Running head: NURSING PROCESS PAPER
Nursing Process Paper
Jerel Hershberger
Kent State University
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Introduction
The purpose of this paper is to take a patient that I had cared for on the clinical floor and
put together a research paper on the patient from a holistic standpoint. This process paper
describes the medical diagnosis, all lab work and diagnostic tests, my assessment of the patient,
treatments, a concept care map of the patient, medications the patient is taking, and nursing
diagnosis, goals, interventions, and desirable outcomes. This patient was chosen because of her
interesting past medical history and her current medical diagnosis. I will describe the patient as
PR.
Client Profile
PR is a female patient that is sixty-eight years old. She is a very pleasant but frail lady
with a weight of one hundred six pounds, five feet five inches tall, and a calculated BMI of 17.6.
PR has a social history of actively smoking one to two packs per day and denies alcohol use.
Time of the assessment and patient care was on September 18, 2012. She was admitted on
September 17, 2012 through the emergency department with abdominal pain, nausea and
vomiting.
PR was diagnosed with complete small bowel obstruction which is blockage in the small
intestines. Normally the fluid in the bowels is reabsorbed, but with bowel obstruction the bowels
partially retain the fluid which can cause distention. Beatrice Harold writes in the Emergency
Nurse (2011) that patients with bowel obstruction can become hypovolemic due to vomiting,
poor fluid intake, and fluid that is retained in the bowel lumen and not reabsorbed as normal.
This can cause a decrease in blood volume and can lead to hypotension, hypovolemic shock, and
diminished renal and cerebral blood flow (Black & Hawk, 2009). Signs and symptoms of bowel
obstruction is abdominal pain, abdominal distention, vomiting, and sometimes peristaltic waves
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can be visible (Black & Hawk, 2009). Assessments of the vital signs should be made
immediately (Harold, 2011).
PR also has a current diagnosis of an Abdominal Aortic Aneurysm (AAA). AAA is an
out-pouching of the wall of the descending aorta in the abdominal region. AAA is caused by the
weakening of the musculoelastic middle layer of the arterial wall, usually caused by plaque
build-up or cholesterol deposits (Brunner & Sommers, 2011). Over time, as the pulsating blood
rushes through the aorta, the vessel wall becomes increasingly weak, and the aneurysm can
enlarge (Brunner & Sommers, 2011). The enlargement and weakening of the vessel wall can
become extremely dangerous. Signs and symptoms may include a pulsating abdominal mass. A
bruit may also be heard on auscultation of the abdomen (Brunner & Sommers, 2011). Severe
back and abdominal pain, decrease in blood pressure, increase in pulse, increase in respirations,
and pain, pallor, absent pedal pulses, and paresthesia in the lower extremities are all signs of
aneurysm rupture (Brunner & Sommers, 2011).
PR has an extensive past medical history. The history includes the following: AAA,
Anxiety Disorder, severe Chronic Obstructive Pulmonary Disease (COPD), Lumbar Disc
Disease, Depression and Anxiety, long Tobacco history, Hypertension, Hyperlipidemia,
Osteoporosis, Peripheral Vascular Disease (PVD), and prior extremity Deep Venous Thrombosis
(DVT). Looking at the list of the past medical history, the history of long tobacco use may have
had significant impact on her health. Tobacco use may be a cause or part of the cause of her
development of COPD, hypertension, PVD, hyperlipidemia, and AAA (Centers for Disease
Control and Prevention, 2012). The past surgical history for PR is as follows: Aortofemoral
bypass, appendectomy, hysterectomy, and a vaginal and bladder suspension. PR also has a list
of allergies. The allergies are Augmentin, Penicillins, Cephalosporins, Lincosamides,
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Betalactams, Carbapenem, Streptokinase Analogues, Alterplase, Clindamycin, Clavulanic Acid,
Potassium Clavulanate, Amoxicillin, Retavase.
PR presented to the Emergency Department on September 17, 2012 with abdominal pain.
The ED reported she had been vomiting about a dozen times the previous three days, has pain in
the epigastrium, is nauseous, but has no abdominal swelling.
