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Medical Diagnoses:Abdominal pain, Nausea, Vomiting, Breast cancer,Hypokalemia and bowel obstruction


Clinical Assessment Worksheet

Student                                 Date of Care             xx/xx/xxxx                               Worksheet #  629

 

Demographic Information

Health History

Care Prescriptions

Age: 83

Chronic Health Conditions & Previous Health Problems:

Diet: NPO

Gender: Female

Race: White

Hx of uterine cancer (patient states dx at age 47)

Osteopenia

Activity:  Up with Assist of 1

 

Code Status:  Full Code                            

Weight: 42.6 kg

Height:

58 inches

Hx of bowel obstruction (pt states 3-4 times a year)

IV Access:     saline lock     X continuous

Reason for Admission [patient’s own words]:

Abdominal pain, Nausea, Vomiting

Breast cancer

Hypokalemia

 

     Solution:  D5 1/2NS+KCL 20 mEq

 

 

     Rate: 100cc/hr

 

 

Previous surgeries:              

Thyroidectomy

Hysterectomy

I & O:  X voiding   Foley catheter   X NG tube 

        

Medical Diagnosis [medical terms]:

 

Cholecystectomy

Appendectomy

Wound Care:

SBO (small bowel obstruction)

Colon resection

Breast lumpectomy for breast cancer

drains (Type, Location, Drainage from]

 

 

 

Pulmonary care:

Date of admission:

Xx/xx/xxxx

Medical Complications:                    

Hypokalemia

Scar tissue build up in small bowel

    O2   _____ L/min  via   N/C     mask   

Surgery:                                                 Date:

 

 

    IS q ___ hrs.     MDI   HHN         

 

 

 

Nursing Diagnoses (3 - prioritized)

1. Diarrhea related to malabsorption secondary to scar tissue accumulation in small bowel as evidenced by frequent and urgent liquid stools.

    Med. albuterol atrovent 

            other _____________

Allergies: Amoxicillin, Codeine, Morphine,

2. Imbalanced nutrition: less than body requirements related to

Glucometer:      ac & hs

Penicillin, Sulfa

Inability to procure adequate amounts of food as evidenced by

                       sliding scale insulin

 

NPO status.

Other:

Discharge Plan Needs: Education r/t fluid balance,

3. Impaired oral mucous membrane related to drying effects of

 

management of health conditions, medication side effects

NPO longer than 24hr as evidenced by dry lips, sore throat, runny nose.

 


Describe pathophysiology of primary illnesses (acute and chronic) Intestinal blockage stops the normal flow of intestinal contents through the intestinal tract.  Obstructions can be partial or complete.  When a small bowel obstruction occurs, intestinal contents, fluid, and gas build up above the obstruction.  Abdominal distention and retention of fluid cause absorption of fluid to decrease.  Reflux vomiting may be caused to abdominal distention.  When patient came into emergency room, she complained of extreme abdominal pain, nausea, and vomiting.  Assessment states abdominal distention.  The patient states had radiation and chemotherapy years ago because of uterine cancer.  Said her intestinal tract was badly damaged and suffers a small bowel obstruction several times a year.  Patient states has had large portion of intestinal tract removed and has scar tissue that complicates the passage of food despite her efforts of following the recommended diet.  Patient says knows sign/symptoms well and immediately seeks treatment when feeling nausea, vomiting,  and does not have bowel movement shortly after eating.

Hypokalemia indicates a deficit in potassium storage.  Potassium is stored in large amounts in the intestinal fluids.  Sometimes diuretics or other medications cause low levels of potassium, other times it is GI loss, including vomiting or gastric suction.  Potassium deficit can also occur with diarrhea.  Because my patient was vomiting and is now on gastric suction and having diarrhea, her potassium levels are continually monitored. 

Osteopenia is bone mineral density being lower than normal.  It often occurs because lack of estrogen.  Because the patient had uterine cancer at a young age including a hysterectomy, her estrogen levels may have been affected (Smeltzer, Bare, Hinkle, & Cheever, 2010).

 

Medications

Name

Action

Major Side Effects

Nursing Implications

Reason Client Taking Medication

 

D5 1/2NS+KCL 20 mEq

100mL/hr

IV- continuous

 

 

Corrects extracellular volume deficit

Redness or pain at injection site, fever, trouble breathing, swelling

Follow dosage as directed by doctor order, check visually for particles or discoloration.

Extracellular volume replacement, based on patients fluid and electrolyte imbalance.  Patient NPO status. Potassium added because body cannot conserve potassium.  Potassium added to avoid hypokalemia.

 

Hydromorphone HCL (Dilaudid)

0.5mg/0.25mL

q2hrs PRN

IV

 

Binds with opiod receptors in CNS, alters perception of pain.  Decrease moderate to severe pain. Can also suppress cough reflex

Dizziness, sedation, fever, headache, hypotension, bradycardia, edema, blurred vision, nausea, vomiting, constipation, weight loss, diarrhea, dry mouth, muscle spasms, bronchospasm, physical dependence

Assess blood pressure, pulse, respirations before and during administration.  Assess bowel function frequently. Assess pain type, location, and intensity prior to administration and frequently after. Can lead to physical dependence. Assess cough and lungs sounds.

Patient taking when in pain.  Taking PRN pain that is severe (score 7-10 on pain scale)

 

Zofran

4mg/2mL

q4hrs  PRN

IV

 

 

Blocks 5-HT3 receptors.  Used to prevent nausea and vomiting

Constipation, diarrhea, increased liver enzymes, headache, dizziness, fatigue, chest pain, arrhythmias, injection site reaction

Assess patient condition before and after. Assess blood pressure. Monitor patient closely.  Overdose s&s: sudden transient blindness, severe constipation, hypotension. Assess for drug induced headache. Maintain adequate hydration.

Patient is taking when needed to help with nausea and vomiting due to small bowel obstruction


LAB VALUES/TEST RESULTS

 

a.   Important lab tests to monitor    Why? (Consider diagnosis, pre-existing conditions,  medications, complications, etc)          

Potassium

Inadequate oral intake can deplete electrolytes, electrolyte imblance

Sodium

Electrolyte imbalance, changes can suggest losing/retaining fluid

Glucose

Patient is NPO

Calcium

Joint and bone health, patient has osteopenia

BUN

Increased BUN could be sign of dehydration

Albumin

Nutritional status

Total Protein

Nutritional status

 

b.      Hematology   Normal values      Patient’s Values (include serial labs)                    Significance for this patient                                                                                                     

 

 

7/11/12

7/12/12

7/13/12

 

WBC

4.50-10.70

5.49

4.17

No Lab

 

         Bands

 

 

 

Values

 

         Segs

 

 

 

7/13

 

Plt

140-500

181

154

 

 

Hgb

11.9-15.5

11.5

10.8

 

Infection, anemia, oxygen, increased indicate dehydration

Hct

35.6-45.5

36.2

34.1

 

Infection, anemia, oxygen, increased indicate dehydration

RBC

3.90-5.20

4.15

3.88

 

 

 

c.      Chemistry     Normal values         Patient’s Values (include serial labs)                  Significance for this patient

K+

3.6-5.0

4.4

4.2

7/13/12

Inadequate oral intake can deplete electrolytes, electrolyte imblance

Na+

135-144

138

138

No Lab

Electrolyte imbalance, changes can suggest losing/retaining fluid

Cl-

100-111

106

104

Values

Electrolyte imbalance, fluid loss

CO2

23-32

26

29

7/13

Electrolyte imbalance, changes suggest losing or retaining fluid

BUN

6-20

9

8

 

Increased BUN could be sign of dehydration

Cr

0.44-1.03

0.72

0.62

 

Assess kidney function

Glucose

72-112

170

112

 

Nutritional status

Albumin

3.4-4.7

No value

No value

 

Was 3.6 7/9 per ER report; low albumin is an indicator of poor nutritional status. Patients scar tissue prevents adequate absorption of nutrients from GI tract. moves calcium/medications through blood.keeps fluid from blood from leaking to tissues

 

d.      Coagulation   Normal values        Patient’s Values (include serial labs)                 Significance for this patient

PT

 

 

 

 

 

INR

 

 

 

 

 

PTT

 

 

 

 

 


e.      Urine              Normal values             Patient’s Values (include serial labs)               Significance for this patient

Color

 

 

 

 

 

Appearance

 

 

 

 

 

Spec. gravity

 

 

 

 

 

PH

 

 

 

 

 

Glucose

 

 

 

 

 

Ketones

 

 

 

 

 

Nitrates

 

 

 

 

 

RBCs

 

 

 

 

 

WBCs

 

 

 

 

 

Casts

 

 

 

 

 

Protein

 

 

 

 

 

 

 

f.       ABGs             Normal values               Patient’s Values (include serial labs)             Significance for this patient

pH

 

 

 

 

 

PaCO2

 

 

 

 

 

HCO3

 

 

 

 

 

PaO2

 

 

 

 

 

SaO2

 

 

 

 

 

 

g.      Other             Normal values                Patient’s Values (include serial labs)             Significance for this patient

Calcium

8.5-10.1

8.0

 

 

 

Total Protein

6.4-7.9

No value

No value

 

6.2 on 7/9 per ER report; low total protein is an indicator of poor nutritional status. Patients scar tissue prevents adequate absorption of nutrients from GI tract.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Pertinent x-rays or radiological studies Due to abdominal pain- CT Abd and Pelvis w/ contrast. 

