NUR 152 Patient Information & Preplanning
Student Name
Marlee Asher
Date of Care:
4/7/22
Admit Date:
Admitting Diagnosis:
Acute Cholecystitis
Occupation: Harbison-Walker/RHI
Refractory
□ DNR:
□ Advanced Directive/Living will
□ DPOA: Relationship
Insurance: Aetna Medicare
Advantage; Medicaid; Blue Cross
Support services (RT, PT, OT, ST, SS, Chaplain):
Gender:
Room #: Marital
Age:
Male
114
Status:
77
Race:
S M
White
D W
Stage of Growth and Development (Erickson):
Egointegrity vs Despair
Height: 5’8
PT/OT; Social Services; Surgery Consult
Admission Weight: 84 kg
Current Weight: 74.4 kg
Isolation: □ Yes □ No
Type:
Allergies/Reactions/Intolerances:
NKA
List Treatments (Dressings, Ice, IS, etc.):
Diet: Regular diet
Dietary/Fluid Restrictions:
Incision dressing change
□ Tube feedings N/A
N/A
Assistive Equipment (cane, walker,
crutches, prosthetics):
□ Aspiration Precautions
□ Dentures/Partials
□ Requires assistance with feeding
□ Fall Risk Score:
□ Braden Score:
Providers
Activity orders:
Smith, Claire
As tolerated with
assistance
Walker/ gait belt
Other (HOH/Hearing aids, Visual deficit/Glasses, Speech deficit, etc.):
Ask your client: “What is your goal for tomorrow…?”
Surgical Procedure(s) this admission (briefly describe) and surgery Date: 4/8/22 Cholecystectomy Laparoscopy with operative
Cholangiogram
Past Medical History/Chronic Illnesses/DSM 4/TR 5:
Acute gangrenous cholecystitis with cholelithiasis
Chronic anemia
Dementia
Borderline low B12 levels
Hypertension
Dyslipidemia
Constipation
Weakness
Past Surgical History:
N/A
Patient Information
(Complete PRIOR to Clinical Day)
Current Medical Diagnosis: Acute Cholecystitis
Textbook Signs and Symptoms (from textbook):
Intense, sudden pain in the upper right part of your
belly. Pain (often worse with deep breaths) that
spreads to your back or below the right shoulder
blade. Nausea. Vomiting. Fever. Yellowing of the skin
and eyes (jaundice)Loose, light-colored bowel
movements. Belly bloating.
Presenting Signs and Symptoms (from pt. chart):
Diffuse abdominal pain more on his right upper quadrant, the
pain was burning, intermittent, started 4/7/22. Also c/o R sided
chest pain, states he had some chills, denies nausea, vomiting,
cough, SOB, palpitations, diarrhea, or dysuria.
Admitting Vital Signs:
97.9 71 16 109/43 100%
Risk Factors:
Being female. Pregnancy. Hormone therapy. Older age. Being Native American or Hispanic. Obesity. Losing or
gaining weight rapidly. Diabetes.
Potential/Actual Complications:
Untreated cholecystitis can cause tissue in the gallbladder to die (gangrene). It's the most common
complication, especially among older people, those who wait to get treatment, and those with diabetes. This can
lead to a tear in the gallbladder, or it may cause your gallbladder to burst. Injury to the bile ducts draining the
liver (may occur after gallbladder surgery) Pancreatitis. Perforation
Pathophysiology for this diagnosis (what happens at the cell level in student words):
Most often, cholecystitis is the result of hard particles that develop in your gallbladder (gallstones). Gallstones
can block the tube (cystic duct) through which bile flows when it leaves the gallbladder. Bile builds up, causing
inflammation. Acute cholecystitis is inflammation of the gallbladder that occurs due to occlusion of the cystic
duct or impaired emptying of the gallbladder. Often this impaired emptying is due to stones or biliary sludge.
Reference (APA format):
NCBI - Acute Cholecystitis. (2021, September). National Library of Medicine. Retrieved April 20, 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK459171/
Etiology (Cause of condition):
Gallstones. Most often, cholecystitis is the result of hard particles that develop in your gallbladder (gallstones).
