MS 1 Care Plan
Patient: Patient X Age: 49 Gender: Female
Allergies: NKDA
Code Status: Full code Wt: 94.8 kg Ht: 5 ft 7 in
Admit Date: 10/05/2018
Past Medical and Surgical History (PMH/PSH):
Non-morbid obesity due to excess caloric intake; Vitamin D deficiency
Social history (ethnicity, occupation, marital status, family support, living situation):
Ethnicity: African American
Occupation: Works at Freddie Mac
Marital status: Married, with two kids (both under 15 years old)
Family support: Husband; Mother is still alive and was diagnosed with dementia 8 years ago
Living situation: Local of Loudoun County
Admitting Diagnosis:
Diverticulitis of large intestine with perforation and abscess without bleeding.
Synopsis of Current Hospitalization (timeline):
Patient arrives to emergency room 10/05/18 presenting with chills, fever (Temp 102.4 Fahrenheit), and abdominal cramping. Patient is accompanied by her husband, and believes symptoms are related to consuming recalled beef from Walmart. Admitting doctor diagnosed diverticulitis and ordered CT and Chest X-ray. CT verifies diverticulitis with perforation (tear) and access in large intestine. Chest X-ray is clear, showing no pneumonia or sepsis. Patient transferred to medical surgical unit 10/05/18. White blood cell (WBC) count upon admittance is elevated (19.77). Patient is kept in Med-Surg unit, continuing daily labs to monitor WBC count and pain related to diverticulitis. 20-guage PIV placed in left antecubital on 10/09/18 and shows no sign of infection. Patient placed on clear liquid diet upon admittance and diet was advanced to low fiber diet 10/10/18. 12-lead EKG ordered 10/11/18 showing bradycardia demonstrated by low heart rate during last vital check (53). Plan is to discharge patient evening of 10/11/18.
Current Medical Diagnosis: Diverticulitis
Pathophysiology: Diverticulitis is characterized by presence of pseudodiverticula in the mucosa and submucosa of the colon (large intestine). These pseudodiverticula develops in ranges of size and number in each patient, but they are usually present in the sigmoid colon (Porth, 2015). These diverticula are 0/5 to 1.0 cm in diameter and are small pouches. These pouches form and push out in weak spots in the wall of your colon. Diverticulitis is simply the inflammation of one of more of these pouches (diverticula) which causes the lining of your color to becomes inflamed (NIDDK, n.d.).
Signs and Symptoms: Most patients are asymptomatic, but signs and symptoms include: bloating, diarrhea, flatulence, constipation, adnominal discomfort in lower left quadrant, fever, elevated WBC count.
Risk Factors: Aging, lack of fiber in diet, decreased physical activity, and poor bowel habits (for example, neglecting the urge to pass bowel movement)
Common Diagnostics: Disease may be confirmed by CT scans or ultrasonographic tests. Flat X-rays for acute cases. Complete blood count to access for WBC elevation.
Nursing Care/Considerations: Monitor for further complications such as obstruction, bleeding, and increased swelling. Assess patient’s pain and vital signs during hourly rounds. Check temperature and monitor CBC for signs of worsening infection. Administer IV therapy and medication as prescribed. Patient teaching for importance of high fiber in diet. Use nasogastric tube with low suctions if ordered by MD. Oral care for patients with NG tubes, dry lips and mouths. Assist patient with activities so the do not strain/bend/lift too much and end up hurting themselves.
Treatments: Treatment intended to prevent symptoms and further complications. High fiber diet will be established to guarantee BM to prevent further complications. Patients with acute issues will withhold solid foods for a few days and start antibiotics. Management of inflammation and infection, medications, surgical options for severe causes experiencing bleeding and large tears in bowel linings
References:
Porth, C., & Gaspard, K. J. (2015). Essentials of pathophysiology: Concepts of altered health states. Philadelphia: Wolters Kluwer.