Assessment
Upon initial report from the night nurse, PR was alert and oriented times three. She had
complaints of some abdominal spasms, was on two liters of oxygen nasal cannula. PR was up
with one assist. Nasogastric tube was to continuous wall suction. PR was medicated for pain
with morphine early in the morning at 0530. PR was on routine I&O and was NPO except for
medications.
PR was a pleasant and cooperative lady. For the head-to-toe assessment findings refer to
table one below.
Table 1
Assessment Data
Assessment
Vital Signs
Neurological
Musculoskeletal
Findings
BP – 165/79
Oral Temperature – 98.6
Radial Pulse – 82
Respiration Rate – 14
Pulse Ox – 98% on 4L NC
Pain – 0
A&O X 3
LOC – active
Speech – clear
PERRLA – pupils 3mm and brisk
Facial Expressions – symmetrical
Shoulder Shrugs - Strong
Upper Extremities – Strong and full ROM
Lower Extremities – Weak bilaterally
Gait – Unsteady
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Cardiac
Respiratory
Vascular
Gastrointestinal
Genitourinary
IV Site
Output
Intake
Braden Scale
5
Hand Grasps – Strong Bilaterally
Generalized Weakness – Mild
S1 and S2 noted
No murmurs noted
Respiration Rate – Regular
Breath Sounds – Clear, decreased in bases bilaterally
Cough – Occasional nonproductive cough
Oxygen – 2L NC humidified
Skin – Warm and dry, no paleness or cyanosis
Mucous Membranes – Pink and moist
Capillary Refill – Less than 3 sec
Pulses – Radial and brachial +2 bilaterally
Pedal Pulses - +1 bilaterally
Edema – None
SCD – Removed
Abdomen – Soft and flat
Bowel Sounds – Hypoactive
Emesis – None
NG Tube – Yes in right nare to continuous wall suction at 25mm Hg,
secretions are dark brown liquid
Pain – None on palpation
Last Bowel Movement – 1 week ago from admission
Catheter – Foley inserted on 9/17/12
Urine Assessment – Amber urine
Output on Shift – 700ml
Foley Site – Free of redness
Left antecubital - #20 gauge
Site free of redness without swelling and drainage
Urine – 700ml
NG – 250ml
Parenteral – 713ml
Amount of Free Text – 139ml
NG – 360ml
Moisture – 4
Mobility – 3
Activity – 4
Nutrition – 1
Friction and Shear – 3
Total Braden Score - 15
Treatments
An oral contrast dye was administered through the NG tube for a CT that was ordered.
This was for an abdominal CT to view the bowel obstruction. I was not on shift for the results of
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the CT. Continuous wall suction for decompression of the stomach was administered. PR was
on continuous two liters nasal cannula oxygen and incentive spirometry every one hour while
awake was also ordered.
Lab Information and Diagnostic Tests
For a complete list of the lab work for PR, refer to tables two through four below. The
following tables will give arterial blood gases (ABG’s), CBC, and electrolytes. The table will
show the test, normal ranges, patient results, and the relevance for this specific patient.
Table 2
Arterial Blood Gases
Test
pH
Normal Values
7.35 – 7.45
Patient Results
7.37
pCO2
35 – 45 mm Hg
68.7 mm Hg
O2
75 – 100 mm Hg
51 mm Hg
HCO3
22 – 26 mEq/L
38.5 mEq/L
BE
+1 - -2
10.0
Normal Values
*5,000 – 10,000/mm3
Patient Results
12.2/mm3
Relevance to Patient
Patient is within
normal range but
slightly acidosis.
Patient has CO2
retention because of
COPD.
Lack of diffusion
across alveolar wall
from COPD/ hx. of
smoking. Patient may
be hypoxic.
Kidney’s
compensating for
respiratory acidosis.
High volume of base
compensating for
increased CO2.
