579b care plan
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Azusa Pacific University
School of Nursing
GNRS 579BCare Write-Up with Nursing Process
Name: Crystal Mann Young Chang Date: 02/10/12 Care Write-Up 1
IDENTIFYING DATA
Patient initials: D.L.
Age: 18
Ethnicity: White European
Gender: Female
Occupation: Student
Allergies (include allergen and reaction to allergen): Amoxil causes skin rash and/or hives; lactose class (not screened) causes skin rash
and/or hives, shock and/or unconsciousness, asthma and/or shortness of breath, nausea and vomiting, anemia and/or blood disorders;amoxicillin trihydrate causes skin rash and/or hives
Admit date: November 29, 2011
Hospital day #: 1 Post-operative day #: Same day of operation
Physician(s) (include physician specialty): D.M. (operating room surgeon); J.J. (anesthesiologist); S.G. (physician); G.P. (physician)
ADMITTING DATA
Medical diagnosis (admitting): Appendicitis
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History of Present Illness (HPI):
On November 28th, 2011, D.L. began having abdominal pain with nausea and vomiting in the morning. The pain gradually worsened and was
continuous. The pain radiated from the periumbilical region to the right lower quadrant or McBurneys point. Moving and coughing
aggravated her pain. D.L. was admitted to the hospital 11-28-11 and was diagnosed with appendicitis without the rupture of the appendix. Sheunderwent a laparoscopic appendectomy. Postoperatively, she has been experiencing continuous cramping in her ribs due to the air trapped in
the abdominal and thoracic regions. She feels a sharp pain when she inhales, especially when using the incentive spirometer. Relaxedbreathing minimizes the cramping and eliminates the sharp pain.
Past Medical and Surgical History: D.L. had varicella on 12-21-95. D.L. has no history of surgeries.
Findings that support admittingmedical diagnosis
Physical Exam Diagnostic Tests
Nausea and vomiting, acute pain radiating to right
lower quadrant from the umbilical region.
CT scan was performed and revealed acute
appendicitis.
Admit Plan (per physicians notes): D.L. will undergo diagnostic laparoscopy and laparoscopic appendectomy.
PATHOPHYSIOLOGY
Pathophysiology of admitting diagnosis:
Appendicitis is the inflammation of the appendix, which is the finger like organ located at the beginning of the colon. Appendicitis occurs in7%-12% of the worlds population. It occurs most often in young adults although it can occur at any age and more often in males. The
mortality and morbidity rates are higher in patients over 70 years old. Causes of appendicitis include fecal accumulation obstructing thelumen of the appendix, excessive growth of lymphoid tissue, presence of foreign bodies, or tumors in the cecum or appendix. Obstruction can
cause distention, venous engorgement, and the accumulation of mucus and bacteria, which can lead to gangrene and perforation of theappendix. Without treatment, the appendix may burst, releasing the pathogens into the abdominal cavity and resulting in peritonitis.
Fortunately, in the case of D.L., her appendix did not burst.
(Lewis, Bucher, Camera, Dirksen, & Heitkemper, 2011, p. 1020).
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Correlation of admitting diagnosis to comorbidities or past surgical history (if any):
D.L. is an adolescent at the age of 18. Adolescence is not a comorbidity but it is a major risk factor for appendicitis. She does not have a pastsurgical history. Appendicitis often occurs on its own without regard to genetic or lifestyle.
(Monahan, Green, & Neighbors, 2011, p. 466)
PHYSICAL EXAM
Ht: 51 Wt: 67.858 kg (149 lb) BMI: 28.28
VITAL SIGNS: 2 sets required
Time Temperature (include
route)
Pulse (apical/radial) Resp BP Pulse Ox
0800 98.6F 69/67 16/min 116/69 96%
1230 99.3F 68/66 20/min 107/70 98%
PAIN ASSESSMENT: 2 sets required
Time Pain Tool Used Pain Rating Pain Description
(OLDCART)
Functional Pain Goal Pain Medication Response To Tx
0800 Numeric Scale 5/10 3/10 Norco 10-325 mg
1 tab at 0820
Pain was reduced to
3/10
1230 Numeric Scale 7/10 (see below) 3/10 Morphine 4 mg
IV at 1245
Pain was reduced to
4/10
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O (Onset) Began around 1215 after the patient ate a cup of ice chips
L (Location) Left and right lower ribs and the incisions at the infraumbilical region and suprapubic region.