Gallstones can block the tube (cystic duct) through which bile flows when it leaves the gallbladder. Bile builds
up, causing inflammation. Tumor. A tumor may prevent bile from draining out of your gallbladder properly,
causing bile buildup that can lead to cholecystitis. Bile duct blockage. Kinking or scarring of the bile ducts can
cause blockages that lead to cholecystitis. Infection. AIDS and certain viral infections can trigger gallbladder
inflammation. Blood vessel problems. A very severe illness can damage blood vessels and decrease blood flow
to the gallbladder, leading to cholecystitis.
Reference (APA format):
NCBI - Acute Cholecystitis. (2021, September). National Library of Medicine. Retrieved April 20, 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK459171/
Think about it: How do the past/current medical-surgical diagnoses r/t current hospitalization/problem? Are they a factor/cause?
Could they represent additional risks? (You may concept map):
Psychosocial and Spiritual Assessments
Questions in white may be completed by visiting with the client prior to and/or on the clinical day
Questions in gray must be completed at the end of the clinical day
Patient/family strengths and weaknesses:
Health Promotion/Education Needs for patient/family and community resources:
Spiritual/Psychosocial beliefs that help the client cope with stress? and/or What gives your life meaning?
Role of Faith/Belief in health/illness/diagnosis: Have your beliefs influenced how you take care of yourself in this illness?
Spiritual Cues:
Spiritual/Psychosocial Support (person or group) identified: Do you belong to a spiritual/religious community? (i.e.: church)
Are they a source of support to you?
Spiritual/Psychosocial Interventions Provided and reflection: How would you like me to address these issues in your health
care? Include your perception of the interactions between the patient, family, and staff. Examples could include but are not
limited to civility, abuse and neglect.
Generic Name
of Medication
(Include all
scheduled
meds; PRNs
administered
within last 24
hrs; Diabetic
Protocol meds;
Resp meds)
Dose,
Route,
Time
Classification
Calcium
channel
blocker
HTN
Amlodipine
5 mg
PO
0900
Atorvastatin
40 mg
PO
2100
HMG-CoA
reductase
inhibitor
High
cholesterol
HX
Water soluble
vitamin
Anemia
Cyanocobalamin
1000 mcg
PO
0900
50/8.6 mg
PO
0900
1700
10 mg
PO
2100
Stimulant
laxative
Constipation
Cholinergic:
cholinesterase
inhibitor
Dementia
12.5 mg
PO
0900
Thiazide
diuretic
HTN
25 mg
PO
0600
1800
15 g
PO
0900
1700
Beta blocker
HTN
Osmotic
laxative
Constipation
Docusate +
Senna
Donepezil
Hydrochlorothia
zide
Metoprolol
Polyethylene
glycol
Reason
Ordered for
Client
(Therapeutic
effect)
Nursing Considerations
(Side Effects, Patient Teaching, Labs,
Nursing Implications – SE, PT, L, NI)
SE-swelling LE, dizziness, irregular heartbeat
L-liver function, AST, ALT
PT-monitor BP/HR, change positions slowly, wkly
BP
NI-monitor BP/HR; monitor labs
SE-rhabdomyolysis, constipation, heartburn
L-AST, ALT, serum cholesterol, CK levels
PT-Report unexplained muscle tenderness or pain,
diet restriction (alcohol), cholesterol
NI-Administer with food, monitor labs
SE-headache, heart failure, diarrhea, hypokalemia
L-folic acid, vitamin B12, iron, hgb, hct
PT- Encourage patient to comply with diet
recommendations of health care professional.
