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
Unit _Med/Surg__
Rm # __874
Age _44__
PT INITIALS _HR__
ALLERGIES _NKDA__
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:
Hunger and an empty feeling in the stomach, often 1 - 3 hours after a meal
Chest pain
Fatigue
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
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)
drug (indication)
administration of
medication
-Thrombocytopenia,
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
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
Vancomycin (Vancocin)
1.5g in normal saline 30ml
1.5g q12h IV piggyback
Anti-infective
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
-Monitor CV status
-Supervise pt suring
ambulation
-Monitor VS
-Asses pain character,
location, and intensity
-Monitor I&O
-Monitor bowel elimination
Antiflatulent
GI upset indigestion
Magnesium sulfate 6g in
D5W 100ml IV piggyback
Electrolyte
replacement
Hypomagnesia
Normal Range
tolerance
Mild constipation, diarrhea,
hypermagnesemia,
hypokalemia,
hypophosphatemia
pattern
-Check lab data
Confusion, dizziness,
hypotension, N, V, arrhythmias,
anorexia, flatulence, muscle
weakness, respiratory paralysis
Lab Data
New Value
Clinical Day
(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
Glucose
< 100
111 H
Stress response
PT/INR
10-14/2-3
14.3
4.3-5.7
3.32 L
Anemia, hemorrhage
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
Neuro:
LOC
Confusion
Describe
Describe
Restraints
Dysphagia/Aspiration
Precautions
Fall risk
Cardio-thoracic:
Capillary refill
BS clear bilat
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
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
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
DRUGS
Name + Dose (Need to know action to link to
Problem box)
Supportive Therapies
And Devices
28. Walker
29. Incentive spirometer
Nursing Diagnosis #2
____Risk for infection________
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
10