Jesse Mosier Nursing 214



Jesse Mosier Nursing 217

Nursing Diagnosis: Acute Pain R/T inflamed pancreas, GB distension, Bililary Obstruction, AEB Pain 7/10

Goal: Patient pain level will decrease to pt’s comfort level of 2-3/10.

|OUTCOME CRITERIA: |INTERVENTIONS: |SCIENTIFIC RATIONALE: |EVALUATION: |

|1. Pt’s pain level will trend |1. Assess pain characteristics q hr and |1. Establishing a patient’s pain comfort level will provide a basis to determine |1. P- Patient states pain 7/10 located in |

|to 2-3/10 q hr as assessed PRN. |PRN. (Independent/Collaborative) |effectiveness of pain management interventions. Single dimension pain ratings are valid |midepigatric area (UL and UR abdomen |

| | |and reliable as measures of pain intensity level. Self report is considered the single |quadrants) sharp, constant, unrelieved by |

| | |most reliable indicator of pain presence and intensity. My patient states he has a sharp, |repositioning, vomiting. With administration |

| | |constant pain in his midepigastic area which radiates to his back that is unrelieved by |of Demerol and Morphine level decreased to |

| | |changing position. This is a cardinal finding in cases of acute pancreatitis. Because this|6/10 then 5/10. Alternative pain techniques |

| | |pain is not static but dynamic, it is necessary to monitor pain levels on a regular basis.|(massage, distraction) although reported to be|

| | |Failure of clinicians to assess a client's pain, accept the findings, and treat the report|relaxing by the patient did not further |

| | |of pain is a common cause of unrelieved pain and suffering. As my patient has reported a |decrease pain level. Will continue to monitor |

| | |pain level of 7/10 it is important to know the location, duration, characteristics of his |pain level, characteristics, and apply |

| | |pain to property treat and relieve it, and identify any changes in underlying physiologic |interventions. |

| | |status. Using OLDCARTS analysis is a valid way to obtain information on pt’s pain and | |

| | |assess for interventions/treatments that were effective in the past. Effective pain relief| |

| | |is critical for decreasing risk factors for complications with this patient including | |

| | |respiratory dysfunction, tachycardia, Hypertension, Hyperglycemia, increased muscular | |

| | |contraction and spasm, muscular weakness, fatigue, nausea, and decreased immune response, | |

| | |weakness, fatigue, and catabolism. |2. P-HR trending down (117 1/6, 76 on end of |

| | | |shift 1/7). Systolic BP trending down from |

| | | |admission (152/92 on 1/6, 117/76 on end of |

| | | |shift 1/7) Respiration trend remained 12-20 |

| |2. Assess Pt’s VS q 4 hr, PRN (Independent)|2. As pain impulses ascend the spinal cord toward the brain stem and thalamus, the |bpm, easy, regular, O2 Sat. remained >93% |

| | |autonomic nervous system becomes stimulated as part of the stress response. Pain elicits |stable, Temp. trending |

| | |the fight-or-flight reaction of the general adaptation syndrome. Stimulation of the |up(99.4/100.1/101.7/101.4/101.3) but decreased|

| | |sympathetic branch of the autonomic nervous system results in physiological responses |with Tylenol PRN order administration (99.3 |

| | |including dilation of bronchial tubes and increased respiratory rate, increased heart |(1/6) 100.0 (1/7) Will continue to monitor. |

|2. Pt’s pulse will trend to | |rate, peripheral vasoconstriction (pallor, elevation in blood pressure), increased blood |Offered cold compress, encouraged ice chip |

|below 100 bpm, Systolic BP will | |glucose level, diaphoresis, increased muscle tension, dilation of pupils, and decreased |consumption. |

|trend to below 120mm/Hg, | |gastrointestinal motility. By identifying vital sign trends the pt’s physiological | |

|Dystolic BP will remain below | |response to pain can be identified and interventions can be taken. An example regarding | |

|80mm/Hg, Temp. will trend to | |this effect is illustrated with the pt’s increased temperature. This increased temp trend| |

|below 100*F , Respirations will | |suggests infection and inflammatory response. (WBC at 11.3, and Neut % at 82 to support) | |

