UNIVERSITY OF SOUTH FLORIDA
UNIVERSITY OF SOUTH FLORIDA
COLLEGE OF NURSING
| |Student: Elizabet Iankova |
|Fundamental Patient Assessment Tool . |Assignment Date: 7/10/2014 |
| ( 1 PATIENT INFORMATION |Agency: FHT |
|Patient Initials: M.M |Age: 66 |Admission Date: 6/21/2014 |
|Gender: F |Marital Status: Married |Primary Medical Diagnosis with ICD-10 code: Gallstone Pancreatitis |
| | |k.85.9 |
|Primary Language: English | |
|Level of Education: High school Diploma |Other Medical Diagnoses: (new on this admission)- none |
|Occupation (if retired, what from?): Security guard | |
|Number/ages children/siblings: 2 Children (44 + 46 years old) Brother, 59 Sister,63 | |
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|Served/Veteran: none |Code Status: Full resuscitation |
|Living Arrangements: At home with husband |Advanced Directives: No |
| |If no, do they want to fill them out? No |
| |Surgery Date: 6/22/2014 Procedure: laparoscopic |
| |gallbladder |
|Culture/ Ethnicity /Nationality: American, Caucasian | |
|Religion: Catholic |Type of Insurance: n/a |
|( 1 CHIEF COMPLAINT: |
|The patient complained of back pain and feeling nauseous when awake. |
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|( 3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course) |
|Patient was admitted to the hospital on 6/21/14 for back pain and nausea while awake. The patient reports having back pain for a few years but before coming to the|
|hospital the pain would come and go for two days. She described the pain as a dull aching pain towards the back of her heart. Every time she felt pain in her back,|
|she had nausea as well. She did not try any remedies before coming to the hospital. The patient is now on 4 south for treatment of gallstone pancreatitis. |
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( 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical illness or operation
|Date |Operation or Illness |
| |Type 2 diabetes – managed with Insulin lispro medium dose |
| |Hypertension- managed with losartan 100 mg daily |
| |Congestive heart failure – managed with carvedilol 12.5 mg 2 times daily |
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|( 2|Age (in years) |
|FAM| |
|ILY| |
|MED| |
|ICA| |
|L | |
|HIS| |
|TOR| |
|Y | |
| |Mother had uterine cancer. The radiation caused scar tissue in the kidneys. |
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|( 1 immunization History |
|(May state “U” for unknown, except for Tetanus, Flu, and Pna) |Yes |No |
|Routine childhood vaccinations |X | |
|Routine adult vaccinations for military or federal service | |X |
|Adult Diphtheria (Date) | |X |
|Adult Tetanus (Date) | |X |
|Influenza (flu) (Date) | |X |
|Pneumococcal (pneumonia) (Date) | |X |
|Have you had any other vaccines given for international travel or occupational purposes? Please List | |X |
|( 1 ALLERGIES OR ADVERSE |NAME of |Type of Reaction (describe explicitly) |
|REACTIONS |Causative Agent | |
|Medications |NKA |No known allergies |
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|Other (food, tape, latex, dye, |NKA | |
|etc.) | | |
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|( 5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to diagnose, how to treat, prognosis, and include any |
|genetic factors impacting the diagnosis, prognosis or treatment) |
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|Acute or chronic pancreatitis is an inflammation and potential necrosis of the pancreas. The cause of tissue damage from pancreatitis occurs because of the |
|activation of proteolytic and lipolytic pancreatic enzymes that are normally activated in the duodenum. Proteolytic enzymes breakdown proteins, while lipolytic |
|enzymes break down fats. The enzymes cause autodigestion with leakage of the enzymes and fluid into the surrounding tissues. There is permanent destruction in |
|chronic pancreatitis. Precipitation of proteins causes pancreatic duct obstruction. Edema and distention cause drainage and loss of the aciner cells, which |
|normally produce digestive enzymes. The normal cells are replaced with necrosis. Risk factor for pancreatitis in adult females is cholelithiasis and bilary tract |
|obstructions. Symptoms in females with gallstone related to pancreatitis can occur after a large fatty meal. Symptoms include pain in the back around the costal |
|margins and also nausea and vomiting. Several different methods can be used to diagnose pancreatitis including diagnostic tests that test for abnormal levels of |
|enzymes and a computed tomography that will show pancreatic enlargement, inflammation or fluid collection. The immediate goal of treatment is to control and |
|decrease the inflammation of the pancreas by reducing the secretions of pancreatic enzymes. Surgical interventions may be indicated for managing the complications |
|associated with pancreatic necrosis. . (Nursing Central, 2014, Pancreatitis.) |
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( 5 Medications: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and generic name.]