(Cavanaugh, 2009)
Table 3
Complete Blood Count (CBC)
Test
White Blood Cells
(WBC)
Relevance to Patient
Increase WBC can
indicate presence of
infection, may be
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Red Blood Cells
(RBC)
Hemoglobin
*4.2 – 5.4
million/mm3
*12 – 16 g/dl
4.12 million/mm3
Hematocrit
*38 – 47%
37.6%
Platelets
*150 ,000 –
450,000/mm3
140,000/mm3
11.7 g/dl
related to COPD,
small bowel
obstruction as well.
Patient is just below
norm. Age may have
Slightly below
normal. Could cause
slight anemia.
Slightly below
normal.
This could cause
decrease in clotting,
as caused by heparin.
*indicates female values (Cavanaugh, 2009)
Table 4
Electrolytes
Test
Sodium Na+
Potassium K+
Normal Values
135 – 145 mEq/L
3.5 – 5.0 mEq/L
Patient Results
144 mEq/L
3.3 mEq/L
Chloride ClBlood Urea Nitrogen
(BUN)
Creatinine
95 – 105 mEq/L
5 – 20 mg/dL
99 mEq/L
8 mg/dL
0.6 – 1.2 mg/dL
0.710 mg/dL
Glucose
70 – 110 mg/dL
136 mg/dL
(Cavanaugh, 2009)
Diagnostic Tests
Relevance to Patient
Within normal range.
Low K+. Administer
K+ and monitor for
muscle weakness,
dysrhythmias. May
be result of NPO
status, and fluid buildup in abdominal
region.
Within normal range.
Within normal range.
Good renal function.
Within normal range.
Good renal function.
Slightly elevated.
May be because of
continuous D5% RL.
136 mg/dL is not a
critical level.
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The following are diagnostic tests on PR such as Ultrasounds, Chest X-ray, Computed
Tomograhy (CT), Echocardiogram, and Venous Doplex Studies. These are tests that were
current up to the end of my shift. Refer to table five for a complete study of these tests.
Table 5
Diagnostic Tests
Test
Ultrasound of Abdominal
Aorta
Date
9/08/2011
Ultrasound of Abdominal
Aorta
3/20/2012
Chest PA/AP Lateral
9/17/2012
Computed Tomography (CT)
of Abdominal and Pelvis
Region
9/17/12
Echocardiogram
9/17/12
Venous Doplex Study of Both
Legs
Administration of Oral
Contrast Dye for Computed
Tomography of Abdomen
9/18/12
9/18/12
Patient Findings and Relevance
Focal aneurismal dilation involving the midto-distal aorta. Measures 4.4cm in
anteroposterior dimensions and 3.8cm in
transverse dimensions. Aorta is
atherosclerotic.
Sonographic images of the abdominal aorta
demonstrate diffuse atherosclerotic plaque.
Aneurysmal dilation of the distal abdominal
segment.
Lungs are emphysematous. Aorta calcified
and mildly tortuous.
Complete small bowel obstruction identified
in small-mid. Fusiform infrarenal abdominal
aortic aneurysm measuring 4.6 cm transverse
dimensions. Slight ascites.
Aortic valve is mildly sclerotic. Not enough
to be aortic stenosis. All other findings
normal.
No evidence of deep or superficial venous
embolisms.
Administration of 500ml of oral contrast dye
through nasogastric tube. This treatment will
help show the small bowel obstruction.
The ultrasounds show the history of PR’s growing Abdominal Aortic Aneurysm. The
results also show atherosclerosis of the aorta as well. The results of the Echocardiogram also
show a mildly sclerotic aortic valve. This may be relevant with the history of hyperlipidemia.
This patient will need to have frequent ultrasounds on the abdominal region to monitor the
growth of the aneurysm, and may need to eventually have surgery to fix the aneurysm. The CT
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scan shows the complete small bowel obstruction. This explains PR’s lack of bowel movements.
Fluid can also accumulate in the intestine because of the obstruction which is why the slight
ascites was seen on the CT scan (Brunner & Sommers, 2011). This can cause a loss of fluid for
the patient, and may cause fluid volume loss. It is important to keep PR hydrated with IVs.
Medications
For a complete list of medications that PR was prescribed refer to table six below. You
will find the medication’s name, purpose, route, dose, class, side effects, and the reason PR is
taking the medication.