Relevant Medical ORDERS (Do not record assessment data here)
VS freq: Every 4 hours
Diet: Clear liquid diet upon admittance; Diet advanced to low fiber diet 10/10 Blood sugar frequency: Once per day, before meals
Activity: As tolerated; Ambulates without assistance
Oxygen: N/A Respiratory Tx: N/A
Dressing Changes: N/A
Other relevant orders: (Such as PT, OT, Speech therapy, falls precautions, circulation or neuro checks, SCD’s, etc.)
SCD’s, incentive spirometry
Safety & Communication
Primary Language: English Translator required: Y N
Special Communications Needs: Y N Patient is HOH Deaf
Family (specify _______________) is HOH Deaf
Hearing aids at BS: Y N
Sign Language Interpreter Required: Y N
Isolation: Y N Type: Related to:
Falls Risk Score: 5 (Low)
Scale used: John Hopkins Fall Scale Related to:
On 1 high fall risk drug (3 points)
IV presence (1 point)
SCD use (1 point)
Aspiration Risk: Y N Related to:
Bleeding Precautions: Y N Related to: Heparin
Clinical Week
Physical Assessment Findings
(You must complete all assessment sections on each care plan) Analysis of Findings
(DO NOT WRITE “NORMAL FINDINGS”- Explain significance related to current diagnosis and/or PMH.)
Week 1 Vital signs:
10/05/2018 2000 (admittance): BP 123/71; HR 94; Temp 102.4 F; RR 17; SpO2 96%
10/11/2018 811: BP 135/80; HR 53; Temp 98.8; RR 14; SpO2 97%, Intake: 85% of low fiber meal, Output: No BM, urine x2
Vital sign changes since admission: Temp is lowered, demonstrating break of fever and infection is decreasing; HR is lower, measuring in the 50s; Dr. ordered 12-lead EKG showing bradycardia. Other vitals stable and within normal limits. Continue vital sign checks every four hours. Medical orders for low-fiber diet to monitor abdominal pain, bloating, and BMs. Patient ate 85% of low fiber meal; Last BM 10/08/2018; Urine output not measured but patient notes on urine output twice so far; Monitor for BM as this will indicate proper function of the intestines and GI tract.
Week 7 Neurological/Sensory: A&O x4. Clear speech. Symmetry in face. No reported numbness or tingling.
Patient is alert and orientated to self, time, place, and others. Speech is clear, face is symmetric, currently showing no signs of neurological impairment or stroke. Patient reports no numbness or tingling and has appropriate strength in extremities. Negative for dizziness and headaches.
Week 4 Cardiovascular:
Heart rate measuring low. Presence of S1S2. Capillary refill <3 for upper and lower extremities. +2 bilateral radial and pedal pulses; No edema in extremities. Heart rate is low (Bradycardic in 12-lead EKG). +2 pulses are regular. Capillary refill is sufficient showing blood perfusion in all extremities.
Week 3 Respiratory:
No wheeze, rales, or crackles. Clear lung sounds in all fields.
Respiratory system is stable, demonstrated by Chest X-ray. Lungs are well inflated and clear. No edema, pleural effusion, pneumothorax, evidence of acute process, or pneumonia. No cough or sputum present.
Week 5 Gastrointestinal & Nutrition:
Hypoactive bowel sounds in all quadrants. Lower fiber diet. No nausea or vomiting. Ate
85% of low-fiber lunch. Abdominal pain with movement. No rebound or guarding. Last BM 10/08/18 (moderate amount, soft, no bleeding). Patient tolerates low-fiber meals. Abdominal swelling is no longer present. Monitor GI for changes and bleeding due to Heparin medication; Hypoactive bowel sounds suggests that there is limited bowel movement occurring
Week 2 Musculoskeletal:
+5 muscle strength, coordinated; able to ambulate freely; Full ROM against gravity, maximum resistance; Low fall scale 5(Johns Hopkins Fall Risk Assessment).