Explain that the best source of vitamins is a wellbalanced diet with foods from the four basic food
groups
NI- administer with meals to increase absorption,
monitor labs
SE-electrolyte imbalance, abd cramps, nausea
L-n/a
PT-encourage fluid intake, avoid straining
NI-administer with a full glass of water, don’t
administer within two hours of other laxatives
SE-diarrhea, nausea, headache
L-n/a
PT-may cause dizziness, take same time everyday,
NI-administer in the evening just before bedtime,
administer with or without food
SE-hypokalemia, dizziness, drowsiness
L-K+, BUN, creatinine, uric acid, bilirubin, Ca, mag
PT-change positions slowly, use sunscreen
NI-administer in am to prevent disruption of sleep
cycle, give with food or milk to minimize GI upset
SE-heart failure, decreased BP, decreased HR
L-BUN, creatinine, AST, LDH
PT-report dizziness
NI-check BP, HR within 30 min admnistration
SE-abd distention, abd pain, nausea, fatulence
L-n/a
PT-may mix in juice or water
NI-assess for abd distention, bowel sounds, last BM
Generic Name
of Medication
(Include all
scheduled
meds; PRNs
administered
within last 24
hrs; Diabetic
Protocol meds;
Resp meds)
Dose,
Route,
Time
Classification
Reason
Ordered for
Client
(Therapeutic
effect)
Nursing Considerations
(Side Effects, Patient Teaching, Labs,
Nursing Implications – SE, PT, L, NI)
SELPTNISELPTNISELPTNISELPTNISELPTNISELPTNISELPTNISELPTNISELPTNI-
Generic Name
of Medication
(Include all
scheduled
meds; PRNs
administered
within last 24
hrs; Diabetic
Protocol meds;
Resp meds)
Dose,
Route,
Time
Classification
Reason
Ordered for
Client
(Therapeutic
effect)
Nursing Considerations
(Side Effects, Patient Teaching, Labs,
Nursing Implications – SE, PT, L, NI)
SELPTNISELPTNISELPTNISELPTNISELPTNISELPTNISELPTNISELPTNISELPTNISELPTNI-
IV Medication Only
Generic Name
of Medication
(Include all
scheduled
meds; PRNs
administered
within last 24
hrs; Diabetic
Protocol meds;
Resp meds)
Heparin
Rate of
infuDose,
sion &
Route,
Total
Time
infusio
n time
Reason
Ordered
for Client
Classifi-cation
(Therapeutic
effect)
5000
units
IV
0600
1800
anticoagulant
DVT PE
prevention
Compatibi
lity with
all IV
meds/
Soln.
(Medicatio
n/
IV fluids)
Nursing Considerations
(Side Effects, Patient Teaching,
Labs,
Nursing Implications – SE, PT,
L, NI)
SE-hemorrhage, ecchymoses,
thrombocytopenia
L-prothime, PTT, INR
PT-report any bruising or unusual
bleeding
NI-assess for s/s bleeding
SELPTNISELPTNISELPTNISELPTNISELPTNISELPTNISELPTNISELPTNI-
Laboratory Studies
White: Complete PRIOR to Clinical Day Gray – Complete DURING Clinical Day
Values
Complete Blood Count w/Diff.
Lab
Component
WBC
RBC
Hemoglobin
Hematocrit
Platelets
Abs Neut
Abs Lymph
Abs Mono
Abs Eosin
Abs Baso
Abs Imm
Gran
Normal
Range
Adm or
Preop
Date:
Pre-plan
Date:
Clinical
Date:
Rationale
Why ordered?
8.9
MONITOR INFECTION
3.3-11.7
3.74-5.70
4.85
MONITOR O2 LEVEL
11.1-17.7
9.8
MONITOR
BLEEDING/O2
34.1-49.7
31.2
150-450
205
BLOOD
DISORDER/DEHYDRAT
ION
CLOTTING ABILITY
/SIGN OF INFECTION
1.2-8.0
8.3
MONITOR INFECTION
0.4-3.7
0.4
MONITOR INFECTION
0.2-1.0
0.2
MONITOR INFECTION
0.0-0.4
0.0
MONITOR INFECTION
0.0-0.1
0.0
MONITOR INFECTION
0.0-0.1
0.3
MONITOR INFECTION
Laboratory Studies
White: Complete PRIOR to Clinical Day Gray – Complete DURING Clinical Day
ABGs
Values
Normal Adm or
Pre-plan Clinical Rationale
Lab
Range
Preop
Date:
Date:
Why ordered?