D(Duration) Continuous
C (Characteristics, i.e. sharp, burning, ache, etc.) Pain in the ribs feels like cramping. Soreness around the incisions.
A (Aggravating factors) Ambulating, deep breathing
R(Relieving factors) Lying quietly, sleeping
T (Treatment) Morphine 4 mg IV at 1245
General
Level of consciousness (awake, alert, drowsy, lethargic, etc.): Awake, alert, and oriented x 4
Orientation to: Person: Yes Place: Yes Time: Yes Purpose: Yes
Able to hold conversation: Yes Speech: Clear and articulate Follows directions: Easily follows direction
Stature, posture and position: The patient stands erect. Posture is straight.
Nutrition (Well nourished, well developed, obese or cachectic, etc.): Patient is well nourished, overweight.
Medical appliances patient is currently using: The patient is using an IV infusion pump attached to a single-lumen peripherally insertedcentral catheter. D.L. is also using an incentive spirometer.
I.V. Site #1 Location: Right forearm Solution: 1000 ml of 2O mEq/L in 5% Dextrose and half normal saline Rate: 125 ml/hr
Assessment of site: Dry, clean, and intact. No pain or tenderness.
I.V. Site #2 Location: Right forearm Solution: Cleocin Phosphate piggyback in 5% dextrose Rate: 900g/50 ml Assessment ofsite: Dry, clean, and intact. No pain or tenderness.
Skin
Skin:
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Color: Even and appropriate for ethnicity Turgor: Within normal range Temp: Warm to touch Moisture: DryEdema: No edema
Lesions (describe findings): Moderate acne on face
Incisions (location): Infraumbilical region and suprapubic region Description of incision (dressing, S/S of infection, etc.): Incisionsare about 1 inch in length. Dressing is dry, clean and intact. There are no signs of infection.
Drains (type such as JP, Penrose, negative pressure, chest tubes and location): None
Varicose Veins: None Scars: None Nails: No clubbing or fungal infections in the hands or feet. Capillary refilling isless than 2 seconds.
Unusual Pigmentations/Tattoos/Piercings: 1 piercing in each lobe.
Head, Face and Neck
Head: General size (i.e. normocephalic): Normocephalic Deformities (i.e. atraumatic): No deformities
Face: Symmetry: Symmetrical Involuntary movements: No involuntary movements
Neck: ROM (Supple): Supple with Full ROM without pain or crepitus Cervical lymph nodes: Not palpable Thyroid gland: Not enlargedor palpable Trachea (midline): midline with
Ears, Eyes, Nose, Mouth, Throat
Ears: Size, shape: Equal size bilaterally. No swelling or lesions Tenderness: No tenderness Drainage: No drainage or dischargeHearing: CN VIII intact, response is appropriate.
Otoscope exam (external canal, tympanic membrane): N/A
Eyes: Inspect external/interior eye structures: Symmetrical, equal bilateral shape and position. Sclera is white, conjunctiva clear, iris intact, no
discharge, no excessive tearing. Bilateral eyebrow movement. Eyes approximate completely Cardinal eye gazes: CN III, IV, VI intact
PERRLA: PERRLA intact with no lid lag
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Nose: Symmetry: Symmetrical and midline Patency: Patent without obstruction Drainage: None Sinus Tenderness: No frontal ormaxillary sinus tenderness
Mouth: Mucosa (color, lesions): Red/pink with no inflammation. No tenderness. No lesions. Number of teeth: 32 teeth
Dentures: No Ability to eat/drink: CN V, IX, X, XII intact.