Low risk for falls; +5 strength demonstrates coordination and full range of motion; Patient able to get out of bed by herself; Patient walks freely (once disconnected from IV)
Week 5 Genitourinary/Reproductive:
Continent of urine. No foul odor or abnormal color. Patient still has monthly cycle. Last menses: 09/2018
Negative for dysuria and frequency. Stable genitourinary function; continue to monitor for urine incontinence and change in urine odor/color. Patient in premenopausal phase, still having menses.
Week 2 Integumentary (including incisions and drains):
Normal for ethnicity. Warm skin. No dampness or flaking. No incisions or wounds. Braden scale: 23.
Negative for skin color change or rash; Reposition patient and have patient move about room to prevent pressure sores. Braden scale (23) related to: Sensory perception (4), moisture (4), activity (4), mobility (4), nutrition (3), friction/shearing (4).
IV Assessment:
20G PIV in left antecubital inserted on 10/09/18; Clean, dry, intact skin. IV flushing and infusing well
Continue to monitor PIV for infiltration or phlebitis; PIV is working well and stable; PIV due to be changed 10/16/2018
Week 2 Pain:
Patient denies pain with exception of bending at the waist; Patient reports 0/10 at 1430 on 10/11/2018 while patient is in bed, sitting
Reassess pain on numeric pain scale with patient; Continue to monitor pain and occurrence; PRN Tylenol every 4 hours if patient desires
Psychosocial:
Husband visits patient; Patient has good judgement skills; Happy attitude; Normal behavior; Does not exhibit anxiety or depression
Patient is in good spirits; Continue to monitor to psychosocial changes such as mood swings; Patient currently clear of anxiety or depression
Laboratory Tests (relevant admission and current labs)
Date Lab Test Abnormal Lab Results Normal Range Lab Trend Significance of Result Nursing Considerations
10/05/2018
CBC Elevated WBC (19.77) 4.5-10 White count continued to raise during 10/05-06; Recent WBC measured 9/49. Results of high WBC indicate onset of infection; decrease indicates antibiotics are working Increased WBC count mean the body is trying to fight off the infection; medical interventions such as antibiotics to prevent sepsis. Continue to monitor WBC and watch for elevation since it has lowered significantly
10/05/2018
CBC MCH low (27.5) 28-32 Continuously low. Measuring 27.2 during last CBC Low results indicate low platelet count, iron, B12
Patient at risk for thrombocytopenia and high blood viscosity – this is why patient is taking Heparin. Monitor MCH count with daily CBC. Risk for bleeding related to Heparin. Monitor fluid levels and hydration. Minimize bleeding risks teaching patient to use call light and avoid sharp objects such as razors. Good oral care must be performed by patient or nurse/tech.
10/05/18 CBC Elevated neutrophil (17.09) 1.8-8.1 Back within range 10/10: 6.61 Neutrophils rush to the site of infection; Increased count indicates onset of infection; decrease indicates antibiotics are working Increased neutrophil count mean the body is trying to fight off the infection; medical interventions such as antibiotics to prevent sepsis. Continue to monitor WBC and watch for elevation since it has lowered significantly
10/05/18
Metabolic Panel Low sodium (135) 136-145 mEq/L Elevated to 137 to be within normal limit Lowered sodium levels indicate possibility of fluid intoxication where they is excess extra/intracellular water and it dilutes sodium,
Monitor sodium levels in next metabolic panel to check if it remains within normal range. Monitor patient for hyponatremia symptoms including nausea, confusion, headache, drowsiness, and fatigue.
