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Process Paper
Emily A. Dehnke
NURS 30030 Nursing of Adults
Professor Aller
1 November 2010
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Process Paper
Client Profile
D.L. is a seventy-three year old white male who came into the hospital on October 3rd, 2010 with a chief complaint of
epigastric and right lower quadrant pain. He has a history of Crohn’s disease with three bowel resections, hypertension,
hypercholesterolemia, cholelithiasis, and a previous history of pancreatitis. He came into the hospital because while he was eating at
his son’s house in Bolivar, he became dizzy, nauseous with dry heaves, and cold sweats. Then he felt severe epigastric pain radiating
to the right lower quadrant. His family brought him to the hospital. His admission and primary medical diagnosis is pancreatitis.
Pancreatitis, which is inflammation of the pancreas, can be acute or chronic; in this case, it is acute. Acute pancreatitis is
common but can be lethal due to edema, gastric juices in the pancreas digesting the pancreas, fat necrosis, and sometimes hemorrhage
(Black & Hawks, 2005). Pancreatitis in the United States is most commonly caused by alcohol use but can also be caused by
gallstones, drugs, and metabolic disorders (Black & Hawks, 2005). The pancreas is a large gland behind the stomach; it secretes
enzymes, or digestive juices, into the small intestine through the pancreatic duct where the enzymes join with bile, a liquid made by
the liver and stored in the gallbladder, to digest food (Black and Hawks, 2005). The pancreas also releases insulin and glucagon into
the bloodstream, which help regulate blood glucose (Black & Hawks, 2005). In a normal functioning pancreas, the digestive enzymes
secreted by the pancreas don’t become activated until they reach the small intestine, but when the pancreas is inflamed (pancreatitis),
the enzymes inside it attack and damage the tissues that produce them (Black & Hawks, 2005). How or why the enzymes become
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activated in the pancreas is unknown but it could be related to bile reflux or pancreatic duct obstruction (Black & Hawks, 2005). The
most common sign of pancreatitis is pain and it usually starts in the middle epigastric region and hurts the most a couple hours later;
most of the time, the pain radiates to the back, chest, flanks, and lower abdomen (Black & Hawks, 2005). People with gallstoneassociated pancreatitis usually experience pain after a large meal, which could have been what happened to D.L. this most recent
hospital admission; his abdomen started hurting after eating lunch (Black & Hawks, 20005). Nausea and vomiting often occur with
the pain because it activates the vomiting center along with gastric and intestinal hypo-motility (Black & Hawks, 2005). People with
severe pancreatitis may exhibit circulatory problems such as hypotension, pallor, cool and clammy skin, hypovolemia, hypo-perfusion,
and shock; hemorrhage is also a risk in pancreatitis which is manifested by Turner’s syndrome, which is bluish coloring of the left
flank, and Cullen’s sign, which is bluish coloring of the periumbilical area (Black & Hawks, 2005).
In July 2009, D.L. had his first case of pancreatitis. He came into the hospital with the same kind of epigastric and right lower
quadrant pain he felt during his most recent hospital visit. He was in the hospital for five days on an NPO diet except for sips with
medications and ice chips. He eventually started feeling better so they put him on a low fat diet and then sent home; the low fat diet is
a health promotion intervention meant to reduce gallstone formation; a person eating a low fat diet will also be eating a diet lower in
cholesterol (Black and Hawks, 2005). During this hospital stay, the doctors discovered that D.L. had cholelithiasis, or gallstones,
which is not surprising because patients with Crohn’s Disease have an increased risk of cholelithiasis. Gallstones are crystal-like
structures formed by hardening or accumulation of normal or abnormal bile components (Black & Hawks, 2005). There are three
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types of gallstones: cholesterol, pigment, and mixed; there are four explanations for gallstones: bile that changes what it is made up of,
gallbladder stasis that leads to bile stasis, infection, and demographics and genetics (Black and Hawks, 2005). D.L. probably got
gallstones as a result of the first explanation dealing with bile that changes what it is made up of; for example, cholesterol gallstones
show that the bile is supersaturated with cholesterol and lacking bile salts (Black & Hawks, 2005). D.L. is most at risk for this cause
of gallstones because the chance that bile becomes cholesterol-saturated increases with age and D.L. also has hypercholesterolemia,
which just means he has high cholesterol levels (Black & Hawks, 2005). It is interesting to note that hypercholesterolemia is
associated with a family history of heart disease and diabetes; D.L.’s mother died of coronary artery disease and his father died of
diabetes complications (Black and Hawks, 2005).