|remain 12-20per min, O2 sat will| |Further Inflammation will exacerbate and increase patient’s pain level as the enlargement | |

|remain >93% on RA as assessed q | |of the pancreas and stretching of the peritoneum will increase peritoneal/abdominal | |

|4hrs, PRN. | |pressure and pain. By identifying this change a medical intervention can be applied, in | |

| | |this case Tylenol which will reduce the pt’s temperature and associated discomfort, and |3. P- Pt. identified one noninvasive pain |

| | |would aide in reducing pt’s pain in conjunction with opioid analgesics. |control method. Will continue to reinforce |

| | | |teaching. Additional pharmacological |

| | | |interventions are needed to further decrease |

| |3. Instruct patient to utilize noninvasive |3. Distraction directs a client's attention to something other than pain and thus reduces |pt’s pain level. |

| |methods q shift, PRN. (Independent) |the awareness of pain. Distraction works best for short, intense pain lasting a few | |

| | |minutes, such as during an invasive procedure or while waiting for an analgesic to work. | |

| | |Use activities enjoyed by the client that will act as distractions. My patient really | |

| | |enjoys talking about his work and his family. Relaxation techniques include meditation, | |

| | |yoga, Zen, guided imagery, and progressive relaxation exercises. Relaxation is mental and| |

| | |physical freedom from tension or stress that provides individuals a sense of self-control.| |

| | |You are able to use relaxation techniques at any phase of health or illness. Physiological| |

| | |and behavioral changes associated with relaxation include the following: decreased pulse, | |

| | |blood pressure, and respirations; heightened global awareness; decreased oxygen | |

| | |consumption; a sense of peace; and decreased muscle tension and metabolic rate. Massage is| |

| | |effective for producing physical and mental relaxation, reducing pain, and enhancing the | |

|3. Pt will demonstrate/verbalize| |effectiveness of pain medication. Massaging the back, shoulders, hands, and/or feet for 3 | |

|three effective methods of | |to 5 minutes relaxes muscles and promotes sleep and comfort. Stimulation of the skin helps| |

|noninvasive pain management | |relieve pain. The proper use of cutaneous stimulation helps reduce muscle tension that |4. P-after first teaching session pt was not |

|after one on one teaching | |increases pain. When using cutaneous stimulation, eliminate sources of environmental |able to successfully demonstrate technique. |

|session. | |noise, help the client to assume a comfortable position, and explain the purpose of the |Further instruction was given and pt |

| | |therapy. Other noninvasive medthods include music, guided imagery, and biofeedback |successfully demonstrated and stated decreased|

| | | |pain when technique utilized. |

| | |4. Abdominal splinting can done either seated upright or lying down. Instruct the patient | |

| | |to hold a pillow or rolled blanket over the abdomen, and to wrap both arms or hands as | |

| |4. Demonstrate proper Abdominal Splinting |fully as possible across the pillow and press firmly. Instruct pt to then take a slow, | |

| |technique to patient. (Independent) |deep breath and then cough at the end of the deep breath pressing firmly over abdomen. | |

| | |Splinting with a pillow or a rolled blanket provides support to the abdominal area thereby| |

| | |decreasing pain from movement. It also aids in decreasing pain when coughing and assists | |

| | |in expectoration of secretions and keeping lung fields clear. | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | |5. M- Lipase/Amylase levels on 1/6 were 5504 |

| | | |units/L and 278 units/L, 1/7 Lipase 1218 |

| | | |units/L and Amylase 110 units/L. |

| | | | |

| | | | |

| | |5. Serum amylase levels in patients with pancreatitis vary depending on the severity of | |

| | |the disease. On average, during uncomplicated cases, the serum amylase level starts | |

| | |increasing from two to 12 hours after the onset of symptoms and peaks at 12 to 72 hours. | |

| | |It usually returns to normal within one week with treatment. Although it lacks | |

|4. Pt will return demonstrate | |sensitivity, measurement of the serum amylase level is the most widely used method of | |

|proper Abdominal splinting after| |diagnosing pancreatitis and the degree of its severity. Lipase levels increase within four| |

