Date: Feb 4
Patient: Mrs S
Room: 200-1
Age:
Diagnosis:
BCIT Level 2 Nursing Care Plan
Treatments:
PMHx:
Medications:
Diet:
PRN Medications:
Date of Surgery:
Activity:
Type of Surgery:
Potential Problems
What are the anticipated
problems for this patient
and what is potentially
causing these problems.
(due to or related to)
Nausea ( actual)
-due to medication
-pain
Nausea and vomiting
- controlled by the vomit
center (VC) in the medulla of
the brain. GI sensory
receptors send nerve impulses
to the brain in response to
abdominal
distention/irritation. VC
returns impulses that trigger
abdominal contraction and
reverse peristalsis-induce
vomiting
- Also triggered by unpleasant
olfactory, visual stimuli, pain,
emotional factors, ICP,
migraine headache, inner ear
- can also be stimulated when
the CTZ is stimulated by
drugs, chemicals, toxins,
radiation, disease and
VALIDATION PROCESS
ASSESSMENT
EVIDENCE
Wednesday PM – How will Thursday PM – Data
I assess each problem?
collected to indicate a valid
problem
* assess History,
duration,frequency,
severity, precipitating
factors, medication,
measures used to alleviate
the problem
*Assess skin colour,
pale/cool and clammy,
green, temperature and
moisture
*Assess for loss of or
decreased appetite
*Assess bowel sounds
x4
* Assess pt. for
dehydration (ie, skin
integrity, increased thirst,
decreased urine output
of <30cc/hr, increased
respirations and heart
rate, fatigue, dark
coloured urine
*Patient complains of
nausea
*Patient on narcoticshydromorphone, diclofenac
Side effect-N&V
* patient has lack of
appetite
* patient has not had bowel
movement- on bowel
protocol
INTERVENTIONS
Wednesday PM – What will
I do for each of the
potential problems – both
nursing interventions and
medical interventions?
* Help Pt into a comfortable
position (often side-lying)
*small sips of water, ice
chips, ginger ale
* offer crackers
* administer cold cloth
* oral care to freshen
mouth
* ambulate –patient
verbalized this was helpful
* keep emesis basin within
easy reach
* instruct patient to change
positions slowly
-sudden or gross
movements may increase
nausea
* Administer antiemetic as
prescribed.
Metoclopramide
(maxeran) Dopamine
antagonist: dopamine
receptors in the CTZ and VC.
Shortens the bowel transit
EVALUATION/FOLLOW
UP
Thursday PM – What will I do Friday
for each valid problem
metabolic states
During chemotherapy –release
of serotonin from small
intestine that stimulates NKI
((tachykinin neurokinin
receptor found throughout
central and peripheral systems
and in gut) stimulates
vomiting
-increased activity of
neurotransmitters – dopamine
in CTZ and acetylcholine VCinduces vomiting
*Assess pt. last dose of
Anti-emetic and route
given
*Assess if pt. has
excessive saliva due to
nausea
*Assess for reports of
nausea
*pulse rate, >100
beats/min, assess trend
and baseline
Acute Pain ( actual)
*due to incision area
*physiological stress increased cortisol
* fatigue
Continue to
Assess Lotarp and Pain
scale - Q1Hr
Acute pain is frequently
associated with anxiety and
hyperactivity of the
sympathetic nervous
system
Pain has sensory and
emotional components
Gate Control TheoryMelzack
The interplay among these
connections determines
when painful stimuli go to
the brain:
1. When no input comes in,
the inhibitory neuron
prevents the projection
neuron from sending
signals to the brain (gate is
*Observe and monitor
signs and symptoms –
-Increased BP
-Increased HR
-Increased Temperature
-Restlessness
-Ability to focus
-pupil dilation
- Relief or distracting
behaviour ( moaning,
crying, restlessness)
- pallor
-Assess guarding
behaviour – protecting
body part
*Patients report of pain
*Assess last dose and
frequency of analgesics
and/or narcotics
*Complains of pain in
abdomen
*on PCA weaned off
time and in high doses blocks
serotonin receptors
(metoclopramide)., Gravol
Antihistaminics with similar
effects to the 5-HT3 receptor
antagonists. Efficacy is
through high concentrations of
histamine and muscarnic
cholinergic receptors within
the vestibular system
(dimenhydrinate)
Will cause drowsiness.