10/05/18 Liver Panel Elevated Globulin (3.8) 2.0-3.6 g/dL N/A: Not retested High levels of globulin indicate infection, inflammatory disease or immunity disorders (MedlinePlus, 2018)
Increased globulin in the patient’s CBC indicates infection. Patient as risk for sepsis. Monitor CBC and temperature for progression. Administer antibiotics per MD order for infection and inflammation
10/06/18 CBC Hemoglobin (11.4) 12-16 Continuously low, latest measure 11.5 on 10/11 Low hemoglobin indicates low iron. Monitor hemoglobin levels and notify MD if they continue to lower; Prescriber may order blood transfusion of RBCs
10/06/18 CBC Hematocrit (34.4) 37-47 Continuously low, 34.8 on 10/11 Low counts means the percentage of red blood cells is more decreased than normal
Assess patient for weakness and fatigue during position changing, walking, and getting out of bed. Monitor hematocrit levels and notify MD if they continue to lower; Prescriber may order blood transfusion of RBCs
10/06/18 Blood test Blood glucose (91 mg/dL) 70-115 mg/dL
Slight elevation on 10/7 to 119. Back within normal limits 10/11 (90 mg/dL). Blood glucose level elevated during stay, monitor to watch for trends of hyperglycemia as it is potential that patient is pre-diabetic Blood glucose is monitored each morning for patient. Monitor blood glucose levels to prevent hyperglycemia; Watch for glucose readings above 100 mg/dL. Notify MD of extremely high numbers
Diagnostic Tests (x-rays, CT scans, endoscopies, etc.)
Date Test Reason for test Results/Findings Diagnostic Trend Significance of Result
10/05/18
CT Abdominal pain, concern with perforation Diverticulitis with perforation (tear) and abscess in large intestine. No bowel obstruction. Sort segment of moderate thickening of proximal and middle sigmoid colon with inflammation, consistent with diverticulitis N/A Verifies admitted diagnosis of diverticulitis
10/05/18 Chest X-ray
Rule out pneumonia, sepsis check Lungs well inflated; No edema, pleural effusion, pneumothorax, or evidence of acute process N/A Shows lungs well inflated and clear
10/11/18
12-lead EKG Low heart rate during vital checks Bradycardia N/A Heart rate is lower than it should be; continue to monitor
Medications
List and complete first six columns (drug name, dose, freq, route, class, and indications) for all ordered medications.
Complete last five columns (rationale, actions, adverse reactions, patient education, and nursing considerations) for five medications.
Drug Name
(Generic and Brand) Dose Freq Route Med Class Indications Rationale for Patient Mechanism of Action Adverse Reactions Patient Education Nursing Considerations
Heparin (Porcine) 5,000 units Every 8 hours Subcut. anticoagulant Prevent future blood clots Low activity while staying in hospital; MCH low (27.5) Prevention of blood clots and thrombocytopenia Bleeding, Thrombocytopenia (HIT), anemia, fever, hypersensitivity (Vallerand, 2017) Advise patient to report abnormal bleeding or bruising; instruct patient to not take NSAIDS or aspirin while on Heparin; Caution when getting out of bed, brushing teeth/flossing, or when shaving Assess patient for signs of hemorrhage and abnormal bleeding; Assess patient for thrombosis; Observe injection site for infection or inflammation; Monitor patient for rash, fever, or hives; Monitor platelet levels with CBC tests every 2-3 days; Monitor electrolyte levels as it may cause hyperkalemia and increased AST and ALT levels; do not give NSAIDS or aspirin while patient is on Heparin.
Lactobacillus/Streptococcus (RISAQUAID) 1 capsule Daily By mouth probiotic
Gut health prevent diarrhea caused by antibiotics
Patient is taking multiple meds that may contribute to diarrhea/constipation
levofloxacin (Levaquin) 750 mg tablet Daily By mouth Anti-infective Treatment of bacterial infection Increased white blood cell count indicates infection Inhibits bacterial DNA reproduction; Killing bacteria Elevated intracranial pressure; seizure; dizziness; headache; hallucinations; tendon rupture; rash; C-Diff. associated diarrhea; nightmares; Steven’s Johnson syndrome; (Vallerand, 2017) Instruct patient to take drug as needed (if prescribed outside of hospital setting); Advise Dr. of rash or peeling skin and stop taking meds; Caution patient on driving and operating machinery; Encourage patient to maintain adequate hydration (1500-2000ml per day) Assess of infection (sepsis screenings – temp, CBC,); Watch for rash, hives, and allergic responses; Monitor BMs; Monitor glucose levels (may increase serum glucose levels on labs)
metronidazole (Flagyl) 500 mg tablet Every 8 hours By mouth Anti-infective Treatment of bacterial infection Increased white blood cell count indicates infection Treatment of intra-abdominal infections Seizures, dizziness, Steven’s Johnson syndrome; headache; abdominal pain; dry mouth; furry tongue; diarrhea; anorexia; rash; hives; vomiting
(Vallerand, 2017) Advise patient to report rash to Dr.; Advise patient to take meds as directed, do not skip doses; Avoid alcohol during and 3 days after treatment; Inform patient medication may turn urine dark; Inform patient that med has a metal taste Monitor patient for rash and allergic response; Assess for infection (fever and CBC checks); Monitor intake and outtake; Monitor neurological status.