Table 6
Medications
Medications
Purpose
Albuterol Sulf
Used as a
bronchodilat
or for asthma
or COPD
Fluticason/salmeter
Decreases
ol
inflammatio
n and causes
bronchdilatio
n
Tiotropium
Long-term
Bromide
maintenance
tx. of
brochospasm
in COPD
Hepairn Sodium
Prevention
of thrombus
formation
Clonidine HCL
Used for
mild to
moderate
Route,
Dose
Class
Side Effects
2.5mg
INH
q4hr
prn
1 puff
INH 2
times
daily
Bronchodilator
Nervousness,
restlessness,
chest pain,
palpitations
Headache, N/V,
palpitations
18mcg
INH q
day
Bronchodilator Tachycardia, dry
Anticholinergic
mouth
5000
Units
Anticoagulants
Bleeding, pain at
infection site
0.1mg
TD q7
days
Antihypertensi
ve
Drowsiness, dry
mouth,
bradycardia
Long Acting
Beta-2
Agonist,
Corticosteroid
Reason
patient is
taking
medication
History of
COPD
History of
COPD
History of
COPD
Imobility
from being
hospitalized
and prior
DVT, PVD
History of
hypertensio
n and AAA
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hypertension
Protonix
Treatment of
GERD
40mg
IV q
day
Proton pump
inhibitors
Headache,
abdominal pain
Methylprednisolon
e SOD SUCC
Used
systemically
and locally
in chronic
diseases
30mg
IV q
day
Corticosterioid
Peptic
ulceration,
hypertention,
thromboembolis
m, adrenal
suppression
Headache,
constipation,
diarrhea
Zofran
Prevention 4mg IV
of nausea
q6hr
and vomiting
prn
Antiemetic
Ativan
Decreases
anxiety by
depressing
CNS
1mg IV
3 times
daily
PRN
Antianxiety,
sedative,
hypnotics,
analgesic
adjuncts
Dizziness,
drowsiness,
apnea, lethargy
Dextrose 5% RL
Provides
hydration
and calories
Caloric
sources,
carbohydrates
Fluid overload,
hyperglycemia
Morphine sulfate
Reduces
severe pain
1000ml
IV at
70ml/h
r
2mg IV
q4hr
prn
Opioid
analgesics
Respiratory
depression,
constipation,
sedation,
confusion
20mg/h
r
Bronchodilator
Arrhythmias,
tachycardia,
nausea,
vomiting,
seizures, anxiety
Aminopheline
Long term
control of
reversible
airway
obstruction
caused by
COPD
(Deglin & Vallerand, 2012)
For GERD,
relieve
acidic
regurgitatio
n from
bowel
obstruction
Decreases
inflammator
y response
in chronic
COPD
PRN med
for N/V
from bowel
obstruction
History of
anxiety
disorder,
anxiety of
being in
hospital
Caloric
source
because of
NPO status
For pain
reported by
patient
greater than
5 on VAS
scale
History of
severe
COPD
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Nursing Diagnosis
Table 7
Care Plan
Nursing Diagnosis
Risk for fluid volume deficit related to vomiting upon admission
secondary to complete bowel obstruction AEB…
- No bowel movement for 1 week
- NG to continuous wall suction
- Strict NG output recorded
- Decreased Potassium of 3.3
- Ascites on CT secondary to bowel obstruction
Short-term Goal
Patient will maintain blood pressure within patient’s normal range and
show no manifestations of dehydration in next 12 hours.
Long-term Goal
Patient will maintain fluid balance as evidenced by balanced
measuring intake and output and monitory lab electrolyte balance
within normal lab ranges in next 48 hours.
Interventions/Rationales 1. Monitor patient’s vital signs every 4 hours.
a. Note presence and degree of postural BP changes, observe for
temperature elevations or fever.
b. Tachycardia is present along with a varying degree of
hypotension depending on degree of fluid deficit.
2. Maintain patient’s fluid balance by administering parenteral fluids
with sodium chloride, bicarbonate, and potassium added as
ordered.
a. Monitor electrolyte lab data.