|one on one teaching session. | |to eight hours of the onset of clinical symptoms and peak at about 24 hours. Levels | |

| | |decrease within eight to 14 days. The specificity of lipase measurements are better than | |

| | |those of amylase measurements, particularly in detecting alcoholic pancreatitis. The | |

| | |specificity of lipase measurement, as well as amylase measurement, may be improved by | |

| | |raising the threshold to at least three times the upper limit of the normal reference | |

| | |values. Decreases in these lab values would indicate effective treatment as they correlate| |

| | |to a decrease in inflammation and permeability of the pancreas. This decrease in | |

| |5. Assess Lipase/ Amylase lab values when |inflammation will result in decreasing pressure in the peritoneum and abdomen and a |6. U-UltraSound on 1/6 shows pericolic fluid |

| |available, PRN (Dependent) |decrease in pain level for the pt. |with GB distention, Fatty Liver, and trace |

| | | |acities to GB. Further ultrasound(s) should be|

| | | |completed to monitor for improved |

| | | |EF>13%changes in physiology and function. |

| | | |Will continue to apply non-pharmacological and|

| | |6. Abdominal ultrasound is used to examine organs in the abdomen including the liver, |pharmacological (Demerol, Morphine) |

| | |gallbladder, spleen, pancreas, and kidneys. As my pt presented with sharp epigastric |interventions to reduce pain related to |

| | |abdominal pain an ultrasound was performed on 1/6. An Abdominal ultrasound can be very |inflammation and distention. |

| | |useful in detecting acute pancreatitis. In many cases ultrasound can differentiate which | |

| | |type of acute pancreatitis is presenting; mild or edematous and severe or necrotizing. | |

| | |Mild acute pancreatitis sometimes presents with just focal involvement of the gland, | |

| | |especially the head. In addition if associated complications develop such as pseudocysts | |

| | |or vascular abnormalities such as pseudoaneurysms, ultrasound can detect them. By using | |

| | |the data provided by the ultrasound a diagnosis of acute pancreatitis can be made (along | |

| | |with any common complications) and interventions can be put in place to reduce pt’s pain | |

| | |level. | |

| | | | |

| | | |7. P- IV patent, running at 150ml/hr. Pt MM, |

|5. Pt Lipase level will trend to| | |lips moist, skin non-tenting, provided Ice |

|0-60 units/L, Amylase will | | |Chips, Cap refill 45 |

| | |present with laryngospasm, neuromuscular irritability, and even heart failure. The |degrees. |

| | |development of many of these complications would further increase the pt’s pain level. By | |

| | |monitoring for these complications we can apply interventions quickly and keep the pt’s | |

| | |pain level from rising. | |

| | | | |

| | | | |

| | |10. This pt has been diagnosed with acute pancreatitis. Acute pancreatic pain for this pt| |

| | |is located in midepigastic area and radiates retroperioneally. Any enlargement of the | |

| | |pancreas causes the peritoneum to stretch tightly causing increased pain. By having the pt| |

| | |sit up, lean forward, or on side with legs drawn up to chest, pain will be reduced. His |11. U-WBC at 11.3x10^3/ul, Neutrophils 82% on |

| | |current pain level was 7/10. |1/6. No further labs available at this time. |

|7. Pt will remain free of S/S of| | |Will verify CBC is ordered and will review lab|

|FVD, hypovolemia as assessed q | | |values when available. Will monitor trend. |

|sift | | |While waiting for results will continue to |

| | | |utilize non-pharmacological and |

| | | |pharmacological pain relief relief |

| | | |interventions to decrease pt’s pain level from|

| | |11. The body’s natural defense mechanism to infection includes systemic inflammatory |current 7/10 to comfort level of 2-3/10. |

| | |response. With acute pancreatitis the peritoneum has increased pressure on it related to |12. P-Temperature initially trending up on |

| | |the inflammatory process. Any additional inflammation related to infection will increase |shift. Exceeded MD parameters. Notified |

| | |the patients pain level. A tend of decreasing WBC’s and % of Neutrophils indicate this |Primary RN Jenn Schemmerhorn who notified MD. |