Patient need to ambulate. Not
first choice.
* give hydromorphone if
Will choose Tylenol 3
Tylenol 3 is inadequate prn over plain Tylenol
* Assess and document the
intensity of the pain with each
new report of pain and at
regular intervals.
- Systematic ongoing
assessment and
documentation provide the
direction for pain treatment
plans; adjustments are based
on the client’s response.
*warm blanket on abdomen –
patient reported warmth aided
in pain reduction
* encourage patient to report
increase or changes in pain
level or location
*Every q1hr, go into the room
and observe for signs of
increased HR, increased RR
and restlessness
* Prompt responses to
complaints may result in
decreased anxiety in patient
- in the midst of pain,
patient’s perception of time
- if pain his higher than a
closed).
may be come distorted.
2. Normal somatosensory
input happens when there
is more large-fiber
stimulation (or only largefiber stimulation). Both the
inhibitory neuron and the
projection neuron are
stimulated, but the
inhibitory neuron prevents
the projection neuron from
sending signals to the brain
(gate is closed).
3. Nociception (pain
reception) happens when
there is more small-fiber
stimulation or only smallfiber stimulation. This
inactivates the inhibitory
neuron, and the projection
neuron sends signals to the
brain informing it of pain
(gate is open).
Risk of Infection
-Sarcoidosis
-incision
- high end white blood
count (8.4)
-malnutrition
- chronic disease (
fibromyalgia)
*Monitor WBC
.
* Assess for elevated
temperature
*Assess wound area and
ensure that are is free from
signs of infection
- Redness
-swelling
-increased pain
-purulent drainage from site
* If there is any drainage it
should be sent to lab for
c&S - antibiotic therapy is
determined by pathogens
found
*Encourage fluid intake of
200 ml per day of water
- fluid promote diluted urine
and frequent emptying of
bladder; reduces stasis of
urine -> reduces risk of
bladder of infection or
3 Types
-at risk
-actual infection
-sepsis  shock 
death
urinary tract infection
*Assess appearance of
urine
- cloudy, foul smelling urine
with visiable sediment is
indicative of urinary tract
infection or bladder
infection
* assess nutritional statuspatients may be
anergic(lack of reaction by
the body's defense
mechanisms to foreign
substances) and therefore
more susceptible to
infection
- use of incentive
Spirometer – shown
yesterday but will go over
again to make sure she is
doing it properly
-coughing
-deep breathing
Risk for pneumonia
- post surgery
-Sarcoidosis
High end WBC- 8.4
Bacterial pneumonia is a
lung infection caused by
bacteria. The most
common type of bacterial
pneumonia is
pneumococcal
pneumonia.
*Monitor wbc count
*Monitor temp - increase?
* assess hydration
- Water loss is increased
with fever
Monitor oxygen saturation
Symptomsa cough with rust *Ausculate lungs: listen for
presence of adventitious
or green-coloured phlegm
sounds
(mucus) high fever
- Bronchial lung sounds
(temperature often shoots
up as high as 41°C (105°F) are commonly heard over
areas of lung density or
chills
consolidation. Crackles are
teeth chattering
heard when fluid is present.
chest pain
*assess patient c/o chills
*Assist patient with
coughing, deep breathing,
and splinting
- improves productivity of
cough
*Encourage increased fluid
intake
200 cc per hour
-fluid are lost by
fast breathing and heart
beat
bluish lips and finger nails
from lack of oxygen in the
blood
feeling confused or strange
feeling very tired
)
* assess SOB
Assess c/o of pleuritic
chest pain ( pleura
membrane irritated, rub
together, nerve endings ->
pain)
diaphoresis, fever,
tachypnea and are needed
to mobilize secretions
*Incentive Spirometer –
improves deep breathing
and prevents atelectasis
10x hour
*Pace activities for patient
with reduced energy
*Provide oral care
Secretions may cause
nausea and vomiting
*Consult respiratory
therapist for chest
physiotherapy and
nebulizer treatment
Discharge Planning
How is she coping?
What type of support does
she have?
What type of support does
her husband have?
Does she have a
supportive friends that can
come and help with
household chores, making
meals.
Does she have someone to
take her to all the
appointments
If she needs to go to the
hospital will there be
someone to take her if her
husband is not able to?
What does she do for self
care? Taking time for
herself?