|Name carvedilol |Concentration (mg/ml) 12.5mg/ .125ml |Dosage Amount (mg) 12.5 mg |
|Route orally |Frequency 2x BID |
|Pharmaceutical class beta- blockers |Home Hospital or Both X |
|Indication Controlling high blood pressure |
|Side effects/Nursing considerations side effects include dizziness, fatigue, weakness, anxiety, blurred vision and bradycardia. May alter the effectiveness of |
|insulin’s and thyroid preparations. Monitor blood pressure and pulse frequently, also intake and output and daily weight. It may cause an increase in blood |
|glucose levels. |
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|Name cefOXitin |Concentration 100ml/hr |Dosage Amount 1gm |
|Route IV |Frequency Q8h infuse over 30 min. |
|Pharmaceutical class second generation cephalosporins |Home Hospital X or Both |
|Indication To prevent infection after surgery |
|Side effects/Nursing considerations Seizures at high doses, diarrhea, nausea , vomiting and anaphylaxis . Nurse should assess for infection, appearance of wound,|
|urine, stool and WBC count. Observe patient for signs and symptoms of anaphylaxis, such as rash, laryngeal edema and wheezing. |
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|Name Insulin lispro (HumaLOG) |Concentration |Dosage Amount medium dose |
|Route INJ subcu |Frequency Q4h |
|Pharmaceutical class antidiabetics |Home Hospital or Both X |
|Indication Control of hyperglycemia in patient with type 2 diabetes mellitus |
|Side effects/Nursing considerations Use cautiously in stress or infection and renal/hepatic impairment. An adverse reaction would be hypoglycemia and anaphylaxis. |
|Drug-drug interactions with a beta-blocker may mask some of the signs and symptoms of hypoglycemia. |
|Name levothyroxine (Synthroid) |Concentration |Dosage Amount 100mcg |
|Route orally |Frequency PO daily |
|Pharmaceutical class thyroid preparations |Home Hospital or Both X |
|Indication Thyroid supplementation in hypothyroidism |
|Side effects/Nursing considerations Adverse/side effects are usually seen when excessive doses cause iatrogenic hyperthyroidism. May increase the requirement for |
|insulin hypoglycemia agents in diabetes. |
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|Name losartan |Concentration 100mg/ |Dosage Amount 100mg |
|Route Orally |Frequency PO Daily |
|Pharmaceutical class Antihypertensive |Home Hospital or Both X |
|Indication Management of hypertension |
|Side effects/Nursing considerations Most common side effect is diarrhea, and Angioedema is a life threatening adverse effect. NSAIDS may blunt the |
|antihypertensive effect and increase the risk of renal dysfunction. |
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|Name |Concentration |Dosage Amount |
|Route |Frequency |
|Pharmaceutical class |Home Hospital or Both |
|Indication |
|Side effects/Nursing considerations |
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|Name |Concentration |Dosage Amount |
|Route |Frequency |
|Pharmaceutical class |Home Hospital or Both |
|Indication |
|Side effects/Nursing considerations |
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|Name |Concentration |Dosage Amount |
|Route |Frequency |
|Pharmaceutical class |Home Hospital or Both |
|Indication |
|Side effects/Nursing considerations |
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|Name |Concentration |Dosage Amount |
|Route |Frequency |
|Pharmaceutical class |Home Hospital or Both |
|Indication |
|Side effects/Nursing considerations |
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|Name |Concentration |Dosage Amount |
|Route |Frequency |
|Pharmaceutical class |Home Hospital or Both |
|Indication |
|Side effects/Nursing considerations |
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|Name |Concentration |Dosage Amount |
|Route |Frequency |
|Pharmaceutical class |Home Hospital or Both |
|Indication |
|Side effects/Nursing considerations |
|( 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations. |
|Diet ordered in hospital? Diabetic |Analysis of home diet (Compare to “My Plate” and |
|Diet patient follows at home? Diabetic |Consider co-morbidities and cultural considerations): |
|24 HR average home diet: | |
|Breakfast: 2 regular slices of rye bread with 2 tablespoons whipped cream |The patient has been following her diabetic diet for the last three months and |
|cheese |reports feeling a lot better. According to her 24 HR average home diet, she gets |
| |an ample amount of proteins and whole grains. Whole grains are rich in vitamins, |
| |minerals and fiber. According to MyPlate, my patient has 875 calories remaining. |
| |For the rest of her remaining daily categories I would suggest she eat non |
| |starchy vegetables that are high in fiber such as broccoli, spinach, mushrooms |
| |and peppers. I would also add some low glycemic fruits for a snack such as apples|
