency.
Abdominal pain is a common symptom. The pain can differ from person to person, and some people have no pain.
Other symptoms include:

Feeling of fullness and problems drinking as much fluid as usual

Hunger and an empty feeling in the stomach, often 1 - 3 hours after a meal

Mild nausea that may go away with vomiting

Pain or discomfort in the upper abdomen

Pain in the upper abdomen that wakes you up at night

Other possible symptoms include:

Bloody or dark tarry stools

Chest pain

Fatigue

Vomiting, possibly bloody

Weight loss

(http://www.nlm.nih.gov/medlineplus/ency/article/000206.htm)
Laparoscopic Surgery
The traditional management of a perforated duodenal ulcer has been a Graham Omental Patch and a thorough abdominal
lavage. More recently this has been shown to be able to performed using a laparoscope. The only proven advantage of the
laparoscopic technique appears to be decreased postoperative pain. Operating times are longer compared to open
techniques and hospital time appears to be similar to conventional treatment. This technique has not been subjected to any
large prospective trials and at present must not be considered as standard management. Of note several groups have
demonstrated the feasibility of laparoscopic definitive ulcer surgery (Grade A/C).
(http://www.ncbi.nlm.nih.gov/books/NBK6926/)

Standard Nursing Plan of Care for this diagnoses (refer to Gulanick/Myers Nursing Care Plans Text and list references)
List at least 5 interventions
Describe & reference the
rationale for each intervention
1. Assess respiratory system, incentive spirometer, semi fowlers
position, deep breathing, coughing to help prevent pneumonia
2. Manage pain, administer pain meds on a timely manner so
the pain does not get above 4. Have patient ambulate and
reposition so the drain site can stay open and free keeping the
muscles lose, preventing them from tightening up
3. Teach about antibiotic and finishing all meds, monitor labs
WBC, CRP, check for infection, check incision and drainage

1.Monitor for othostatic changes in vital signs and tachycardia


2. It is easier to maintain a pain level than it is to lower it back
down when it gets high.
3. it is important to complete all antibiotics so that the microbes
are killed off and do not for resistants to those antibiotics.
CBC to check for any bleeding abnormalities
4.Teach about home care, daily activities, diet, restrictions and
follow-up

4.Instruct patient regarding disease progress


5.They are causes of gastric ulcers and aggravates them
5. Teach about smoking and alcohol consumption

http://nursingcareplanpepticulcer.blogspot.com/2005/11/nursingcare-plan-to-client-with.html?m=1

Medications List all meds including 3 most frequently used PRN meds ONLY ONE PAGE PAGE +ALLERGIES:
Drug Name, dose, route,
Drug Classification,
Specific reason your
Side effects and nursing
frequency, and time of
i.e. beta blocker or
patient is taking this
implications which you will

Nursing considerations to
be done before

administration
(list Routine medications
first)
Acetaminophen (Tylenol)

proton pump inhibitor


Analgesic, antipyretic

drug (indication)

monitor the patient for

administration of
medication

Mild to moderate pain

-Thrombocytopenia,

Check platelets, WBC, LFTs

tablet 325-650 mg q6h

neutropenia, hepatotoxicity,
rash, hypersensitivity reactions
Dizziness, N, V, diarrhea,
abdominal pain, hypokalemia,
muscle weakness

Bisacodyl (Dulcolax)
suppository 10 mg daily

Laxative

Constipation

Enoxaparin (Lovenox)
syringe 40 mg QD subQ

Anticoagulant

Prevention of PE and
DVT

Dizziness, HA, chest pain, A-fib,


bleeding tendency,
hyperkalemia, fever, pain at
injection site, N, V, constipation,
urinary retention

Hydrocodoneacetaminophen (Norco) 5325 mg tablet 1 tab q4h po

Opiod analgesic,
antitussive

Moderate to severe
pain

Arrhythmias, confusion,
drowsiness, HA, orthostatic
hypotension, N, V, constipation,
respiratory depression, drug
tolerance, dry mouth, gastritis