Component
Date:
pH
pO2
pCO2
7.32-7.42
N/A
ASSESS FOR ACIDOSIS
INFECTION
23-31
N/A
ASSESS RESPIRATORY
FUNCTION/OXYGENA
TION
4-51
N/A
ASSESS RESPIRATORY
FUNCTION
24.0-28.0
N/A
83
N/A
ASSESS BASELINE
METABOLIC ACTIVITY
RESPRITORY
FUNCTION
ASSESS BASELINE
OXYGENATION
LEVELS/RESPIRATORY
FUNCTION
ASSESS ACIDITY/BASE
OF BODY
HCO3
SatO2
Base Excess
N/A
Nursing Action(s) for
abnormal:
What is the nurse going
to do for abnormal?
Monitor labs, dietary
considerations high iron
Monitor labs, dietary
considerations high iron
Nursing Action(s) for
abnormal: What is the
nurse going to do for
abnormal?
Laboratory Studies
White: Complete PRIOR to Clinical Day Gray – Complete DURING Clinical Day
Values
Complete Metabolic Panel or Basic Metabolic Panel
Rationale
Lab
Adm or
Pre-plan Clinical Why ordered?
Normal
Component
Preop
Date:
Date:
Range
Date:
Glucose
115
BLOOD GLUCOSE
MONITORING
21.7
ASSES FOR
HYDRATION LEVEL
KIDNEY/LIVER
FUNCTION
ASSES FOR
HYDRATION LEVEL
KIDNEY/LIVER
FUNCTION
82-115
8.4- 25.7
BUN
1.44
Creatinine
Sodium
Potassium
Chloride
ALT
AST
0.72-1.25
138
MONITOR HYDRATION
LEVELS ASSESS NA
IMBALANCE
3.9
MONITOR
HYDRATION/ ASSESS
FOR K INBALANCE
102
MONITOR HYDRATION
/ASSESS FOR CL
IMBALANCE
11
ASSESS LIVER
FUNCTION/LIVER
DISESE
18
ASSESS LIVER
FUNCTION/LIVER
DISEASE
78
ASSESS FOR
GALLSTONES ABILITY
FOR BONE GROWTH
LIVER
ASSESS FOR STATUS
OF RBC /JAUNDICE/
BILIRUBIN LEVEL
136-145
3.5-5.11
98-107
0-55
5-34
ALK Phos
40-150
Bilirubin
0.2-1.2
0.7
3.7
Albumin
3.4-4.8
Calcium
8.8-10.0
8.8
47
GFR
>60
ASSESS FOR
MALNUTRITION
MALABSORPTION
KIDNEY FUNCTION
ASSESS FOR
MALNUTRITION
MUSCLE/ NERVE/
HEART FUNCTION
<60 ASSESS FOR
ALTERED KIDNEY
FUNCTION CHRONIC
KIDNEY DISEASE <15
END-STAGE RENAL
Nursing Action(s) for
abnormal:
What is the nurse going
to do for
abnormal?
Daily weight, I/O, dietary
considerations, assess for
anemia
Laboratory Studies
White: Complete PRIOR to Clinical Day Gray – Complete DURING Clinical Day
Values
Miscellaneous
Lab
Component
Normal
Range
Admission
or Preop
Date:
2.5-4.5
N/A
1.30-210
1.45
11.5-14.8
N/A
Phosphorus
Magnesium
Protime
N/A
INR
PTT
TSH
23.3-36.2
N/A
N/A
Pre-plan
Date:
Clinical
Date:
Rationale
Why ordered?