Throat: Tonsils (grade): 1+
Pulmonary
Respirations: Rate: 16/min at 0800. 20/min at 1230 Rhythm: Regular Depth: Relaxed
Labored (ICS retractions or use of accessory muscles)/ Unlabored: Unlabored breathing with no use of accessory muscles Chestexpansion: Symmetrical chest expansion
Percussion (which sound and where): Posterior and anterior equal bilateral resonance
Breath Sounds (posterior, anterior and lateral): Posterior: Equal bilateral clear sounds with mostly vesicular sounds in peripheral fields andbronchovesicular between scapulae. Anterior: Equal bilateral clear sounds with bronchovesicular sounds near the sternum at the 2nd, 3rd, 4th
ICS. Adventitious sounds: No adventitious sounds.
Oxygen Therapy: None How Delivered (nasal cannula, face mask, etc.): N/A Rate in Liters: N/A
Trach: N/A Ventilator and settings: N/A Chest tube (water seal or suction, cm of water): N/A
Cardiovascular
Precordium: Visible heaves or lifts: No lifts of heaves Palpate for presence of thrills: No thrills
Neck Vessels: JVD: No JVD Carotid Artery Bruit (with bell): No bruit
Heart Sounds: Rate: 69/min at 0800. 68/min at 1230 Rhythm: Regular Extra Sounds or Murmurs: No murmurs, rubs, clicks or
gallops PMI (location and size): N/A
Pulses (R/L): Temporal: +2 equal bilateral Carotid: +2 equal bilateral Brachial: +2 equal bilateral Radial: +2 equal bilateral
Femoral: N/A Popliteal: N/A Posterier Tibialis: +2 equal bilateral Dorsalis Pedis: +2 equal bilateral
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Capillary Refill (
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Activity Level (Ad lib/BRP/BR): Ambulatory ROM (active/passive): All joints have active full ROM
Mobility (self/assisted): Self. Independent mobility Gait (even/uneven): Even, smooth, coordinated
Muscle Tone/Strength (handgrips, footpushes): Strength to resistance in all joints. Less strength at hip joint due do strain on the incisions.
Assistive Devices: None Prosthesis: No
Other Devices (i.e. CMP, location of use and degree): No
Mental
Mood/ affect: Calm, relaxed Coping: N/A Suicidal ideation: None
Thought process/content: Logical and coherent Perceptions: Consistently aware of reality
LABORATORY TESTS
Test: Results: Normal range: High orLow Relevant Rationale for ABNORMAL Test Results:
CBC & DIFF:
WBC 17.4 4.0-11.0 High Inflammation of the appendix
RBC 3.64 4.3-5.7 Low Blood loss from surgery
HGB 12.0 11.7-15.5 Normal
HCT 35.1 35-47 Normal
Platelets 260 150-400 Normal
Neutrophils 64 42-75 Normal
Lymphocytes 13 20-40 Low Immune system uses WBC against inflammation first
Monocytes 11 4-8 High Inflammation of appendix
Eosinophils N/A
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Basophils N/A
BMP:
Na N/A
K N/A
Cl N/A
CO2 N/A
BUN N/A
Creatinine N/A
Glucose N/A
CMP (BMP plus
the following):
Calcium N/A
Albumin N/A
Total Protein N/A
AST N/A
ALT N/A
Alk Phos N/A
Bilirubin N/A
UA:
Color
Appear N/A
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PH N/A
Specific Gravity N/A
Protein N/A
Glucose N/A
Ketone N/A
Bilirubin N/A
Hgb N/A
Uro-bilinogen N/A
WBC N/A
Nitrate N/A
OTHERS:
Coagulation Panel:PT/INR, PTT,
D-dimer
N/A
Cultures:
Blood, urine,
wound
N/A
Diabetic:
HgbA1C
N/A
Inflammation
Panel:
ESR, CRP, ANA,
RF
N/A
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(Lewis et al., 2011, p. 1799)
DIAGNOSTIC TESTS (X-Ray, Ultrasound, CT, MRI, EKG, etc.)
Test Rationale for Ordering
Test
Results Normal Value Explanation
CT scan of abdomen andpelvis with contrast
To confirm appendicitisand rule out other
illnesses
Liver, lung bases,gallbladder, spleen,
pancreas, kidneys, adrenalglands, aorta, urinary
bladder are unremarkable.Appendix is dilated. Few
appendicoliths seen withinthe appendix.