Magnesium hydroxide
(Milk of magnesia)
suspension 30ml daily po

Laxative

Constipation

Pantoprazole (Protonix Dr)


tablet 40 mg daily po

Proton pump inhibitor

Vancomycin (Vancocin)
1.5g in normal saline 30ml
1.5g q12h IV piggyback

Anti-infective

Reduces gastric acid


secretion and increases
gastric mucus and
bicarbonate production
Infection

Dizziness, HA, chest pain,


tachycardia, N, V, blurred vision,
dehydration, pulmonary
congestion, rash, chills, fever,
dry mouth, osmotic nephrosis
Dizziness, HA, chest pain,
rhinitis, V, N, abdominal pain,
hyperglycemia, rash

Potassium bicarbonate (Klyte) effer tablet 50 mEq


oral

Mineral, electrolyte

Hypokalemia

Diphenhydramine
(Benadryl) solution 25 mg
q6h as needed IV push
Morphine syringe 2-4 mg
q4h IV

Antihistamine

Itching/pruritus

Opioid analgesic

Severe pain

Nephrotoxicity, leukopenia,
neutropenia, N, V, hypotension,
rash, anaphylaxis, chills, fever,
tinnitus, dyspnea, wheezing
Confusion, unusual fatigue,
hypotension, ECG change,
arrhythmias, N, V, abdominal
discomfort, hyperkalemia,
weakness and heaviness of legs
Drowsiness, dizziness, HA,
hypotension, blurred vision,
dysuria, decreased appetite
Respiratory depression,
constipation, N, V, sedation,
blurred vision, hypotension,
bradycardia, urinary retention,
flushing, itching, sweating, drug

-Make sure pt swallows


tablets whole without
chewing
-Monitor pt for electrolyte
imbalances and dehydration
-Monitor CBC and platelet
counts. Watch for signs and
symptoms of bleeding or
bruising
-Monitor fluid intake and
output
-Check BP and respirations
-Tell pt drug may cause
drowsiness
-Instruct pt to move slowly
when sitting up or standing,
to avoid dizziness from
sudden blood pressure
decrease
-Monitor VS
-Monitor urinary output, renal
function test, fluid balance

- Swallow tablet whole. Do


not split, crush, or chew
- Monitor BG
-Check renal function test
-Monitor WBC, VS
-Monitor urine output daily
-Check IV site for phlebitis
-Monitor respiratory status
-Monitor renal function, I&O
-Assess VS. Check ECG for
arrhythmias

-Monitor CV status
-Supervise pt suring
ambulation
-Monitor VS
-Asses pain character,
location, and intensity
-Monitor I&O
-Monitor bowel elimination

Alum-maghydroxidesimeth (MAALOX) 200200-20 mg/5ml suspension


30ml TID po

Antiflatulent

GI upset indigestion

Magnesium sulfate 6g in
D5W 100ml IV piggyback

Electrolyte
replacement

Hypomagnesia

Blood Test if done

Normal Range

Current Value Preclinical Day

tolerance
Mild constipation, diarrhea,
hypermagnesemia,
hypokalemia,
hypophosphatemia

pattern
-Check lab data

Confusion, dizziness,
hypotension, N, V, arrhythmias,
anorexia, flatulence, muscle
weakness, respiratory paralysis

-Recheck serum Mg 2 hrs


after last dose if level was <
1.3
- Recheck serum Mg with
next days am labs if level
was 1.3-1.9
-Monitor electrolyte levels
and LFTs
-Monitor RR and BP

Lab Data
New Value
Clinical Day

Explain why this lab value or specifically for


this patient- No Medical Diagnoses please

(10/22/2014)
WBC

5-10

10.8

HGB/HCT

12-16/37-47

10.0/29.9 L

Platelets

150-400

369

Na

135-145

134 L

3.5-5

3.7

Cl

95-105

99

Mg

1.5-2.5

BUN

5-25

Creatinine

0.5-1.5

0.62 L

Debilitation, decreased muscle mass

Glucose

< 100

111 H

Stress response

PT/INR

10-14/2-3

14.3

4.3-5.7

3.32 L

Anemia, hemorrhage

Decreased dietary intake, excessive oral water


intake

BNP
Other pertinent
lab
RBC
CRP

22.96 H

Other Diagnostic Data with Results: i.e., Xray Reports, EKG reports, Sonography Reports
Physical Therapy/Occupational Therapy Reports, Social Work or Dietician Reports
4