| | |pt’s infection is resolving. The decrease infection will correlate to a decrease in |Temp. (99.4/100.1/101.7/101.4/101.3) but |

| | |inflammation that will decrease pt’s pain level. The presence of an active infection may |decreased with Tylenol PRN order |

| | |also impair or delay the pt’s ability to have a surgical intervention. Any delay would |administration (99.3 (1/6) 100.0 (1/7) Will |

| | |cause the patient to remain at a higher level of pain for a longer period of time. |continue to monitor. Offered cold compress, |

| |8.Maintain NPO with Ice Chips and Meds Per | |encouraged ice chip consumption. Pain 5/10. |

| |MD order(Dependent) | | |

| | | | |

| | | | |

| | |12. Acute pancreatitis causes inflammation and as part of the inflammatory process the | |

| | |hypothalamus has increased body temperature and the pt is now fibrile. Acetaminophen is a |13. P-Zosyn administered per MD order. WBC at |

| | |non-opioid analgesic and antipyretics. The exact mechanism of action of acetaminophen is |11.3x10^3/ul, Neutrophils 82% on 1/6. No |

| | |not known. It is thought to reduce the production of prostaglandins in the brain which |further labs available at this time. Will |

| | |mitigates their effects on the CNS. It reduces fever through its action on the |verify CBC is ordered and will review lab |

| | |hypothalmus. While acetaminophen does not have significant anti-inflammatory properties |values when available to monitor trend. |

| | |will provide pain relief for this pt via other actions including acting as an adjunct | |

| | |analgesic to administered opioid analgesics (e.g. Demerol) to reduce the pt’s pain level, | |

| | |and also reducing discomfort related to the pt’s fever. | |

| | | | |

| | | | |

|8. Pt’s pain level will trend to| | | |

|2-3/10 q as assessed q hr, PRN | | | |

| | | | |

| | |13. Zosyn is an anti-infective and extended spectrum penicillin. It is a combination of | |

| | |two drugs. Piperacillin, a penicillin-type antibiotic that binds to bacterial cell wall |14. U-C-reactive protein lab unavailable at |

| | |membranes causing cell death and Tazobactam a beta-lactamase inhibitor that assists in |this time. Will follow up with MD. Once lab |

| | |mitigating enzyme activity that can destroy pennicillins. The bodies natural defense |data available will assess and analyze result |

| | |mechanism to infection includes systemic inflammatory response. Administering Zosyn will |and apply appropriate interventions to reduce |

| | |decrease the likelihood for additional inflammation in relation to this pt’s infection and|pain. |

| | |will assist the body in mitigating the infection and current inflammation the patient is | |

| | |experiencing. This decrease in inflammation will decrease pt’s pain level. EBP data | |

| | |suggest that the best time to introduce antibiotics is immediately after the diagnosis of |15.P- Pt’s Pain level trended down from 7/10 |

| | |Acute Pancreatitis and the evaluation of its severity. The presence of an active infection|to 5/10 but not to comfort level of 2-3/10. Pt|

| | |may also impair or delay the pt’s ability to have a surgical intervention. Any delay would|did state that it “helped dull the pain”. |

| |9. Monitor for manifestations of |cause the patient to remain in pain for a longer period. |Additional PRN pain med. (morphine) |

| |hypocalcaemia q shift, PRN | |administered. |

| |(Independent) | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | |14. C-reactive protein is a sensitive marker of pancreatic necrosis and it starts to | |

| | |increase significantly 48 hours after the onset of symptoms. C-reactive protein can be | |

| |10. Assist patient in assuming positions of|useful in the identification of patients with high possibility to develop necrosis, in | |

| |comfort q shift, PRN (Independent) |particular when the value is over 150 mg/dl. By identifying if pancreatic necrosis is |16. P-Pt indicated desire to go outside and |

| | |occurring interventions such as |smoke. After teaching session he changed his |

| | | |mind and decided to not go outside and smoke |

| | | |for now. Cessation resources such as nicotine |

|9. Serum Calcium levels will | | |gum or patches, 1-866-NYQUITS, were also |

|trend to 8.2-9.6 mg/dl q day as | | |discussed with the pt. as resources to assist |