Acetaminophen (Tylenol) 650 mg tablet PRN, every 4 hours By mouth Nonnarcotic Analgesic Fever and pain High temp and abdominal pain Inhibit synthesis of prostaglandin that may serve as mediator of fever and pain Steven’s Johnson syndrome; itchy rash; fatigue; renal failure; muscle spasms; N&V (Vallerand, 2017)
Advise patient to report rash to Dr.; discontinue use of meds if rash occurs; Remind patients to avoid drinking alcohol when taking Tylenol; Avoid excessive use – no more than 4 times a day Assess other drugs used to manage pain; Monitor patient’s skin for blister-like rashes; Monitor pain on numeric scale; Assess fever progression; Evaluate kidney and liver function with labs
Melatonin 3 mg tablet PRN, at bedtime By mouth Hormone supplement Sleep aid To assist patient with falling asleep and preventing insomnia Activates sleep and relaxation response in body Headache; Dizziness; Nausea; Drowsiness; depression, mild tremors, anxiety, abdominal cramps, irritability, reduced alertness, hypotension
(MFMER, 2018) Can cause daytime drowsiness; do not drive or operate machinery within 5 hours of taking it; Advise patient that they should not take melatonin if they develop an autoimmune disease (MFMER, 2018).
Do not give to patients with autoimmune disorders, Monitor for adverse effects; Give melatonin PRN for patient as ordered; Give med at bedtime to keep patient on normal sleep cycle (Awake during the day, sleeping at night)
Naloxone (Narcan) 0.2 mg PRN IV Opioid antagonist Unlabeled use: Anti-constipation Patient is taking multiple meds that may contribute to constipation Reversal of opioid excess; Constipation aid V-Fib, hypertension, hypotension, nausea, vomiting (Vallerand, 2017)
As medication is used, explain use to patient and family; Inform patient about signs of withdrawal; Patient should use call light when getting in and out of bed; Notify patient that taking medication will stop effectiveness of any opioids they have taken and they may experience a rise in pain Monitor respiratory rate, pulse, BP, level of consciousness; Dilute for patients taking opioids for >1 week; Assess patient for signs of withdrawal; Assess level of pain during hourly rounding; Give drug PRN for constipation relief
Ondansetron (Zofran) 4 mg injection PRN, every 4 hours IV Antiemetics Nausea, vomiting
Nursing Diagnoses
List 5-8 pertinent nursing diagnoses for your patient and prioritize them. You will then choose 2 nursing diagnoses from this list and expand on them.
Nursing Diagnosis
Prioritization
Acute pain related to biological injury (inflammation and perforation of large intestine) as evidenced by self-report of pain characteristics using standardized pain scale (5/10) upon ER admission.
1
Constipation related to decrease in gastrointestinal motility (diverticulitis) as evidenced by abdominal pain and hypoactive bowel sounds.
6
Risk for dysfunctional gastrointestinal motility related to infection (diverticulitis).
7
Decreased cardiac output related to alteration in heart rate as evidence by bradycardia.
4
Impaired physical mobility related to activity intolerance as evidence by abdominal discomfort (when moving).