MONITOR
MALNUTRITION
RENAL FUNCTION
LEVELS
ASSESS RENAL
FUNCTION MG LEVEL
ASSESS BLOOD
CLOTTING ABILITY/
BLEEDING DISORDER
ASSESS BLOOD
CLOTTING ABILITY/
BLEEDING DISORDER
ASSESS BLOOD
CLOTTING ABILITY/
BLEEDING DISORDER
THYROID FUNCTION
0.4-4.2
Laboratory Studies
White: Complete PRIOR to Clinical Day Gray – Complete DURING Clinical Day
Values
Urinalysis
Rationale
Admission Pre-plan Clinical Why ordered?
Lab
Normal
or Preop
Date:
Date:
Component
Range
Date:
pH
Leukocytes
Nitrates
Nursing Action(s) for
abnormal:
What is the nurse going
to do for
abnormal?
N/A
ASSESS ACIDITY
HYDRATION &
KIDNEY FUNCTION
N/A
ASSESS FOR UTI
N/A
ASSESS FOR UTI
N/A
ASSESS RENAL /
KIDNEY FUNCTION
N/A
ASSESS INSULIN
PRODUCTION /
DIABETES
N/A
ASSESS RENAL
FUNCTION
5.0-9.0
NEG
NEG
Protein
NEG
Glucose
NEG
Blood
NEG
Sp. Gravity
1.0011.04
N/A
Nursing Action(s) for
abnormal:
What is the nurse going
to do for
abnormal?
Laboratory Studies
(Any other labs drawn go here)
White: Complete PRIOR to Clinical Day Gray – Complete DURING Clinical Day
Values
Any other labs drawn go here
Rationale
Adm or
Why ordered?
Lab
Normal
Pre-plan Clinical
Preop
Component
Range
Date:
Date:
Date:
80-100
64.3
BLOOD LEVEL
MCH
26.0-33.0
20.2
BLOOD LEVEL
MCHC
31.0-36.0
31.4
RDW
11.0-15.0
17.0
BLOOD LEVELS
HEMOGLOBIN IN
GROUP RBC ARE
FRAGILE
RBC SIZE
MPV
6.5-12.0
9.6
NUCLEATED RBC
/100
0
NEUTROPHIL %
42.3-79.8
93
INFECTION
LYMPHOCYTE %
10.7-43.5
4.0
INFECTION
MONOCYTE %
4.5-12.0
2.4
INFECTION
EOSINOPHIL %
0.0-5.9
0.2
INFECTION
BASOPHIL %
0.0-1.1
0.1
INFECTION
IMMATURE
GRAND
0.0-0.9
0.3
INFECTION
Normal
BLOOD CLOT
MCV
PLATELET
MOPHOLOGY
Nursing Action(s) for
abnormal:
What is the nurse going
to do for
abnormal?
Assess for anemia, dietary
considerations
Assess for anemia, dietary
considerations
Assess for anemia, dietary
considerations
BLOOD LEVELS
LARGER THAN
AVERAGE PLATELETS
BLOOD CELLS
Monitor/assess for signs
and symptoms of infection
Monitor/assess for signs
and symptoms of infection
Monitor/assess for signs
and symptoms of infection
Radiology/Other Diagnostics
(Initial and Most Recent)
Test
CT Abdomen +
Pelvis with Contrast
Date
4/7/2022
History
Upper abdominal pain,
chronic diarrhea
XR Cholangiogram
Operative
4/8/2022
Intraoperative
cholangiogram
Findings/Results
Distended gallbladder with cholelithiasis and
associated gallbladder wall thickening/edema
with suggestion of some minimal
pericholecystic inflammation. These findings
are most suggestive of acute cholecystitis. Nondistended urinary bladder with suggestion of
greater than expected diffuse bladder wall
thickening and possible subtle surrounding
perivascular haziness/stranding. These finding
my reflect cystitis versus possible changes of
chronic bladder outlet obstruction. Nonobstructing right nephrolithiasis. Indeterminate
hypodense hepatic lesions. Multiple additional
chronic and incidental findings as above.
No evidence of filling defect within the cystic
duct or extrahepatic mild
Orem’s Three Basic Nursing Systems:
(1) The wholly compensatory nursing system is represented by a situation in which the individual is unable “to engage in those self-care actions
requiring self-directed and controlled ambulation and manipulative movement or the medical prescription to refrain from such activity… Persons
with these limitations are socially dependent on others for their continued existence and well-being.”