Periappendiceal fatstranding is noted. No
abscess formation seen.
Appendix is not dilated. Noappendicoliths.
The patients symptomsare due to the
inflammation of theappendix. The appendix
has not ruptured.
Iron Panel:
Serum iron, ferritin,
TIBC, UIBC
N/A
Lipid Panel:Cholesterol, HDL,LDL, Triglycerides
N/A
Thyroid Panel:
TSH, T4, T3
N/A
Tumor Markers:
AFB, CEA, CA-
125, PSA, etc.
N/A
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MEDICATIONS
Name (generic
and trade), doseand route
Class Indication
(specific to yourpatient)
Mechanism of Action Side Effects Nursing
Implications (labsto monitor, etc)
Patient Education
Acetaminophen
tab 650 mg(Tylenol), every 4
hours PRN, oral
(Epocrates
online, 2011)
Nonopioid
analgesic,antipyretic
For temperatures
greater than38.5C/101.3F
Does not have anti-
inflammatoryproperties.
Antipyretic actionresults from
inhibitingprostaglandins in the
CNS or thehypothalamic heat-
regulating center
Hemolytic
anemia,drowsiness,
nausea, vomiting,renal failure,
rash, urticarial,cyanosis
Monitor quantity
of red bloods,urinalysis for renal
failure. Inspectskin for rashes.
Monitor liverfunction, assess
temperature.Contraindications
are alcohol andtable sugar.
Do not exceed
recommended doselest liver damage
occur. Toxicityincludes nausea and
vomiting andabdominal pain.
Signs of overdose:bleeding, bruising,
malaise, fever, sorethroat.
Clindamycin in
D5W IV premix900 mg
(Epocrates
online, 2011)
Antibacterial,anti-infective
Treatment ofsusceptible
bacterialinfections,
mainly thosecaused by
anaerobes,streptococci,
pneumococci,
andstaphylococci;also for pelvic
inflammatorydisease
Binds to 50S subunitof bacterial ribosomes
and suppressesprotein synthesis
Nausea andvomiting.
Abdominal paindiarrhea, weight
loss, jaundice,rash, urticaria,
pruritus
Assess forabdominal
tenderness.Monitor bowel
movements,nutrition, and liver
function. Inspectskin for rash and
urticaria.
Contraindicationsincludehypersensitivity to
this drug orlincomycin,
tartrazine dye, andulcerative
colitis/enteritis.
Take oral with fullglass of water. Take
with food to reduceGI symptoms.
Complete the entirecourse to prevent
resistance. Reportsore throat, fever,
fatigue. Do not
break, crush, orchew caps.
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D5 NaCl 0.45%
KCl 20 mEq/L IVpremix,
continuous, 1000ml, rate of 125
ml/hr
(Epocrates
online, 2011)
Hypertonic
electrolytesolution
initially.Dextrose
metabolizesand solution
becomeshypotonic
Maintain
hydration andelectrolyte
balance
Balances osmolality
between bloodvessels and tissues.
This particularhypertonic solution
pulls fluids out of thetissues.
Hypervolemia Monitor blood
pressure, inspectbody for edema
Educate patient of
symtoms ofhypervolemia
Diphenhydramine
Inj 25 mg(Benadryl), every6 hours PRN, IV
(Epocratesonline, 2011)
1st
generation
nonselectiveantihistamine
For itching Affects blood vessels.
Competes withhistamine for H1-receptor site;
decreases allergicresponse by blocking
histamine.
Dizziness,
drowsiness, poorcoordination,fatigue, anxiety,
euphoria,confusion,
seizures,wheezing, chest
tightness,
hemolyticanemia, nausea,vomiting,
diarrhea, blurredvision
Contraindications:
hypersensitivity toH1-receptorantagonist, acute
asthma attack,lower respiratory
tract disease.
Watch for urinary
retention,
frequency, dysuria.Monitor CBCduring long-term
therapy. Monitorrespiratory status.
Notify prescriber of
confusion, sedation,hypotension.Avoid driving and
other hazardousactivities. Avoid
alcohol and otherCNS depressants.