| |or peaches. Overall, she is well under the daily limit for oils, saturated fats |
| |and sodium, which is beneficial for her. |
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|Lunch: 1 turkey sandwich with light mayonnaise | |
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|Dinner: chicken fettuccini diet frozen meal. 1 Lean Cuisine meal (9.5 oz.) | |
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|Snacks: 2 fiber one chewy bars (1.4 oz.) | |
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|Liquids (include alcohol): 1 mug (8 fl oz. ) regular brewed coffee. 2 bottles | |
|of water , unsweetened ( 500 ml) | |
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|[pic] |Use this link for the nutritional analysis by comparing the patients 24 HR |
| |average home diet to the recommended portions, and use “My Plate” as a reference.|
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|(1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion) |
|Who helps you when you are ill? Daughter |
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|How do you generally cope with stress? or What do you do when you are upset? |
|My patient reports not that much stress. |
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|Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life) none. |
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|+2 DOMESTIC VIOLENCE ASSESSMENT |
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|Consider beginning with: “Unfortunately many, children, as well as adult women and men have been or currently are unsafe in their relationships in their homes. I |
|am going to ask some questions that help me to make sure that you are safe.” |
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|Have you ever felt unsafe in a close relationship? __________no_____________________________________________ |
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|Have you ever been talked down to?_____no__________ Have you ever been hit punched or slapped? _____no_________ |
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|Have you been emotionally or physically harmed in other ways by a person in a close relationship with you? |
|____________no______________________________ If yes, have you sought help for this? ______________________ |
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|Are you currently in a safe relationship? yes |
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|( 4 DEVELOPMENTAL CONSIDERATIONS: |
|Erikson’s stage of psychosocial development: Trust vs. Mistrust Autonomy vs. Doubt & Shame Initiative vs. Guilt Industry vs. Inferiority Identity vs. |
|Role Confusion/Diffusion Intimacy vs. Isolation Generativity vs. Self absorption/Stagnation X Ego Integrity vs. Despair |
|Check one box and give the textbook definition (with citation and reference) of both parts of Erickson’s developmental stage for your |
|Patient’s age group: As senior citizens, people tend to look back on their lives and think about what they have or have not accomplished. If a person has led a |
|productive life, they will develop feeling of integrity. If not, they might fall into despair. |
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|Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination: |
|My patient is in the ego integrity phase. She does not show and notable signs of despair, and appears content and interacts well with others. She talks highly of |
|her supportive husband and about her work as a security guard. Overall, she shows a positive outlook on her life. The one concern I would have for her that shows |
|different is her thoughts about her obesity. The patient mentioned that she does not want her daughter to become obese as well. Although, she mentioned that she |
|has been trying really hard to stick to her diabetic diet and has lost weight in the last three months. She hopes to continue making progress. |
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|Describe what impact of disease/condition or hospitalization has had on your patient’s developmental stage of life: The impact of disease has made my patient |
|feel vulnerable, as she says. She believes she has been relatively healthy besides her obesity and diabetes before she got gallbladder pancreatitis. Even after |
|this surgery, my patient still does not show despair, she is positive and ready to be discharged. |
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|+3 CULTURAL ASSESSMENT: |
|“What do you think is the cause of your illness?” Patient calls it “random” |
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|What does your illness mean to you? The patient says “All this time I felt healthy, and have not been in pain” She reports feeling more vulnerable because this |
|is her first surgery. She also mentioned that she has been carrying her weight for too long |