Discipline
CT abscess
drain/ catheter
placement
CT abdomen and
pelvis w contrast

Report information
Successful CT guided aspiration of a subdiaphargmatic perihepatic abscess. A 12 French drain was left in position
(10/22/2014)
-Significant interval enlargement of a gas and fluid collection subjacent to the R hemidiaphragm
-A smaller gas collection located along the anterior margin of the gastric antrum is identified
-A small fluid collection along the anterior margin of the R hepatic lob
-Hepatic steatosis is present
-A right renal cyst is identified
-Small right pleural effusion is present with R basilar atelectasis
(10/21/2014)

On a scale of 1-10 (1=poor and 10= excellent) rate your clinical day and explain why you rated it as you did. __8/10___I
think I did a really good job this morning. I was prepared and confident
On a scale of 1-10 (1=poor and 10= excellent) rate your preceptor/RN __9/10___ My preceptor is very helpful. She showed
us how she does care plan in the morning and told us how she would assess her patients before giving meds. Those are
really good instructions.
What did you learn today that was new to you? Today I learn that not every patient is compliant, especially when my partner
encouraged him to use the incentive spirometer. However, after I assessed his lung, RLL, and heard some crackles, I
explained to him that even though he can ambulate independently, his swelling incision from the surgery is affecting his right
lung and he needs to do some expiratory exercise. My pt verbalized that he understood and would use it more often. Thats
when I thought teaching is very important and I need to explain to my pt why they need to do something that I ask them to.

REFLECT ON YOUR DAY AND WRITE, IN DETAIL, YOUR INSIGHTS, FEELINGS AND ACCOMPLISHMENTS ABOUT
YOUR CLINICAL DAY!

Comparing to the previous clinicals, I think I did much better today. I actually think I like it when I assess my pt and get to
know him better. I stepped into the pts room and first I started to observed things around him and I looked at my pt to see
how hes doing like what I was taught. The most interesting part of the day was when I assessed my pt, then I explained to
my pt what I was doing and why I was doing that. During assessment, I would notice how my pt reacted and if I have done a
good job. One thing that I need to remember is med administration that I would identify my pt, scan, and explain. So far I
think I have been improving! I feel like I have learned a lot and its only been 2 months!!

INTAKE

OUTPUT

TIME

Oral
240 ml

IV
80 ml

IVPB

Blood

Urine

100 ml

200 ml

Restrictions: None

% Eaten__100%___

BM

Emesis

Drains
40 ml

1030
TOTAL
Diet Type: Regular

Nutritional interventions (feeding, supplements, tube)


Weight__102.3_kg__# since admission__________#

Physical Assessment to be completed by 9:00 am


Vital Signs: T __98.9__ BP __119/80___ Pulse __80___ RR __18___ O2 Sat ___91____ Pain Rating (0-10) ____4______
Describe your patients environment (observation of patient and enviroment -tubes, IVs, patient safety, room appearance): 1 IV piggyback, 1 JP drain
on RLL, 2 bed rails up, bed is at lowest height, room bright.

Neuro:
LOC
Confusion

Describe
Describe

AXOX3, but still a little confused


Pt able to answer questions and respond appropriately
But still a little confused since he could not remember whether or not his VS
has been taken when we asked
None, only 2 rails up
None, regular diet

Restraints
Dysphagia/Aspiration
Precautions
Fall risk
Cardio-thoracic:
Capillary refill
BS clear bilat

Why and what kind


Describe level

6 moderate risk, he just had surgery 2 weeks ago

Rales, rhonchi, wheezes


Oxygen in use
Cough
Apical auscultated
Pedal Pulses Palpated
Edema (pedal)
Elastic Stockings/SCDs
Gastrointestinal:
Abd soft, non distended
Abd distended, tender
Bowel sounds
Last BM
NGT
Genitourinary:
Voiding or Foley
Incontinent
Integumentary:
Turgor
Temp/color/moisture