|assessed. | | |with cessation. Will continue to reinforce |

| | | |benefits of smoking cession in regards to pt’s|

| | |15. This patient present with a high pain level (7/10) related to the inflammation of his |pain R/T inflammation and pt’s perception of |

| | |pancreas and distention of his gall bladder. Meperidine hydrochloride(Demerol) is a |pain. |

| | |narcotic analgesic for moderate to severe pain with multiple actions similar to those of | |

| | |morphine. The most prominent of these involve the depression of the CNS ,and organs | |

| |11. Assess WBC/Neut% lab values q shift, PRN|composed of smooth muscle. The principal actions of therapeutic value are analgesia and | |

| |(Dependent) |sedation. These are achieved as the drug binds to opiate receptors in the CNS. This alters| |

| | |the perception and response of the pt to painful stimuli including the inflammation and | |

| | |distention related to the pancreatitis. There is also some evidence that suggests that | |

| | |meperidine may produce less smooth muscle spasm, constipation, and depression of the cough| |

| | |reflex than equal doses of morphine an additional benefit to this pt as respiratory | |

| | |complications can occur R/T pancreatitis and its effects on the function of the diaphragm.| |

|10. Pt will demonstrate proper | |Administration of this intervention will decrease pt’s pain level. | |

|positioning for decreased pain | | | |

|after one on one teaching | | | |

|session. | |16. This pt is a current smoker and has a 5 pack yr history. Recent studies and an | |

| | |increasing amount of scientific data have shown that smoking can be a major contributing | |

| | |cause of acute and chronic pancreatitis and that the combination of alcohol and smoking is| |

| | |particularly toxic. Duration of smoking was a better predictor of increased risk than | |

| | |smoking intensity. Several studies have found that smoking cause’s pt’s to perceive pain | |

| |12. Administer Acetaminophen PO 650 mg q 4 |more acutely as Tobacco use effects the nervous system by increasing the sensations and | |

| |hrs, PRN per MD order |perceptions of pain. In addition smokers have been shown to require more medication (both | |

| |(Dependent) |opiate and analgesics) to ease their pain as nicotine is believed to alter the | |

| | |pharmokenetics of medications. In addition to the negative effects on pain level and | |

| | |sensation, smoking is a known contributor to inflammation, decreases O2 levels increasing | |

| | |workload on the heart and lungs, and interferes with the healing process. All three of | |

|11. Pt’s WBC will trend towards | |these issues will contribute to my pt’s overall pain level. It is interesting to note | |

|4.8-10.8 x10^3/ul, Neutrophils | |however that evidence also suggests that rapid dissipation of the systemic effects of | |

|59% | |nicotine contributes to pain-related symptoms during periods of relative nicotine | |

|q day as assessed. | |deprivation. This suggests that nicotine replacement (gum or patch) may be warranted to | |

| | |reduce the pt’s pain level during cessation of smoking. | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|12. Pt’s temperature will trend |13.Administer Zosyn IV 3.375g q 6 hr per MD | | |

|down toward towards 98.6 degrees|order (Dependent) | | |

|30min-1hr after administration | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|13.Pt’s WBC count will trend | | | |

|towards 4.8-10.8 x10^3/ul, | | | |

|Neutrophils 37-80% | | | |

|as assessed q day | | | |

| | | | |

| |14. Monitor C-Reactive Protein lab value | | |

| |when available. (Dependent/Collaborative) | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| |15. Administer Demerol IV 10mg/hr per MD | | |

| |order (Dependent) | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|14. Pt’s C-reactive protein will| | | |

|trend to 0-0.8mg/dL q day as | | | |

|assessed. | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|15. Pt’s pain level will trend |16. Encourage/teach smoking cessation q | | |

|to 2-3/10 following Demerol |shift, PRN(Independent/Collaborative) | | |

|administration as assessed. | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|16. Pt will | | | |

|verbalize/demonstrate | | | |

|understanding of connection | | | |

|between smoking and pancreatitis| | | |

|after one on one teaching | | | |

|session. | | | |

| | | | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download