(2) The partly compensatory nursing system is represented by a situation in which “both nurse and perform care measures or other actions
involving manipulative tasks or ambulation… [Either] the patient or the nurse may have the major role in the performance of care measures.”
(3) In the supportive-educative system also known as supportive-developmental system, the person “is able to perform or can and should learn to
perform required measures of externally or internally oriented therapeutic self-care but cannot do so without assistance.”
Student to complete only 4 Nursing Diagnosis before clinical. Extra pages are included for changes during the clinical day.
Problems not addressed in list that follows:
Constipation, chronic anemia, borderline low B12 levels, hypertension, dyslipidemia, constipation, weakness
#
#
ND: Acute Pain
Supporting Data:
ND: Deficient Knowledge
Supporting Data:
Previous Assessment (Physical
findings): Diffuse abdominal pain more
on his right upper quadrant, the pain was
burning, intermittent, started 4/7/22. Also
c/o R sided chest pain, states he had some
chills, denies nausea, vomiting, cough,
SOB, palpitations, diarrhea, or dysuria
Previous Assessment (Physical
findings): Poor historian
Labs: BUN 21.7 Creatinine 1.44 Na 138
K+ 3.9 Ca 88 Hgb 9.8 Hct 31.2
Meds:
Chief
Chief
Complaint
Complaint
that–brought
Medicalpt to
Dx/Surgery
hospital
(What
(Medical
brought
Dx/Surgery)
patient to
hospital?)
Key Assessments:
History/Other: Poor historian
#
GI assessment
I/O
Pain assessment
Surgical incision assessment
LOC
ND: Impaired Skin Integrity
Previous Assessment (Physical
findings): Surgery 4/8/22
Key Assessment
(Think body system)
Meds:
ND:
Meds:
History/Other: Poor historian
#
ND:R/F deficient fl volume
Supporting Data:
Supporting Data:
Labs: BUN 21.7 Creatinine 1.44 Na 138
K+ 3.9 Ca 88 Hgb 9.8 Hct 31.2
Labs: BUN 21.7 Creatinine 1.44 Na
138 K+ 3.9 Ca 88 Hgb 9.8 Hct 31.2
#
ND:
Previous Assessment (Physical
findings): alert and confused
Poor appetite and poor intake
Labs: BUN 21.7 Creatinine 1.44 Na
138 K+ 3.9 Ca 88 Hgb 9.8 Hct 31.2
Meds:
Levaquin
History/Other: Poor historian
History/Other: Poor historian
All areas in white to be completed before clinical. All areas in gray to be completed by submission for grading.
One teaching intervention is required when possible. Only 4 pages to be completed before day of care.
Supporting Data on Day of care
(pertinent to nursing diagnosis):
Nursing Diagnosis #
Acute pain r/t cholecystectomy
Assessment day of care:
Goal/Outcome(s): Pt will report pain management regimen achieves
comfort function goal without side effects during shift of care
Labs/Diagnostics:
Wholly Compensatory _______
Partly Compensatory _______
Supportive Educative _________
Medications:
Nursing Interventions:
Rationale:
Patient Responses to Interventions:
1. Administer a nonopioid analgesic
for mild to moderate pain and add an
opioid analgesic if indicated for
moderate to severe pain during shift
of care
2. Prevent pain by administering
analgesia before painful procedures
whenever possible during shift of
care
3. Reinforce the importance of taking
pain meds to maintain the comfortfunction goal during shift of care
1. Non opioids are first-line
analgesics for treatment of mild to
moderate pain
1.
2. Adults inpatient experience
numerous sources of procedural
pain
2.
3. Teach pts to stay on top of their
pain and prevent it from getting
out of control to accomplish the
goals of recovery
4. Pain causes cognitive
impairment
3.