Famotidine (PF)inj 20 mg
(Pepcid), every12 hours, IV
(Epocratesonline, 2011)
H2-histaminereceptor
antagonist
For maintenancetherapy and
treatment ofduodenal ulcer,
treatment ofgastroesophageal
reflux disease(GERD), active
benign gastriculcer,
Competitivelyinhibits histamine at
histamine H2 receptorsite, decreasing
gastric secretionwhile keeping pepsin
at a stable level.
Headache,dizziness
paresthesia,depression,
anxiety,somnolence,
insomnia, fever,taste change,
constipation,nausea, vomiting,
Assess epigastricand/or abdominal
pain. Inspectemesis or stools for
blood. Monitorblood counts for
decreased platelets.Assess patient for
fatigue. Inspectskin for bruising,
Must be taken forthe entire
prescribed time.Report bleeding,
bruising, fatigue,malaise. Possibility
of decreased libido.Avoid alcohol,
aspirin, smoking.Avoid tasks
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pathological
hypersecretoryconditions.
anorexia, cramps,
abnormal liverenzymes,
diarrhea, rash,myalgia,
dysrhythmias
bleeding, poor
healing.
requiring alertness
due to dizzinessand drowsiness.
Gentamicin IV
piggy back 70mg, every 8
hours, duration30 minutes
(Epocratesonline, 2011)
Anti-infective Treatment of
infections causedby susceptible
strains of Proteusaeruginosa,
ProteusKlebsiella,
Serratia,Escherichia coli
Enterobacter,Citrobacter,
Staphylococcus,
Shigella,Salmonella,Acinetobacter,
acute PID.
Inhibits protein
synthesis of bacterialcells by binding to
ribosomal subunit,with misinterpretation
of genetic code.Peptide sequences of
protein chains arecompromised causing
bacterial death
Renal
damage/failure,confusion,
depression,numbness,
tremors,convulsions,
dizziness,vertigo, deafness,
visualdisturbances,
nausea, vomiting,
anorexia,hypotension,hypertension,
rash.
Weight before
treatment. Monitorintake/output.
Daily urinalysis.Monitor vital signs
during infusion.Check IV site for
pain, redness,swelling, phlebitis.
Monitor renalfunction. Hearing
tests.
Contraindications:severe renaldisease,
hypersensitivity.
Report headache,
dizziness, renalimpairment,
symptoms ofovergrowth of
infection. Reportloss of hearing,
ringing or roaringin ears, or feeling
of fullness in thehead.
Metoclopramid
Inj 10 mg(Reglan), every 6
hours PRN, IV(Epocrates
online, 2011)
Cholinergic,
antiemetic
For nausea and
vomiting
Enhances response to
acetylcholine oftissue in upper GI
tract and causescontraction of gastric
muscle, relaxespyloric, duodenal
segments, increasesperistalsis without
stimulatingsecretions, blocks
dopamine in
Sedation, fatigue,
restlessness,headache,
dizziness,drowsiness,
suicide ideation,seizures, dry
mouth,constipation,
nausea, vomiting,diarrhea,
decreased libido,
Assess mental
status fordepression, anxiety
and irritability.Assess GI
complains fornausea, vomiting,
anorexia,constipation.
Contraindications:Hypersensitivity,
seizure disorder,
Avoid driving or
other hazardousactivities. Avoid
alcohol, other CNSdepressants that
may enhancesedation.
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chemoreceptors in
CNS.
hypotension,
supraventriculartachycardia, rash,
breast cancer, GI
obstruction.
Morphine Inj Syg2 mg or Syg 4
mg, every 2 hoursPRN, IV
(Epocratesonline, 2011)
Opiateanalgesic
2 mg for severebreakthrough
pain (7-10) andfor moderate pain
(4-6).
4 mg for severe
pain (7-10).
Inhibits transmissionof pain impulse at the
spinal cord level byinteracting with
opioid receptors
Drowsiness,dizziness,
confusion,headache,
sedation,euphoria,
palpitations,bradycardia,
change in B/P,shock, cardiac
arrest, nausea,vomiting,
anorexia,constipation,
cramps, urinary
retention, rash,bruising, pruritus,respiratory
depression, apnea
Assess pain. Givebefore pain
becomes severe.Assess bowel
status. Monitorintake and output.