3. Monitor (check) patient’s urinary output hourly.
a. Measure or estimate fluid losses from all sources (i.e. NG
tube, foley, diaphoresis).
b. Fluid replacement needs are based on correction of current
deficits and ongoing losses.
4. Palpate patient’s peripheral pulses, note capillary refill and skin
color and temperature every 4 hours.
a. Conditions that contribute to extracellular fluid deficit can
result in inadequate organ perfusion to all areas and may
cause circulatory collapse and shock.
Evaluation/Outcomes
Evaluation of goals could not be determined because the student’s
shift ended before the goal’s time frame. Appropriate outcomes of the
goals are electrolyte and acid-base balance, fluid balance, and
hydration. If goals are met, teaching of oral hydration of 4 12oz cups
of water per day and report to physician if there is a drop in BP and
pulse, or a decrease or increase in urine output.
Reference/Evidence(Black & Hawk, 2009)
based Research
(Doenges, Moorhouse, & Murr, 2010)
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Table 8
Care Plan
Nursing Diagnosis
Impaired Gas Exchange related to decreased ventilation secondary to
history of severe COPD/emphysema AEB…
- 2L O2 NC to maintain SpO2 at 98%
- Decreased lung sounds at bases bilaterally
- History of smoking 1-2 packs per day
- ABGs – pO2-51; pCO2-68.7
Short-term Goal
Patient will maintain pulse ox of greater than 92% with 2L O2 NC or
less for next 1 week.
Long-term Goal
Patient will maintain adequate gas exchange as evidenced by ABG
values at baseline for next 1 month.
Interventions/Rationales 1. Monitor the patient’s respiratory rate, pattern, and pulse oximetry
every 4 hours, ABG results, and manifestations of hypoxia
and hypercapnia.
a. Prompt recognition of deteriorating respiratory function can
reduce potentially lethal outcomes.
2. Administer low-flow oxygen therapy (1-2 L/min) as needed via
nasal cannula.
a. Oxygen corrects existing hypoxemia.
3. Assist the client into the high-Fowler position.
a. The upright position allows full lung excursion and enhances
air exchange.
4. Administer bronchodilators as ordered. Monitor for side effects.
a. Bronchodilators relax bronchial smooth muscle, facilitating
air flow. Common side effects include tremor, tachycardia,
and other cardiac dysrhythmias.
Evaluation/Outcomes
Evaluation of goals could not be determined because the student’s
shift ended before the goal’s time frame. Appropriate
outcomes of the goals are adequate Acid-Base balance,
Ventilation, and Gas Exchange. If goals are met, home-going
patient teaching of effects of smoking, deep breathing, and
coughing would be appropriate interventions. Also monthly
physician check-ups for pulmonary functions would be
appropriate.
Reference/Evidence(Black & Hawk, 2009)
based Research
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References
Black, J.M. & Hawks, J.H. (2009). Medical-surgical nursing: clinical management for positive
outcomes. (8th ed). St. Louis: Sounders Elsevier Inc.
Brunner, L.S. & Sommers, M.S. (2011). Diseases and disorders: a nursing therapeutics
manual. (4th ed.). Philadelphia: F.A. Davis Company.
Cavanaugh, B.M. (2009). Nurse’s manual of laboratory and diagnostic tests. Philadelphia: F.A.
Davis Company.
Centers for Disease Control and Prevention. (2012). Smoking and tobacco use. Retrieved from
http://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smokin
g/
Deglin, J.H., & Vallerand, A.H. (2012). Davis’s drug guide for nurses. (12th ed.). Philadelpia:
F.A. Davis Company.
Doenges, M.E., Moorhouse, M.F. & Murr, A.C. (2010). Nursing care plans: Guildelines for
individualizing client care across the life span. (8th ed.). Philadelphia: F.A. Davis
Company.
Harold, B. (2011). Urgent treatment of patients with intestinal obstruction. Emergency Nurse,
18(11), 28-31. Retrieved from web.ebscohost.com.proxy.ohiolink.edu