5
Acute pain related to diverticulitis as evidenced by abdominal cramping and tenderness in abdomen while positioning to ease pain.
2
Deficient knowledge related to insufficient information (regarding diverticulitis) as evidence by insufficient knowledge. 3
Nursing Diagnosis #1: Deficient knowledge
R/T: Insufficient information (regarding diverticulitis)
AEB: Insufficient knowledge
SMART Short-Term Goal: By the end of the shift, the patient will demonstrate knowledge of her condition (diverticulitis) using the teach back method.
Nursing Intervention (including teaching): Rationale for Intervention and Reference: Evaluation: Was the short-term goal MET or UNMET? Substantiate evaluation based on assessment of patient post intervention.
Discuss disease processes and progression to patient using laymen’s terms. Laymen’s terms eliminate medical jargon and confusion.
When patients understand disease processes and progression, compliance with medication and follow-up appointments are more likely to occur.
Reference: Gulanick, 2017 MET: Patient understands progression of diverticula in the large intestine and has scheduled follow-up appointment with her primary care physician. Patient describes disease process using teach back method.
Nurse will assess the patient’s motivation and willingness to learn. Adult learners need to have purpose in their learning. Some patients are ready to learn while others deny or delay any patient teaching.
Reference: Gulanick, 2017 MET: Patient is happy to talk about condition and asks questions about “what’s next.”
Nurse explains procedures and medications necessary for stabilization. Nurse provides explanations before procedures are performed, prior to administering medication, and as patient asks questions. When a patient understands procedures and medications the nurse is able to provide patient centered care and establish a trusting environment during their stay in the hospital.
Reference: Gulanick, 2017 MET: Patient verbalizes understanding medications as they are given per MAR timing. Patient understands testing procedures and asks questions regarding labs and diagnostic test records. Nurse explains to her fullest capability.
SMART Long-Term Goal: By discharge, the patient will state 3 strategies to manage further progression of diverticulitis condition.
Nursing Intervention (including teaching): Rationale for Intervention and Reference: Evaluation: Was the long-term goal MET or UNMET? Substantiate evaluation based on assessment of patient post intervention.
Nurse will recommend dietary changes to the patient to prevent further complications.
Diet changes such as smaller meals and increased fiber intake are tolerated for patients with diverticular disease. Making these changes reduces patient’s discomfort, pain, and GI distress.
Reference: Gulanick, 2017 MET: Patient verbally states dietary changes she must make for her condition. Patient acknowledges high-fiber diet and portion size change for future meals.
Nurse encourages patient monitors changes in bowel movements while condition is being managed. Nurse tells patient to keep record of BMs while primary care provider is still following up.
Patients with diverticulitis may experience changes in BMs including diarrhea and constipation.
Reference: Gulanick, 2017 MET: Patient know to look for changes in BMs, noting texture, color, odor, and presence of blood to PCP during follow-up appointment.
Nurse notifies patient of the importance of abstaining from excessive alcohol. Alcoholic beverages contribute to gastric irritation and increase GI related pain.
Reference: Gulanick, 2017 MET: Patient describes alcohol intake as problem for her gastric system and denies excessive alcohol intake.
Nursing Diagnosis #2: Acute pain
R/T: biological injury (inflammation and perforation of large intestine)
AEB: self-report of pain characteristics using standardized pain scale (5/10) upon ER admission.
SMART Short-Term Goal: By the end of the shift, the patient will use pharmacological and nonpharmacological pain management strategies.
Nursing Intervention (including teaching): Rationale for Intervention and Reference: Evaluation: Was the short-term goal MET or UNMET?
Substantiate evaluation based on assessment of patient post intervention.
Nurse will provide medication (Tylenol) prescribed by MD as needed every 4 hours. Medicating for diverticulitis will allow pain to diminish.
Reference: Gulanick, 2017 MET: Patient requested Tylenol 10/05-10/10 to decrease abdominal pain associated with diverticulitis.