Assess respirationsand B/P, pulse.
Monitor CNSchanges such as
hallucinations,euphoria, LOC,
pupil reaction,drowsiness. Assess
respirations. Notify
prescriber ifrespirations areless than 12 per
minute.
Change positionsslowly. Orthostatic
hypotension mayoccur. Report any
symptoms of CNSchanges and allergic
reactions. Physicaldependency can
occur. Avoidalcohol, CNS
depressants.Withdrawal
symptoms mayoccur such as
nausea vomiting,
and faintness.
Norco 10-325 or
5-325 mg 1 tab(Hydrocodone-
acetaminophen),every 4 hours
PRN, oral
(Epocrates
online, 2011)
Antitussive
opioidanalgesic
For moderate
pain (1-3)
Directly acts on
cough center inmedulla to suppress
cough. Binds toopiate receptors in
CNS to reduce pain.
Drowsiness,
dizziness,confusion,
headache,sedation,
hallucinations,dependence,
convulsions,nausea, vomiting,
dry mouth,constipation,
increased urinary
Assess pain, CNS
changes such asdizziness,
hallucinations,LOC, pupil
reaction. Assessfor allergic
reactions. Monitorcoughing and
respiratorydysfunction.
Notify prescriber if
Report any
symptoms of CNSchanges and allergic
reactions. Physicaldependency may
result with extendeduse. Withdrawal
symptoms mayoccur such as
nausea andvomiting. Avoid
driving or
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output, urinary
retention, rash,pruritus,
tachycardia,bradycardia,
respiratorydepression
respirations are
less than 10 perminute.
hazardous activities.
Avoid other CNSdepressants. Do not
break, crush orchew tabs.
Ondansetron (PF)inj 4 mg (Zofran),
every 6 hoursPRN, IV
(Epocratesonline, 2011)
Antiemetic For nausea andvomiting
Prevents nausea andvomiting by blocking
serotoninperipherally, centrally
and in the smallintestine
Diarrhea,constipation,
abdominal pain,headache
dizziness,drowsiness,
fatigue, rash,shivering, fever,
urinary retention
Assess absence ofnausea and
vomiting duringchemotherapy.
Monitor and assessbowel movements.
Assess forhypersensitivity.
Report diarrhea,constipation, rash,
or changes inrespirations or
discomfort atinsertion site.
Zolpidem tab 5
mg (Ambien),
every bedtimePRN, oral
(Epocrates
online, 2011)
Sedative-
hypnotic
For insomniaProduces CNS
depression at limbic,thalamic,hypothalamic levels
of CNS; possiblemediation by
neurotransmitters y-aminobutyric acid.
Causes sedation,
hypnosis, skeletalmuscle relaxation,anticonvulsant
activity, anxiolyticaction
Leukopenia,
headache,
lethargy,drowsiness,dizziness,
confusion,irritability,
amnesia, poorcoordination,
nausea, vomiting,diarrhea,
heartburn,abdominal pain,
constipation,chest pain,
palpitation
Blood studies for
Hct, Hgb, RBC.
Hepatic studies forAST, ALT,bilirubin if liver
damage hasoccurred. Mental
status for mood,sensorium, affect
memory (long,short). Inspect skin
for bruising, rash, jaundice. Assess
for fever, sorethroat, and
epistaxis.
Dependence is
possible after long-
term use. Avoiddriving and otherhazardous activities.
Avoid alcohol,other CNS
depressants.Alternative
nonpharmocologicalmethods should be
used assupplementary.
Hangover iscommon. Effects
may take 2 nights.
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OTHER TREATMENTS
(Examples include RT, PT, OT, ST, TCDB, IS, ROM, CPM, TEDs, Trapeze, Traction, Sitz Bath, Drains, Dressing Changes, etc.)