Describe where
Face mask, nasal cannula
Dry or Productive
Regular/ Irregular and rate
Describe
Describe
Describe

< 2 sec
Clear on LUL, LLL, and RUL, but some crackles on his RLL A&P. Stated that
he quit smoking 2 months ago, and used to smoke 1 pack/day in 15 years
Crackles at base on the left side
Rate of flow None
Color of sputum, amount None
2+ regular
2+ regular bilat
No tibial edema
None

Describe
When and describe
Describe drainage

Left abdomen soft and distended


Right abdomen distended, red, warm, and tender
Gurgling all 4 quadrants
2 days ago, 10/22/2014
None
Voiding using urinal, clear yellow color
none

Describe
Describe

Skin elastic
Skin warm, pink undertones, and moist

Heels blanchable
Coccyx blanchable
Pressure ulcers
Wounds
Surgical incision/drains
Dressings
Musculoskeletal:
Gait stable
Moving all extremities
Independent in ADLs
Strength

If not, describe
If not describe
Where and describe stage
Where and describe
Where and describe
Where and describe drainage
If not, describe
If not, describe

Blanchable
Blanchable

None present
None present
Incision on RLQ at midaxillary line, around 2 cm, JP drain, creamy, purulent
drainage with foul odor
Transparent, occlusive dressing
Stable, be able to walk without assistance
Yes
Yes, be able to walk without walker, raise bed up and down, bath himself
Strong

N3005 Concepts and Clinical Competencies


Critical Thinking Wizard Link all the surrounding boxes to the Priority Problem Section
Patients Chief Complaint & Brief History of Present Illness

Postoperative fever and abdominal pain/ Peptic Ulcer with Perforation

SUBJECTIVE & OBJECTIVE Assessment


Findings that Support Problems

13.Abdominal surgery
14.Purulent, foul odor drainage
15.Oxygen level is low 91%
16.Crackles heard at R lung base
17.Distended, tender RLQ
18.Pain rated 4/10
19. Last BM was 2 days ago
20. Confused during assessment

PRIORITY PROBLEMS
Use Nanda nursing diagnoses
only

Impaired gas exchange


4 5 7 10 12 13 15 16 17 22 25 27 29
Acute pain
1 3 4 10 13 17 18 26
Risk for infection
1 3 7 14 17 24 25 26 27
Risk for fall
3 6 10 13 20 22 28
Fatigue
4 9 12 13 20 21 22
Risk for constipation
2 3 4 10 13 19

Diagnostics & Lab

21. Creatinine 0.62 L


22. HGB/HCT 10.0/29.9 L
23.Na 134 L
24. Glucose 111 H
25.Small right pleural effusion CT

Related Medical Problems

26. Perforated peptic ulcer


27. Former smoker

DRUGS
Name + Dose (Need to know action to link to
Problem box)

1. Acetaminophen (Tylenol) tablet 325-650


mg q6h
2. Bisacodyl (Dulcolax) suppository 10 mg
daily
3. Enoxaparin (Lovenox) syringe 40 mg QD
subQ
4. Hydrocodone-acetaminophen (Norco) 5325 mg tablet 1 tab q4h po
5. Magnesium hydroxide (Milk of magnesia)
suspension 30ml daily po
6. Pantoprazole (Protonix Dr) tablet 40 mg
daily po
7. Vancomycin (Vancocin) 1.5g in normal
saline 30ml 1.5g q12h IV piggyback
8. Potassium bicarbonate (K-lyte) effer
tablet 50 mEq oral
9. Diphenhydramine (Benadryl) solution 25
mg q6h as needed IV push
10. Morphine syringe 2-4 mg q4h IV
11.Alum-maghydroxide-simeth (MAALOX)
200-200-20 mg/5ml suspension 30ml TID po
12.. Magnesium sulfate 6g in D5W 100ml IV
piggyback

Supportive Therapies
And Devices

28. Walker
29. Incentive spirometer

Care Plan with top two PRIORITY Nursing Diagnosis


Nursing Diagnosis #1
___Impaired gas exchange_____

Nursing Diagnosis #2
____Risk for infection________

R/T ___surgery_____ AEB __low oxygen level, crackles, and pleural


effusion___

R/T __abdominal surgery____ AEB __ Purulent, foul odor drainage and


distended, tender RLQ,____

Goal: The patient will:

Goal: The patient will:


Remain free of infection at the end of my shift.