4. Teach the pt about and
4.
pharmacological and nonpharmacological interventions when
pain is controlled during shift of care
Evaluation: Summarize patient’s progress toward the outcome: Circle one: Met, Partially Met, Not met
Explain:
All areas in white to be completed before clinical. All areas in gray to be completed by submission for grading.
One teaching intervention is required when possible. Only 4 pages to be completed before day of care.
Supporting Data on Day of care
(pertinent to nursing diagnosis):
Nursing Diagnosis #
Impaired skin integrity r/t surgical incision
Assessment day of care:
Dsg dry and intact
Pressure dressing in place RUQ abdomen
Goal/Outcome(s): Pt will have a dry and intact dressing during shift of
care
Wholly Compensatory _______
Labs/Diagnostics:
None drawn
Partly Compensatory _______
Supportive Educative _________
Medications:
n/a
Nursing Interventions:
Rationale:
Patient Responses to Interventions:
1. Observe the color and character of
the drainage during shift of care
1. Initially, drainage may
contain blood and bloodstained
fluid, normally changing to
greenish brown (bile color) after
the first several hours
2. Keeps the skin around the
incision clean
1. 0900 dsg dry and intact
Pressure dressing in place
3. Place the patient in low- or semiFowler’s position periodically during
shift of care
3. Facilitates drainage of bile
3. 0900 HOB 30 degrees 1100
HOB 45 degrees 1300 HOB 35
degrees
4.Assess for signs and symptoms of
infection during shift of care
4.early recognition and prevention
is key
4. afebrile, no signs or symptoms
of infection noted
2. Change dressings daily and as
often as necessary during shift of care
2. 0900 dsg dry and intact
No dressing change at this time
Evaluation: Summarize patient’s progress toward the outcome: Circle one: Met, Partially Met, Not met
Explain:
Dressing remained dry and intact during shift of care
All areas in white to be completed before clinical. All areas in gray to be completed by submission for grading.
One teaching intervention is required when possible. Only 4 pages to be completed before day of care.
Supporting Data on Day of care
(pertinent to nursing diagnosis):
Nursing Diagnosis #
Deficient knowledge r/t dementia
Assessment day of care:
Goal/Outcome(s): Pt will verbalize understanding of post-surgical
process and potential complications during shift of care
Wholly Compensatory _______
Labs/Diagnostics:
Partly Compensatory _______
Supportive Educative _________
Medications:
Nursing Interventions:
Rationale:
Patient Responses to Interventions:
1. Demonstrate care of incisions,
dressings, and drains. Promote
good hand hygiene during shift of
care
2. Discuss avoiding or limiting the
use of alcoholic beverages during
shift of care
1. Promotes independence in care
and reduces the risk of
complications
1.
2. Minimizes risk of pancreatic
involvement
2.
3. Review activity limitations
depending on the individual situation
during shift of care
3. Reduces the risk of reflux, strain 3.
on tube or appliance seal. Provides
information about the resolution of
ductal edema and return of ductal
function for appropriate timing of
T-tube removal.
4.Indicators of obstruction of bile
4.
flow or altered digestion, requiring
further evaluation and intervention
4. Teach pt signs and symptoms
requiring notification of healthcare
provider during shift of care
Evaluation: Summarize patient’s progress toward the outcome: Circle one: Met, Partially Met, Not met
Explain:
All areas in white to be completed before clinical. All areas in gray to be completed by submission for grading.
One teaching intervention is required when possible. Only 4 pages to be completed before day of care.