Nurse describes necessity for alterations in diet while in hospital. Liquid diet order placed 10/05 and progressed to low-fiber diet 10/10
Diet changes are imperative for patients with diverticular disease. Making changes such as smaller meals and increased fiber intake are tolerated for reduces patient’s discomfort, pain, and GI distress.
Reference: Gulanick, 2017 MET: Patient understands she cannot eat foods outside of her low-fiber diet as she denies Chick-Fil-A from husband while he is visiting on 10/11/18. She explains she does not want to upset her stomach.
Nurse encourages patient to engage in activities such a walking, relaxation techniques, and psychosocial support systems to decrease focus on her abdominal pain.
Distraction heightens a patient’s concentration on pain. A patient’s social network can reduce the burden of pain and relaxation. Relaxation techniques are used to provide tranquility and limit pain.
Reference: Gulanick, 2017 MET: Patient talks on phone with family members and friends often. Patient enjoys walking down the hallway to look outside the window. Patient enjoys conversating with nurses and I. Patient has visitors such as husband and 2 children.
SMART Long-Term Goal: By discharge, the patient will report absence or effective control of pain when walking.
Nursing Intervention (including teaching): Rationale for Intervention and Reference: Evaluation: Was the long-term goal MET or UNMET? Substantiate evaluation based on assessment of patient post intervention.
Nurse will access patients’ pain during hourly rounding. Nurse will use standardized pain scale and get description of pain type using words such as dull, aching, stabbing, etc. Changes in pain can predict healing or progression of diverticulitis.
Reference: Gulanick, 2017 MET: Patient describes abdominal pain using scale and descriptive words. Patient notes that pain occurs when bending and getting out of bed. Nurse reminded her to take it easy, limit bending at the waist, and to use call light if she needs help. Patient denies pain while performing walking throughout hallways.
Nurse will encourage patient to ambulate as much as possible. Remind patient to avoid straining and bending.
Walking aids in promotion of GI movement and prevents muscle fatigue due to prolonged bed rest.
Reference: Gulanick, 2017 MET: Nurse and I encouraged patient to re-position frequently and to take walks. Nurse created a goal to walk at least 3 times during the shift and patient was working on walk #2 of the day when I walked with her.
Nurse sets pain goal with patient during introduction to establish goal of pain management. Patients goal is to be at pain less than a 2 before discharge. Setting this goal shows the effectiveness of pain relief options that have occurred during hospital stay.
Reference: Gulanick, 2017 UNMET: While patient notes that pain has decreased significantly since being admitted, pain experiences pain during movement and stretching her abdomen. Patient has not been discharged so I am unable to access pain management throughout entire stay.
References
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2014). Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span (9th ed.). Philadelphia, PA: F.A. Davis Company.
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes (9th ed.). St. Louis, MO: Elsevier.
Herdman, T.H. & Kamitsuru, S. (Eds.). (2014). NANDA International Nursing Diagnoses: Definitions and classification, 2015-2017. Oxford: Wiley Balckwell.
Ignatavicius, D. D., Workman, M. L., & Blair, M. (2016). Medical-surgical nursing: Patient-centered collaborative care (8th ed.). St. Louis: Elsevier.
Mayo Foundation for Medical Education and Research (MFMER). (2018, March 30). Melatonin. Retrieved October 15, 2018, from https://www.mayoclinic.org/drugs-supplements-melatonin/art-20363071
MedlinePlus: Globulin Test Lab Test Information. (2018, July 11). Retrieved from https://medlineplus.gov/lab-tests/globulin-test/
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (n.d.). Diverticular Disease. Retrieved from https://www.niddk.nih.gov/health-information/digestive-diseases/diverticulosis-diverticulitis
Porth, C., & Gaspard, K. J. (2015). Essentials of pathophysiology: Concepts of altered health states. Philadelphia: Wolters Kluwer.
Vallerand, A. H., & Sanoski, C. A. (2017). Davis's drug guide for nurses (15th ed.). F. A. Davis.