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|+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion) |
|Consider beginning with: “I am asking about your sexual history in order to obtain information that will screen for possible sexual health problems, these are |
|usually related to either infection, changes with aging and/or quality of life. All of these questions are confidential and protected in your medical record” |
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|Have you ever been sexually active?__________yes__________________________________________________________ |
|Do you prefer women, men or both genders? ______men_______________________________________________________ |
|Are you aware of ever having a sexually transmitted infection? ______no_________________________________________ |
|Have you or a partner ever had an abnormal pap smear?_____________________________________________________ Have you or your partner received the Gardasil (HPV) |
|vaccination? __________no_________________________________ |
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|Are you currently sexually active? ______________no_____________When sexually active, what measures do you take to prevent acquiring a sexually transmitted |
|disease or an unintended pregnancy? ________________none__________________ |
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|How long have you been with your current partner?_______39 years_________________________________________________ |
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|Have any medical or surgical conditions changed your ability to have sexual activity? __no_________________________ |
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|Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy? |
|no |
±1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)
What importance does religion or spirituality have in your life?
_____Patient says she is more spiritual because of her daughter_________________________________________________________________________________________________
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Do your religious beliefs influence your current condition?
_________________________________________________________________________________________________________________________Patient says she is thankful for her health in general. _____________________________________________________________________________
|+3 Smoking, Chemical use, Occupational/Environmental Exposures: |
|1. Does the patient currently, or has he/she ever smoked or used chewing tobacco? Yes No X |
| If so, what? |How much?(specify daily amount) |For how many years? 0 years |
|Never has smoked | |(age thru ) |
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|Pack Years: | |If applicable, when did the patient quit? |
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|Does anyone in the patient’s household smoke tobacco? If so, what, and how much? |Has the patient ever tried to quit? |
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|2. Does the patient drink alcohol or has he/she ever drank alcohol? Yes No X |
| What? |How much? (give specific volume) |For how many years? |
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| If applicable, when did the patient quit? | | |
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|3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes No X |
| If so, what? |
| |How much? |For how many years? |
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| Is the patient currently using these drugs? Yes No |If not, when did he/she quit? | |
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|4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks |
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( 10 Review of Systems Narrative
|General Constitution (OLDCART anything checked above) |
|Pt’s perception of health: Patient feels vulnerable after this surgery |
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|Integumentary: Patient reports dry skin, but denies problems with nails, dandruff, Psoriasis, hives, rashes, skin infections and does not go out in the sun often. |
|HEENT: Patient reports dental problems due to neglect, but denies difficulty seeing, cataracts, Glaucoma, difficulty hearing, ear infections, sinus pain or |
|infections, nose bleeds, post-nasal drip, oral/pharyngeal infection, regular vision and dental visits. |
|Pulmonary: Patient denies difficulty breathing, coughing, Asthma, Bronchitis, Emphysema, Tuberculosis, environmental allergies |
|Cardiovascular: Patient has hypertension and congestive heart failure, but denies hyperlipidemia, chest pain/angina, myocardial infarction, murmur, thrombus, |
|Rheumatic fever, Myocarditis, arrhythmias, last EKG was 6/21/14 |