Supporting Data on Day of care
(pertinent to nursing diagnosis):
Nursing Diagnosis #
Deficient fluid volume r/t gastric hypermotility
Assessment day of care:
Denies nausea, good oral intake Input 950
Output 500 mL
Cap refill less that 3 sec
Good skin turgor
Moist mucous membranes
Goal/Outcome(s): Pt will demonstrate adequate fluid balance as
evidenced by good skin turgor and cap refill less than 3 sec during shift
of care
Wholly Compensatory _______
Labs/Diagnostics:
none drawn
Partly Compensatory _______
Supportive Educative _________
Medications:
n/a
Nursing Interventions:
Rationale:
Patient Responses to Interventions:
1. Maintain accurate record of I&O
during shift of care
1. To provide information about
fluid status and circulating volume
needing replacement
1. Input 950 Output 500
2. Monitor for signs and symptoms of
increased or continued nausea or
vomiting during shift of care
2. Prolonged vomiting,
gastric aspiration, and restricted
oral intake can lead to deficits
in sodium, potassium, and chloride
2. Denies nausea during shift
of care
3. Perform frequent oral hygiene with
alcohol-free mouthwash; apply
lubricants during shift of care
3. Decreases dryness of oral
mucous membranes; reduces risk
of oral bleeding
3. 0900 1100 oral hygiene
care provided
1400 oral rinse provided
4.Eliminate noxious sights or smells
from environment during shift of care
4. Reduces stimulation of
vomiting center
4. Denies nausea during shift
of care, states the smell of
eggs upsets stomach
Evaluation: Summarize patient’s progress toward the outcome: Circle one: Met, Partially Met, Not met
Explain:
Pt demonstrated adequate fluid balance with good skin turgor and cap refill less than 3 seconds during shift
All areas in white to be completed before clinical. All areas in gray to be completed by submission for grading.
One teaching intervention is required when possible. Only 4 pages to be completed before day of care.
Supporting Data on Day of care
(pertinent to nursing diagnosis):
Nursing Diagnosis #
Decreased cardiac output r/t Change in level of consciousness
Assessment day of care:
0800 BP 123/ 61 HR 56 98%
0820 BP 126/63 HR 62
1130 BP 109/54 HR 60 100%
1430 BP 124/62 HR 64 98%
Goal/Outcome(s): Patient demonstrates adequate cardiac output as
evidenced by blood pressure and pulse rate WNL for pt range during
shift of care
Pt regular 120/60 HR above 60
Wholly Compensatory _______
Labs/Diagnostics:
Partly Compensatory _______
None drawn
Supportive Educative _________
Medications:
Amlodipine, hydrochlorothiazide, metoprolol
Nursing Interventions:
Rationale:
Patient Responses to Interventions:
1.
1.
Compensatory tachycardia is a
common response for patients with
significantly low blood pressure to
reduce cardiac output.
1. 0800 BP 123/ 61 HR 56
2. Weak pulses are present in
reduced stroke volume and cardiac
output
2. 0800 weak peripheral pulses
3. Capillary refill is sometimes
slow or absent
4. An alteration in oxygen
saturation is one of the earliest
signs of reduced cardiac output.
Hypoxemia is common, especially
with activity
Evaluation: Summarize patient’s progress toward the outcome: Circle one:
Explain:
Pt BP and HR below parameters during shift of care at times
3. 0800 cap refill less than 3
seconds
4. 0800 98% 1130 100% 1430
98%
Patient demonstrates adequate
cardiac output as evidenced by
blood pressure and pulse rate
during shift of care
2. Check for peripheral pulses during
shift of care
3. Perform capillary refill test during
shift of care
4. Assess oxygen saturation with
pulse oximetry both at rest and during
and after ambulation
0820 BP 126/63 HR 62
1130 BP 109/54 HR 60
1430 BP 124/62 HR 64
Met, Partially Met, Not met
All areas in white to be completed before clinical. All areas in gray to be completed by submission for grading.
One teaching intervention is required when possible. Only 4 pages to be completed before day of care.
Supporting Data on Day of care
(pertinent to nursing diagnosis):
Nursing Diagnosis #
r/t
Assessment day of care:
Goal/Outcome(s
Wholly Compensatory _______
Labs/Diagnostics:
Partly Compensatory _______
Supportive Educative _________
Medications:
Nursing Interventions:
Rationale:
Patient Responses to Interventions:
1.
1.
1.
2.
2.
2.
3.
3.
3.
4.
4.
4.
Evaluation: Summarize patient’s progress toward the outcome: Circle one: Met, Partially Met, Not met
Explain: