Nursing Care Plan


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Medical Diagnoses:Acute pain related to inflamed bowel, deficient fluid volume and risk of peritonitis


1. Acute pain related to inflamed bowel

·         Pt. rates pain 9 out of 10 on pain scale at admission

·         Pain increases during ambulation

·         Pain increases after eating

6. Risk for deficient fluid volume related to inflammation

·         Nausea

·         Abdominal pain

·         Unable to tolerate oral intake

·         diabetes

2. Nausea related to inflamed bowel and pain

·         Pt. reports feeling “sick to stomach”

·         Abdominal pain

·         Unable to tolerate oral intake

·         Clear liquid diet

·         diabetes

3. Anxiety related to the symptoms of disease and fear of the unknown.

·         Nausea

·         Abdominal pain

·         Pt. reports feeling uneasy about her bouts that she has due to diverticulitis and possibly having to have a colectomy

Chief Complaint: A 77 year old, black female with pain and cramping followed by nausea and dry heaving located in abdomen.  Fourteen year history of diverticulitis and diabetes.

 

Priority Assessment:  Monitor vitals and pain level. Monitor fluid input and output.  Monitor LOC and mobility.  Monitor prescribed diet and comfort. Monitor glucose levels and reposition every 2 hours.

8. Increased risk of peritonitis due to perforation of the intestinal wall, related to inflammatory process.

·         Nausea

·         Abdominal pain

·         History

·         diabetes

5. Deficient knowledge related to disease process and dietary management

·         Anxiety

·         Not knowing foods that irritate bowels

·         Balancing both her diabetes and bowel complications

7. Risk for constipation related to inflamed bowel and pain

·         Unable to tolerate oral intake

·         Limited mobility

·         Medications

·         diabetes

4. Imbalanced nutrition: less than body requirements related to pain and nausea

·         Abdominal pain

·         Unable to tolerate oral intake

·         diabetes


NANDA Diagnostic Statement: Acute pain related to inflamed bowel AEB pain being 9 out of 10 on the pain scale and the cramps and tenderness in abdomens resulting in nausea and dry heaving.

 

Behavioral Outcome / Goal: Pt. will report a decrease in pain from 9 to 0 on pain scale upon discharge 11/18/xx  Pt. will have a bowel movement before discharge.  Pt. will understand dietary instructions and restrictions.


Nursing Interventions:

 

1.      Monitor pt. for pain at least every 2 hours using the numeric pain scale and behavior assessment.

 

2.      Check bowel elimination at least once per shift.

 

3.      Administer antiemetic medication prescribed by physician. Monitor for effects.

 

4.      Provide pt. a peaceful and quiet environment for resting and healing.

 

5.      Provide pt. clear liquid diet physician prescribes and monitor.______________

Rationale:

 

1.      Pain is subjective in nature and only the client can fully describe it (Cox’s Clinical pg: 487)

 

2.      Immobility caused by pain may decrease the parasympathetic stimulation to the bowel.

 

3.      Response to medication is unique to each client (Cox’s Clinical pg: 488)

 

4.      Promotes action and effect of medication by providing decreased stimuli (Cox’s Clinical pg: 488)

 

5.      Ensures that the devised plain has food choices based on dietary guidelines (Cox’s Clinical pg 193)_____________________________

Client Response:

 

1.      Pt. rates pain on pain scale 0 being no pain to 10 being most pain ever felt.

 

2.      Pt. had a bm before discharge with no complications

 

 

3.      Gave pt. medication for nausea and pt. is comfortable.

 

4.      Pt. is sitting up and watching television in no distress.

 

 

5.      Pt. understands the diet restrictions from physician but is wanting solid foods.________________________

Summarize impressions of client progress toward outcomes / problem resolution: Pt. is stable.  Pt. was experiencing pain of 9 out of 10 on pain scale at admission but now experiencing no pain and is comfortable. Pt. has a history of diverticulitis for 14 years and has bouts often.  Physician recommends colectomy.  Pt. said she follows dietary instructions and drinks plenty of fluids. Physician has pt. on clear liquid diet.  Pt. is a diabetic and takes insulin routinely.  No evidence of neurotropy and has sensation and pulses bilaterally in both upper and lower extremities. Pt. has son and daughter that is supportive and helps when needed.  Pt. understands diet instructions and follows them as much as possible.  Pt. will follow up with physician about possible colectomy._____________________________________________________________________


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