Use incentive spirometer 10 times every 2 hours at the end of my shift


Supporting Physical Assessment Data: (to be completed after assessing
patient during clinical):
-Crackles heard at lung base on right side
-Oxygen level is low 91%
-Pt is a former smoker for 15 years
-Abdominal surgery on 10/3/2014
Supporting labs:
Hgb level is low
Supporting radiological exams:
Small R pleural effusion identified by CT
Relative medications:
- Hydrocodone-acetaminophen (Norco) 5-325 mg tablet 1 tab q4h po
- Magnesium hydroxide (Milk of magnesia) suspension 30ml daily po
- Vancomycin (Vancocin) 1.5g in normal saline 30ml 1.5g q12h IV
piggyback
- Morphine syringe 2-4 mg q4h IV
LIST ALL POSSIBLE INTERVENTIONS:
-Monitor respiration rate, depth, and effort, including use of accessory
muscles, nasal flaring, and abdominal breathing patterns
-Auscultate breath sound every 1 or 2 hours
-Monitor oxygen saturation continuously using pulse oximetry
-Observe for cyanosis of skin
-Position clients in semi-Fowlers position, with an upright posture at 45
degrees if possible
-Turn the client every 2 hours
-Help the client deep breathe and perform controlled coughing
-Monitor the effects of sedation and analgesics on the clients respiratory
pattern, use judiciously
-Assess nutritional status including serum albumin level and BMI

Supporting Physical Assessment Data: (to be completed after assessing


patient during clinical):
-Purulent and foul odor drainage
-Distended, red, warm, tender RLQ
-Lung sounds crackles present at base on R side
Supporting labs:
WBC is 369 on 10/22/2014, high
CRP high 22.96
Supporting radiological exams:
According to CT scan, small R pleural effusion is present with R basilar
atelectasis
Relative medications:
- Acetaminophen (Tylenol) tablet 325-650 mg q6h
- Vancomycin (Vancocin) 1.5g in normal saline 30ml 1.5g q12h IV
piggyback
- Pantoprazole (Protonix Dr) tablet 40 mg daily po
LIST ALL POSSIBLE INTERVENTIONS:
-Observe and report sign of infection such as redness, warmth, discharge,
and increased body temperature
-Assess temperature in 24hrs
-Note and report lab values
-Assess skin for color, moisture, texture, and turgor
-Encourage a balance diet, emphasizing protein, fatty acids, and vitamins
-Monitor weight loss, leaving 25% or more of food uneaten at most meals
-Encourage fluid intake
-Use appropriate hand hygiene
-Follow standard precautions and wear gloves during any cotact with
blood, mucous membrane, nonintact skin, or any body substance except
sweat. Use gloves, goggles, and gowns when appropriate
-Sterile technique must be used when inserting urinary catheters.
Catheters must be cared for at least every shift
Other supporting data:

Other supporting data:

For each diagnosis listed above, document the interventions that you actually implemented for that specific diagnosis. Then write the evaluation of
your intervention and the outcome. If you did not meet your goal, how would you modify the plan of care and or your goal?
#1
-Teaching pt to use the incentive spirometer and explain why he needs to use it
-Check lab data to see if there is any changes in his oxygen level
-Monitor oxygen saturation using pulse oximetry

-Assess skin for sign of cyanosis


-Auscultate his breath sounds
-Monitor respiration rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns
-Position patient in semi-Fowlers position at 45 degrees
Partially met my goal. My pt stated that he used the incentive spirometer this morning a couple of times.
#2
-Assess skin for sign of redness, warmth, and discharge
-Monitor temperature
-Check lab values
I met my goal. My pts vital sign is stable. His temperature is within normal limit.

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