1. Evidence of small bowel obstruction early or partial

2. Surgical absence of the uterus with apparent radiation induced changes of the sacrum and iliac.  No chance since prior study.

3. Large fixed hiatus hernia, stable.

 

i. Other (e.g. EKG / telemetry)



Assessment

History of present illness:  Patient is an 83 year old woman who has had multiple episodes of partial small bowel obstruction which have generally resolved with conservative therapy.  She has had radiation to the pelvis for uterine cancer many years ago.  She did have a small bowel resection for obstruction at one point many years ago.  She typically has frequent bowel movement and takes Questran, which has helped somewhat in regulating her bowel function.  After dinner 7/9, she had a typical bout of severe nausea.  She has not vomited.  She stopped having bowel movements.  CT scan in the emergency room showed a hiatal hernia and partial small bowel obstruction.

 

Vital Signs:  7/12      BP 121/63     O2 Sat 91%      Temp 98.9 Oral     HR 82    R 20

                      7/13      BP 122/57     O2 Sat 94%      Temp 98.3 Oral     HR 87    R 20

 

Neuro / Musculoskeletal Activity (Movement, Strength, Sensation):  Patient is alert and oriented X3.  Patient easily aroused.  Patient able to move and raise all extremities symmetrically with equal strength bilaterally.  Sensation of all extremities found to be intact by patient confirming ability to perceive light touch with tissue.  Patient able to ambulate around nurses station often with assistance of 1.  Patient able to toilet herself with assistance getting to restroom. 

 

Skin (CUSPS/4Ts):  Patient skin color even throughout, No ulcerations, No swelling, No pitting edema.  Patient has long midline scar on abdomen from previous surgery.  Patient skin warm and dry.  Some tenting of skin, loss of elasticity.  No tenderness.

 

Cardiac (Heart Sounds, Rate & Rhythm, Capillary Refill, Radial & Pedal Pulses):  Heart-regular rhythm and rate, no murmur.  S1 auscultated at apex, S2 auscultated at base. Capillary refill less than 2 seconds.  Radial and pedal pulses palpable and equal bilaterally.

 

Pulmonary (Lung sounds, Rate, Rhythm, Effort):  Ausculated lungs-clear bilaterally.  Respirations not labored.  Symmetrical expansion.

 

GI / Nutritional Status (Diet, Weight, Bowel Sounds, Abdomen-Flat/Distended & Soft/Firm, Last BM):  Abdomen- soft, flat.  Patient states no current nausea.  Long midline scar on abdomen.  Active bowel sounds in all 4 quadrants.  Frequent bowel movements while I was with patient.  Small amounts of loose stool produced.  NG tube in place all day 7/12.  NG tube removed 0920 7/13.

 

GU/Reproductive (Urine Color and Amount, Menses for Women):  Clear, light yellow urine.  Urine not measured.  No menses.

 

Psychosocial:  Patient’s husband visits most of the day everyday.  Husband participates in ambulation with patient and encourages her to walk further/longer distance.  Patient said has friends in hospital as well so husband goes to visit them and comes back to tell her what is going on.  Patient states has no children but has a dog at home.  Patient states her condition (SBO) and signs/symptoms occur often so she is used to it and tries to monitor her diet.  Patient very positive, upbeat, pleasant to work with and very cooperative. 

 

Learning Needs:  Continue to monitor diet and comply with doctors order of diet and restrictions.    

 

 


Date/Time

Nurses Notes

xx/xx/xxxx 0800

Patient hit call light to be disconnected from NG tube suction/unplug IV to use restroom.  Met patient for first time.  Assisted to restroom, patient produced small amount of loose stool.  Immediately upon standing up and washing hands, patient stated needed to go again.  Assisted back to toilet.  Patient produced small amount of loose stool.  Patient returned to sit in chair rather than back in bed.  Patient elevated feet using recliner.  Patient connected back to NG tube suction, IV plugged in.  Patient stated 0645 produced large amount of loose stool.  Initial assessment completed.  Active bowel sounds heard in all 4 quadrants.  Patient states has not had pain medication since night before at 2130.   Patient states no feelings of nausea.  Skin warm, dry, and intact.  Patient oriented X3.  Patient NPO.  CMunson SUNS-------------------------

xx/xx/xxxx 0910

Patient hit call light to be disconnected from NG tube suction/unplug IV to use restroom. Patient produced small amount of loose stool.   Patient husband arrived.  I assisted patient along with spouse while ambulating around nurses station 1 time.  Patient returned to room and got back into bed.  Patient connected back to NG tube suction/IV plugged in. Patient requested ice chips.  Ok by her doctor who had come to assess her in room.  CMunson SUNS----------------------------------

xx/xx/xxxx 1000

Patient hit call light to be disconnected from NG tube suction/unplug IV to use restroom.  Patient produced very small amount of loose stool.  I assisted patient to ambulate once around nurses station.  Patient tried to use restroom again but produced no stool.  Patient then got back into bed.  Irrigated NG tube with 60cc tap water. When irrigated, NG suction measured 500mL. CMunson SUNS-------------------------------------------------------------------------------------------------------

xx/xx/xxxx 1045

Went to check on patient.  Patient asleep.  Husband in room watching tv.  Said patient had been asleep since return from last walk.  CMunson SUNS-----------------------------------------------------------------------------------------------------------------

xx/xx/xxxx 1130

Assisted patient to use restroom.  Produced very small amount of stool.  Patient ambulated once around nurses station with my assistance, returned to room and in bed.  NG Suction now measured 750mL, dark brown.  CMunson SUNS-------

xx/xx/xxxx 0700

Patient hit call light to use restroom.  Produced small amount loose watery stool.  Immediately had to go back to restroom after washing hands.  More loose watery stool.  NG wall suction 300mL.  Patient back in bed, call light in place. Vital signs taken. BP 122/57 T 98.3 HR 87 R 20 O2 sat 94%. CMunson SUNS----------------------------------------------------------

xx/xx/xxxx 0745

Assessment complete.  Clear lung sounds in all 5 lobes, Auscultate abdomen, active bowel sounds heard in all 4 quadrants after listening for ~1min in each.  Pedal and radial pulses palpable and equal bilaterally.  Skin warm, dry, intact.  Patient alert and oriented X3.  Heart rate regular, capillary refill less than 2 secs. Abdomen soft, NG tube still in place.  Patient states having no pain, no nausea.  Patient wanted to rest some more before bath.  CMunson SUNS-----------

xx/xx/xxxx 0845

Gave patient bed bath, changed linens, assisted patient to use restroom.  Small amount liquid watery stool produced.  Dr entered room, advised NG tube could be removed, clear liquids ordered.  NG suction 400mL.  CMunson SUNS------------

xx/xx/xxxx 0920

NG tube removed without resistance, tip intact. Patient tolerated well, no complaint of discomfort. 450mL clear brown. Patient husband assisted patient to ambulate 2X around nurses station.  CMunson SUNS----------------------------------------

xx/xx/xxxx 1015

Assessed patient.  Patient states no nausea or pain.  Auscultated bowel sounds, active in all 4 quadrants.  Assisted patient to use restroom.  Very small amount of loose watery stool.  CMunson SUNS------------------------------------------------------

xx/xx/xxxx 1100

Assessed patient.  Pedal and radial pulses palpable and equal bilaterally.  Clear lungs sounds, heart regular rhythm and rate.  Patient states no nausea or pain.  Throat a little sore from NG tube.  CMunson SUNS-------------------------------------

xx/xx/xxxx 1130

Husband assisted patient to ambulate around nurses station.  Patient drinking sprite.  CMunson SUNS------------------------

NANDA Diagnostic Statement: Diarrhea related to malabsorption secondary to scar tissue accumulation in small bowel as evidenced by frequent and urgent liquid stools.

 

Behavioral Outcome / Goal: Patient will return to usual bowel elimination habits (loosely formed) by discharge date (7/15) as evidenced by loosely formed stool.  Patient will keep skin free and clear of irritation and moisture after bowel movements as evidenced by minimal discomfort after providing perineal care and use of A&D ointment.  Patient will ambulate at least 3X day to initiate peristalsis as evidenced by frequent bowel movements.

Nursing Interventions:
1. Provide perineal skin care after each bowel movement.  Inspect perianal skin integrity after each bowel movement.	

2. Record color, consistency following each bowel movement.

3. Monitor and record output from NG suction.  Monitor color, consistency, and sudden increase during shift.  

4. Increase patients activity to extent possible with ambulation at least 3X/day.

5. Monitor bowel sounds and abdominal distention throughout shift. 

6. Administer IV fluids D5 ½ NS+KCL 20 mEq as ordered

7. Educate patient regarding maintaining fluids, intake and output, irritating foods, and influence of activity by end of shift. 




Rationale:
1. Perineal care to dry moisture, prevent skin breakdown, prevents perineal infection. Monitor for skin break down (Metcalf, 2007).


2. Basic monitoring of conditioning as well as monitoring of effectiveness of therapy (Newfield, Hinz, Tilley, Sridaromont, & Maramba, 2007).

3. Nasogastric suctioning results in loss of fluid.  Any condition that results in loss of GI fluids predisposes patient to dehydration (Potter & Perry, 2009).

4. Activity promotes stimulation of the bowel and assists in elimination (patient has small bowel obstruction)(Newfield, Hinz, Tilley, Sridaromont, & Maramba, 2007).

5. Bowel sounds indicate the return of peristalsis.  Abdominal distention is a sign of pressure (Potter & Perry, 2009).

6. IV fluid administration corrects or prevents fluid and electrolyte imbalances (Potter & Perry, 2009).



7. Increases client’s knowledge of causes, treatment, and complications of diarrhea.  Promotes self care. (Newfield, Hinz, Tilley, Sridaromont, & Maramba, 2007).
Client Response:
1. Patient states sometimes after having multiple episodes of diarrhea close together, feels some discomfort and soreness.  For most part, no discomfort.  Patient uses A&D ointment regularly.  


2. Once patient began having bowel movements after obstruction, all were loose watery, yellow in color, no foul odor.  Patient participated in observation. 

3. Patient tolerated NG suction well.  Because she has had this many times, she said she could feel when it needed to be irrigated.  Irrigated at her request.  


4. Patient ambulated once every hour while I was there.  Patients husband encouraged her to ambulate often.  Patient responded well and did not appear to be fatigued. 



5. Patient has active bowel sounds in all 4 quadrants.  Abdomen is soft and flat.  Emergency room report from 7/9/12 reports abdominal distention. 

6. Patient tolerates IV fluid administration well, no redness or irritation at injection site.  Patient aware to not flex arm tight to avoid sounding alarm. 


7. Patient understands importance of ambulation.  After ambulating, typically had bowel movement.  Patient aware of irritating foods such as milk, fat, vegetables, and carbonated beverages.

 

 


                                                                                                                       

"Goal Evaluation: Summarize impressions of client progress toward goal statement/ behavioral outcome The goal of returning to normal bowel elimination pattern by discharge date was partially met as evidenced by patient returning to bowel movements, but consistency not typical. Patient began having loose watery stool 7/12 morning after not having bowel movement since 7/9 evening. Patient was pleased having bowel movements despite it being diarrhea. Patient still reports no feelings of pain or nausea. Patient tolerates frequency of using restroom well. The goal of patient keeping skin free and clear of moisture was met as evidenced by patient taking great care to clean perineal area after bowel movements, new briefs, and use of A&D ointment. Patient keeps skin free of moisture and uses A&D ointment to prevent irritation. NANDA Diagnosis evaluation: Is the problem resolved? Why or why not? The problem is not yet resolved. Patient is not back to normal elimination pattern because still having loose watery yellow stool. Diarrhea 7/12 and 7/13 although becoming more solid. Patient was NPO 7/10, 7/11, 7/12, 7/13 until 0920. Patient not back to normal elimination patterns as of 7/13. Patient stool normally loose but not watery. Patient using A&D ointment to protect skin. Patient has complaint of soreness only after repetitive bowel movements. During 7/12 and 7/13, only said felt sore one time on 7/12. Patient almost always had bowel movements immediately after walking around nurses station. The care plan was effective because patients elimination problem is improving. Began to have bowel movements 7/12 again after none since 7/9. The care plan is effective because patient having minmal discomfort related to frequent diarrhea, and having bowel movements but more time is needed for the problem to resolve, and patient to return to normal elimination pattern of loosely formed stool. 



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References

Metcalf, C. (2007). Chronic diarrhoea: investigation, treatment and nursing care. (Cover story).    Nursing Standard, 21(21), 48-56. Retrieved from EBSCO host.

Newfield, S. A., Hinz, M. D., Tilley, D. S., Sridaromont, K. L., & Maramba, P. J. (2007). Cox's    Clinical Applications of Nursing Diagnosis (5th ed.). Philadelphia, PA, USA: F.A. Davis    Company.

Potter, P. A., & Perry, A. G. (2009). Fundamentals of Nursing (7th ed.). St. Louis, MO, USA:      Mosby Elsevier

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Textbook of Medical-Surgical Nursing (12th ed., Vol. 1). Philadelphia, PA, USA: Wolters Kluwer Lippincott Williams & Wilkins.

 


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