|GI: Patient reports nausea, vomiting or diarrhea, constipation and pancreatitis. Patient denies GERD, indigestion, hemorrhoids, yellow jaundice, colitis, |
|diverticulitis , appendicitis, abdominal abscess, irritable bowel, cholecystitis, gastritis/ulcers, blood in stool and hepatitis. |
|GU: Patient reports polyuria, but denies nocturia, dysuria, bladder or kidney infections. |
|Women/Men Only: Patient began menopause at age 50, last mammogram was December 2013 |
|Musculoskeletal: Patient denies injuries, fractures, weakness, pain, gout, osteomyelitis, arthritis. |
|Immunologic: Patient denies chills with severe shaking, night sweats, fever, HIV or AIDS, Lupus, Rheumatoid Arthritis, Sarcoidosis, Tumor, life threating allergic |
|reaction, enlarged lymph nodes. |
|Hematologic/Oncologic: Patient denies anemia, bleeding easily, bruising easily, cancer, blood transfusions |
|Metabolic/Endocrine: Patients has diabetes, and hypothyroid, patient denies intolerance to hot or cold, osteoporosis |
|Central Nervous System: Patient denies CVA, dizziness, severe headaches, migraines, seizures, ticks or tremors, encephalitis, and meningitis. |
|Mental Illness: Patient denies depression, schizophrenia, anxiety and bipolar |
|Childhood Diseases: Patient had chicken pox but denies Measles, Mumps, Polio and Scarlet fever. |
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|Is there any problem that is not mentioned that your patient sought medical attention for with anyone? none |
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|Any other questions or comments that your patient would like you to know? none |
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|±10 PHYSICAL EXAMINATION: |
|General survey _____________________Patient is a 66 year old female who is obese with no visible signs of distress. The patient is alert and orientated |
|X3______________________________________________________________ |
|Height __158cm__________Weight____90.2 kg______ BMI ___n/a________ Pain (include rating and location)_____0______________ Pulse_70______ Blood Pressure (include |
|location)____131/54 right arm _________________Temperature (route taken)__98.8 oral__________ |
|Respirations___20_________ SpO2 ___98%______________ Room Air or O2___Room air________________________ |
|Overall Appearance_clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps |
|Overall Behavior_awake, calm, relaxed, interacts well with others, judgment intact___________________________________________________________________________ |
|Speech___clear, crisp diction________________________________________________________________________________________ |
|Mood and Affect___pleasant, cooperative, and talkative. ________________________________________________________________________________ |
|Integumentary___Skin is warm, dry, and intact, skin turgor elastic, no rashes, lesions, or deformities, nails without clubbing, capillary refill < 3 seconds, hair |
|evenly distributed, clean, without vermin |
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|IV Access___Peripheral IV site, 20 gauge, left side, inserted on 6/21/14, no redness, edema, or discharge. No fluids |
|infusing_____________________________________________________________________________________ |
|HEENT_HEENT: Facial features symmetric, no pain in sinus region, no pain, clicking of TMJ ,trachea midline |
|,thyroid not enlarged, no palpable lymph nodes ,sclera white and conjunctiva clear; without discharge |
|eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness |
|PERRLA ,Peripheral vision intact, EOM intact through 6 cardinal fields without nystagmus |
|ears symmetric without lesions or discharge , nose without lesions or discharge, lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions |
|_________________________________________________________________________________________ |
|Pulmonary/Thorax__Respirations regular and unlabored, clear lung sounds. Transverse AP ratio 2:1, chest expansion symmetric, percussion resonant throughout all lung |
|fields, dull towards posterior bases. _____________________________________________________________________________ |
|Cardiovascular__Regular S1 S2 sounds, no murmurs, clicks, heaves, lifts or thrills. Pulses bilaterally equal 2+ . no temporal or carotid bruits, no edema present. |
|__________________________________________________________________________________ |
|GI_bowel sounds active in all four quadrants, last BM 6/21/14 was liquid and watery. |
|_______________________________________________________________________________________________ |
|GU___Not assessed, patient alert, orientated, denies problems. ____________________________________________________________________________________________ |
|Musculoskeletal____Full ROM intact in all extremities without crepitus, strength bilaterally equal on both upper and lower extremities, vertebral column without |