Treatment Schedule Rationale for Treatment
N/A
CULTURAL & SPIRITUAL ASSESSMENT
General: The patient was suffering from extreme nausea and vomiting. Moving and coughing and simply talking were exasperating her
symptoms. She was scared and uncertain as to why she was suffering from her symptoms. She could not eat or drink anything and justwanted to lie still. The patient was treated immediately after the onset of her symptoms. It disrupted her life for approximately two days. She
had to miss school for two days. She is uncertain as to the cause of her diagnosis.
Cultural:D.L. describes herself as Caucasian. Her primary language is English. She does not eat red meat but that is more of a dietarypreference rather than a religious or cultural practice. Her mother is an Emergency Department nurse and is the authoritative voice over health
care related decisions.
Spiritual: D.L. identifies herself as culturally Christian but does consider herself as a practicing Christian.
DISCHARGE PLAN
The discharge plan will begin from admission. Follow up care will be scheduled. The patient is an adolescent female, living at home, and
commutes to her university. Her mother is an RN and will be home to care for her during her recovery. She is ambulatory and will not needassistance walking due to the minimal nature of her surgery. However, she will need written and verbal information about her medications
such as the drug name, dosage purpose, schedule, precautions, and potential side effects. Contraindications and interactions will be included.Emphasis will be put on about taking the entire prescription of her antibiotic. Instruction on how to care for her incisions will be given such as
dressing changes and bathing instructions. Patient will be informed about indicators of infections such as fevers, chills, incisional pain,redness, swelling, and purulent drainage. She will be instructed not to lift heavy objects of more than 10 pounds for the first 6 weeks or as
directed, be on the watch for symptoms and rest if fatigue occurs, get as much rest as possible and gradually increase the intensity of activitiesto tolerance. Avoid using enemas for the first few weeks after surgery.
(Monahan, Green, & Neighbors, 2011, p. 469)
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NURSING DIAGNOSIS AND PLAN OF CARE
1. Patient care needs of the day: I encouraged the patient to rest and ambulate at regular intervals without placing too much strain onher abdomen. The patient was not compliant with using the incentive spirometer so I was there to watch her use it about 3 times. Hermother, an RN, was also there to help her throughout the day. Her most prominent complaints were about the pain in her ribs from the
air entrapped there and about using the incentive spirometer. Norco and morphine were administered to reduce her pain. I took hervitals at 0800 and 1230. She request ice water and preferred drinking to eating. Her mood was stable throughout the morning and was
amiable.
2. Prioritized nursing diagnosis:1. Ineffective health maintenance2. Risk for infection3. Delayed surgical recovery4. Impaired skin integrity5. Acute pain
3. Explainwhy you choose these particular diagnoses and prioritized them as you did. Please describe the assessment evidencethat supports the choice of your nursing diagnoses for your specific patient? Ineffective health maintenance is top priority
because if the patient is unable or unwilling to properly self-manage her recovery then all other interventions will not be as effective asthey can be. Risk for infection is second because the probability of infection increases after a surgical operation due to the break intissue. Delayed surgical recovery is third because if the client is unable or unwilling to self-manage her recovery or an infection occurs
then recovery time will lengthen. Impaired skin integrity is fourth because in addition to her surgical wound the patient also has IVsites on her right forearm. Acute pain is fifth because the client is not suffering from life-altering pain but it is nevertheless a
complaint that must be remedied.
4. Develop a nursing care plan: Take the top 2 nursing diagnosis and process them each with the following criteria: complete nursingdiagnosis, goal/outcome criteria and interventions. Each diagnosis must have at least one goal and three interventions (with scientificrationale included for each intervention) and evaluation. Goals must be SMART (specific, measurable, attainable, realistic and timed).
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Nursing Diagnosis #1: Ineffective health maintenance related to deficient knowledge regarding self-care after appendectomy as evidenced byher noncompliance with the incentive spirometer and young age of 18 (Ackley & Ludwig, 2011, p. 430).
Nursing Goal/ Expected Outcome By the end of shift, patient will take initiative to collaborate with health providers to plan the therapeutic
regimen that is harmonious with her health goals and lifestyle. She will verbalize her ability to manage therapeutic regimens by the end ofshift (Ackley & Ludwig, 2011, p. 431).
