PATIENT CARE PLAN

Patient Information: 34 year old male pt admitted with primary diagnosis Vomiting
Abdominal Pain. Comorbidities acute pancreatitis and gastroparesis. Full Code. Allergic
Versed. Patient is a diabetic CBG have been 207, 176, 184. Glucose in urine 4+, Keton
3+, Protein 1+. Abdominal pain 9 (0-10 Scale), vomited 100mL with a little blood, N/V,
chills and cold, chart states abdominal pain due to poorly controlled diabetes. On
Clear liquid diet advance as tolerated. History of acute pancreatitis and gastroparesis.
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to
(R/T), as evidenced by (AEB).

Problem #1 Acute pain R/T inflammation process AEB pt chart states abdominal pain 9
out of 10, doctor states in chart abdominal pain due to poorly controlled diabetes,
CBG have been 207, 176, 184, vomited 100mL with some blood, acute pancreatitis,
gastroparesis and N/V.
Desired Outcome: Verbalization of decreased pain of 3 on scale of 0-10 by end of shift.
Nursing Interventions
Client Response to Intervention
1. Assess pain level every hour on scale of 01. Pt pain was between a 7-9 on pain
10.
scale 0-10 all shift.
2. Administer analgesics when due and give
2. I administered PO Norco Q4H which
PRN pain medication Dilaudid Q4H.
helped but still did not bring the pain
below a 7 on pain scale 0-10.
3. Provide alternative comfort measures
3. These were implemented and
including repositioning as needed and quite
maintained through out the day. I kep
environment.
the pt door closed and lights were
turned down low to help promote a
relaxed environment.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed):
These interventions worked ok, however the patient has been dealing with these health
issues for several years and has a high medication tolerance. We were trying to
transition the pt from IV pain medications to PO medications however it wasnt the
smoothest transition so I didnt have many pain meds available to give to help manage
the patients pain. Reposting helped a lot and a quite environment. Another interventio
that the patient said helped relieve pain was a hot shower. I also gave the patient a
warm blanket to wrap around him and to hold against his abdomen, which he said felt
good. Also advocating for different types of pain medication such as PO or transdermal
patch would have been a good intervention as well. Changing my goal to Verbalization
of decreased pain of 3 on scale of 0-10 with in an hour of assessment, would have bee
a better goal.

Problem #2 Deficient Fluid Volume R/T nausea AEB vomited 100mL with some blood, p
chart states abdominal pain 9 out of 10, N/V, acute pancreatitis, gastroparesis, chills,
CBG have been 207, 176, 184, Glucose in urine 4+, Ketones 3+ and Protein 1+, pt stat
I do not have an appetite and pt is receiving IV fluids.
Desired Outcome: Adequate hydration as evidence by balanced intake and output

through out shift.

Nursing Interventions
1. Assess I/O hourly for balance.

Client Response to Intervention

1. Pt was drinking about 240 ml Q2H
and receiving 125 ml/hr IV 0.9% NS
with Potassium. The patient was
urinating hourly.
2. Maintain fluid intake of at least 2500mL/day.
2. Pt had 1,500 fluid intake during my
shift and I hung another 1000ml bag
fluid before I left. Pt also had water
bottles and chicken broth he was
drinking on from lunch as well.
3. Administer fluids as indicated.
3. Pt was receiving 125 ml/hr IV 0.9%
NS with Potassium.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed) :
These interventions worked well as the patient was on a clear liquid diet until the last
hour of my shift. So maintaining his fluids was important as they were his primary mea
of nutrition as well. Another interventions that would have been good since interventio
#2 and #3 were intertwined intervention would have been to administer prescribed
antiemetics in a timely manor. Which was a priority today.

Problem #3 Unstable Blood Glucose level R/T non-adherence to diabetic management

AEB diabetic, CBG have been 207, 176, 184, glucose in urine 4+, Ketones 3+, vomited
100mL with a little blood, N/V, chills and is on a clear liquid diet.
Desired Outcome: Maintain glucose with in satisfactory range 75 110 mg/dL during
shift.
Nursing Interventions
Client Response to Intervention
1. Perform finger stick glucose testing Q4H for
1. CBG 222, 209 and 192 throughout
range 75 110 mg/dL.
the shift.
2. Administer insulin as ordered and rotating
2. 2units of short acting NovoLog was
injections sites.
given before breakfast as well as
30units of long acting Lantus. Then
NovoLog was given again with the pt
lunch came.
3. Observe for signs of hyperglycemia or
3. Checked on pt in between meals a
hypoglycemia QH.
after insulin was administered. When
pt was curled up and not feeling well
and had not eaten much I checked hi
CBG and it was at 209.
Evaluation (evaluate goal & interventions, what worked/what didnt, what would you adapt if needed) :
These interventions worked well as the pt is a diabetic and has issues maintaining an
acceptable glucose range. Another intervention that would have worked well would hav
been to check pt food trays for sugar as the pt had food trays being sent up that had
several sugar packets with different sugary juices. Checking pt food trays and advocati
for diabetic liquid diet might have been a better intervention for #3. As the pt had a
clear liquid diet and non-select trays being sent during meal times.