|kyphosis or scoliosis, neurovascular status intact, peripheral pulses palable, no pain, pallor, paralysis, or paresthesia. |
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|Neurological : |
|Patient awake, alert, oriented to person, place, time, and date , |
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|Sensation intact to touch, pain, and vibration , Romberg’s Negative |
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|Stereognosis, graphesthesia, and proprioception intact ,Gait smooth, regular with symmetric length of the stride |
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|Negative Babinski. |
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|±10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as abnormals, include rationale and analysis. List dates with all labs and |
|diagnostic tests): |
|Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need prior to and after surgery, and pertinent to |
|hospitalization. Do not forget to include diagnostic tests, such as Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that |
|is done preop) then include why you expect it to be done and what results you expect to see. |
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|Lab |
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|Trend |
|Analysis |
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|WBC |
|6.9 |
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|19.8 H |
|Normal (4.5-11) |
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|(03/18/2013) |
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|(03/22/2013) |
|Upon admit, the patients WBC were in the low normal range. However, WBC are trending upwards indicating either an infection or inflammatory process is occurring. |
|Number of infection fighting cells. High WBC indicates the presence of an infection or inflammation. High WBC is often indicated in an exacerbation of ulcerative |
|colitis. |
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|Lipase 195 H |
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|82 |
|Normal (0-50) |
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|( 6/21/2014) |
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|( 6/24/2014) |
|Upon admit, the patient’s lipase was very high, however lipase is trending down significantly after surgery. |
|Lipase is an enzyme that is made by the pancreas to help break down fat in foods that are ingested. A high lipase level indicates a problem with the pancreas or |
|problems with the gallbladder. |
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|WBC 12.2 H |
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|13.1 H |
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|Normal ( 4.5-11 ) |
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|(6/21/2014) |
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|(6/24/2014) |
|Upon admit, the patients WBC were a little above normal, however WBC are trending slightly upward indicating an inflammatory process that could be occurring. |
|Cells of the immune system that defend the body against foreign invaders. High WBC indicates the presence of an infection or inflammation. |
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|Creatinine 1.2 H |
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|.9 |
|Normal (.6-1.2 ) |
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|(6/21/2014) |
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|(6/24/2014) |
|Upon admit, the patients creatinine levels were at the high end of the normal range, however the levels trended downward. |
|Creatinine is a waste product in your blood that comes from muscle activity. High creatinine levels primarily indicate kidney disease but in this patients case, it |
|could me slight dehydration. |
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|Hemoglobin 11.9 |
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|9.6 L |
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|(6/21/2014) |
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|(6/24/2014) |
|Upon admit, the patients hemoglobin level was normal, however they began to trend downward. |
|Hemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues back to |
|the lungs. Low hemoglobin, in this case indicates a loss of blood after surgery. |
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|Calcium 9.4 |
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|7.9 L |
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|Normal (8.6-10.3) |
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|(6/21/2014) |
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|(6/24/2014) |
|Upon admit the patients serum calcium levels were in the normal range however they are trending downward. |
|Necrosis of fat from release of pancreatic enzymes leads to binding of free calcium. |