Intervention #1: Establish rapport and a collaborative partnership with the client to plan and meet health-related goals by the end of shift.
y Rationale: Avoiding the paternalistic approach to care and implementing a partnership approach to care results in an effectivecollaboration between health-care provider and client (Doss, DePascal, & Hadley, 2011).
Intervention #2: Explore the clients interpretation of her illness and experience and identify uncertainties and needs through open-endedquestions.
y Rationale: Studies show that there are discrepancies between the clients view of self-management and the providers view.Noncompliance does not always mean ineffective self-management (Ackley & Ludwig, 2011, p. 431).
Intervention #3: Involve family members in knowledge development, planning for self-management, and shared decision making.
y Rationale: Family support is a strong factor in the full recovery of the patient, especially because D.L. is still young of age at 18 andmay have an immature or undeveloped attitude to her self-care regimen. The involvement of her mother, an RN, is especiallydesirable (Ackley & Ludwig, 2011, p. 431).
Evaluation Patient has verbalized instructions on how to care for her incisions and the use of her medications, especially the antibiotics, bythe end of shift. Family has also verbalized instructions and has encouraged the patient to use the incentive spirometer 10 times per hour by
end of shift. Patient understands the importance of recovery with self-management by verbalizing such sentiment at the end of shift. She hastaken initiative to plan a self-care regimen with the provider by the end of shift.
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Nursing Diagnosis #2: Risk for infection related to incisions in the infraumbilical and suprapubic locations and the patients young age of 18(Ackley & Ludwig, 2011, p. 491).
Nursing Goal/ Expected Outcome Patient will verbalize and demonstrate instructions on how to care for her incisions, remain free from
symptoms of infection, verbalize symptoms of infection to be on the alert for, and demonstrate proper hygiene such as handwashing, perinealcare, and oral care by the end of shift (Ackley & Ladwig, 2011, p. 491).
Intervention #1: Observe and report signs of infection such as redness, warmth, discharge from the incisions and an increased body
temperature by the end of shift.
y Rationale: Fever is a common sign of infection and must be reported immediately. Fever can occur without discharge or otherobservable symptoms (Ackley & Ladwig, 2011, p. 492).
Intervention #2: Assess skin for color, moisture, texture, and turgor every hour throughout shift.
y Rationale: The skin is the bodys first line of defense against infection (Ackley & Ladwig, 2011, p. 492).Intervention #3: Use appropriate hand hygiene such as hand washing with soap and alcohol-based hand rubs followed by wearing gloves
during contact with the incisions throughout shift.
y Rationale: A lower MRSA rate was linked to good hand hygiene and many infectious pathogens are carried via hands. Duringassessment or wound change, gloves must be worn to prevent contact with blood and mucous membranes (Morton & Schultz, 2004).
Evaluation At the end of shift, there are no signs of infection in the incisions at the suprapubic and infraumblical locations. Patient has
demonstrated proper hand hygiene and on how to care for her incisions. She verbalized the symptoms of an infection and has understood thatimportance of reporting them immediately.
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References
Ackley, B.J., & Ladwig, G.B. (2011).Nursing diagnosis handbook: An evidence-based guide to planning care (9th
ed.): Mosby, Inc.
Doss, S., DePascal, P., & Hadley, K. (2011). Patient-nurse partnerships. Nephrology Nursing Journal, 38(2), 115-124. Retrieved from
http://search.proquest.com/docview/857241101?accountid=8459
Epocrates online (2011). Retrieved 12/09/2011, from Https://online.epocrates.com
Lewis, S. L., Bucher, L., Dirksen, S. R., Camera, I. M., Heitkemper, M. M. . (2011).Medical-surgical nursing: assessment and management
of clinical problems (eighth ed. Vol. 2). St. Louis, Missouri: Mosby.
Monahan, F. D., Green, C.J., Neighbors, M. (2011).Manual of medical-surgical nursing: a care planning resource (7th ed.). Maryland
Heights, MO: Mosby.
Morton, J. L., & Schultz, A. A. (2004). Healthy Hands: Use of Alcohol Gel as an Adjunct to Handwashing in Elementary School Children.
Journal Of School Nursing, 20(3), 161-167.