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|+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled diagnostic tests, consults, accu checks, etc. Also provide rationale and |
|frequency if applicable.) |
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|Diet : diabetic diet |
|Activity: ambulate after surgery |
|Accu checks : every four hours |
|Diagnostic checks : EKG on 6/21/2014 |
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|( 8 NURSING DIAGNOSES (actual and potential - listed in order of priority) |
| Risk of infection related to invasive surgery |
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| Nausea related to irritation of gastrointestinal system |
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|Adult failure to thrive related to pain |
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|Readiness for enhanced comfort : express desire to enhance comfort |
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|5. |
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± 15 CARE PLAN
Nursing Diagnosis: Nausea related to irritation of gastrointestinal system
|Patient Goals/Outcomes |Nursing Interventions to Achieve Goal |Rationale for Interventions |Evaluation of Goal on Day Care is Provided |
| | |Provide References | |
|The client will state relief of nausea related to |*Evaluate and document client’s history of N&V, with |The onset and duration of nausea and vomiting may be |The client will have stated relief of nausea after |
|gallstone pancreatitis after surgery and during the |attention to onset, duration, timing, volume of |distinctly associated with specific events and may be|surgery and the remaining hospital stay through |
|entire hospital stay through discharge. |emesis, frequency of pattern, setting, associated |treated differently. (Ackley, 2014, p. 550) |discharge. |
| |factors, aggravating factors, and past medical and | | |
| |social histories. | | |
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| |*Document each episode of nausea and/ or vomiting |A systematic approach can provide consistency, | |
| |separately, as well as effectiveness of |accuracy and measurement needed to direct care. It is| |
| |interventions. Consider an assessment tool for |important to recognize that nausea is a subjective | |
| |consistency of evaluation. |experience. (Ackley, 2014, p. 550) | |
| | | | |
| | | | |
| | | | |
| | |It is important to determine this risk in the | |
| | |preoperative period, to better plan interventions. | |
| |Evaluate for risk factors for postoperative nausea |(Ackley, 2014, p. 551) | |
| |and vomiting (PONV). Strong evidence suggests that | | |
| |client-related risk factors such as female gender, | | |
| |history of PONV, history of motion sickness, | | |
| |nonsmoking behavior and environmental risk factors | | |
| |such as postoperative opioid use. | | |
| | | | |
| | | | |
|The client will be able to explain methods that she |Consider non pharmacological interventions such as |Non pharmacological interventions can augment |The client will be able to verbally explain methods |
|can use to decrease nausea and vomiting. |acupressure, acupuncture, music therapy, distraction,|pharmacological interventions because they |that she can use to minimize her nausea. |
| |and slow and deliberate movements. |predominately affect the higher cortical centers that| |
| | |trigger N&V. (Ackley, 2014, p. 550) | |
| |*Include client education on the management of PONV | | |
| |(postoperative nausea and vomiting) for all | | |
| |outpatients and discuss key assessment criteria. | | |
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| | | | |
|±2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching) |
|Consider the following needs: |
|X SS Consult |
|X Dietary Consult |
|□PT/ OT |
|□Pastoral Care |
|□Durable Medical Needs |
|X F/U appointments |
|□Med Instruction/Prescription |
|□ are any of the patient’s medications available at a discount pharmacy? □Yes □ No |
|□Rehab/ HH |
|□Palliative Care |
References
Ackley, B. J., & Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care (10th ed., pp. 549-551). United States: Mosby, an imprint of Elsevier Inc.
Baker, M. (2013). . Retrieved July 11, 2014 from
Nutrients Report. Retrieved July 11, 2014 from
Sommers, M., Brunner, L., Disease and Disorders: A Nursing Therapeutics Manual (Fourth Edition).
Retrieved from Unbound Medicine mobile platform
Vallerand, A., Sanoski, C., Deglin, J., (2014, February 20). Davis’s Drug Guide For
Nurses, 13th edition . Retrieved from Unbound Medicine mobile platform.
Van Leeuwen, A., Poelhuis-Leth, D., Bladh, M., (2013) Davis’s Comprehensive
Handbook of Laboratory and Diagnostic Test with Nursing Implications.
Retrieved from Unbound Medicine mobile platform
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