In November 2009, D.L. came into the hospital again with the same epigastric pain from his earlier incidence of pancreatitis.
The doctors decided that the cholelithiasis was aggravating the pancreas and causing pancreatitis. Because of this, they wanted to
perform a cholecystectomy, or surgical removal of the gallbladder, but they waited until December 2009 to do it. The laparoscopic
cholecystectomy was done in December 2009 by Dr. Ramad.
D.L. had not had any signs or symptoms of pancreatitis until Oct 3, 2010, when he again had the epigastric and right lower
quadrant pain. The doctors diagnosed him again with pancreatitis by using an abdominal and pelvic CT scan. As of Oct 5, 2010, the
doctors were performing more tests on D.L. such as an MRCT without contrast in order to determine the cause of the pancreatitis.
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The results for the MRCT were not determined before we left the floor on Oct 5, 2010, so I am not sure the cause of D.L.’s last
pancreatitis episode.
D.L. has a history of Crohn’s disease. He was diagnosed when he was twenty-eight years old and has had three bowel
resections before 1980 because of it. Crohn’s disease is one of the chronic inflammatory disorders that characterizes inflammatory
bowel disease (IBD); the other is ulcerative colitis (Baumgart, 2009). These diseases are chronic and recurrent and people are usually
diagnosed between the ages of fifteen to thirty years of age; there is no cure and treatment is symptomatic (Black & Hawks, 2005).
Crohn’s disease affects all layers of the submucosa, meaning it is transmural, and can affect any part of the gastrointestinal tract from
the mouth to the anus, but it usually affects the intestines (Baumgart, 2009). It isn’t known why people get Crohn’s disease and the
only proven risk factor is genetic; there are no preventative measures (Black & Hawks, 2005). Crohn’s disease is chronic
inflammation in the bowel resulting from immune system malfunction; the bowel lumen narrows because of all the inflammation
(Black & Hawks, 2005). Lesions can develop in the bowel and the tissue becomes edematous, heavy, and reddish-purple (Black &
Hawks, 2005). Glanular spots, enlarged lymph nodes, and Peyer’s patches are all common in the intestines from Crohn’s as well as
small superficial ulcers with granulomas and fissures, which are cracks or tears (Black & Hawks, 2005). The fissures can become
abscesses and fistulas, which can release toxic substances and fluids from the intestine into the blood, abdomen, or other areas of the
body (Black & Hawks, 2005). Bowel resections are often times needed in order to get rid of the damages intestine. Malabsorption,
kidney stones, stomatitis, and peripheral arthritis are all problems related to Crohn’s (Black & Hawks, 2005). Common symptoms of
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Crohn’s disease are diarrhea, abdominal pain, fever, and blood or mucus in stool (Baumgart, 2009). Patients may have nutritional
deficiencies, anorexia, weigh loss, anemia, debility, fatigue, dehydration, and metabolic imbalances (Black & Hawks, 2005). A
person with Crohn’s often cannot wait a long time to use the restroom; when they feel the urge to defecate, they must find a restroom
quickly.
Gordon’s Functional Assessment
Include client’s admission date: 10/3/2010
Occupation: Retired in 1995: was in Navy Construction Batalian. Worked at Allegheny Ludlum for 35 yrs.
Diet: NPO except for ice chips and sips of water for medication
Religion: Catholic
Activity: Up as tolerated (no fall risk)
Allergies: Magnesium, Mercaptopurine, Azathioprine, Cladribine, Fludarbine
Current Medications: SCH: Carvedilol (Coreg), Cholecalciferol (Vit D), Enoxaparin (Lovenox), Ferrous sulfate, Multivitamin
(Centrum), Normal Saline, PRN: Amlodipine Besylate (Norvasc), Hydromorphone HCl (Dilaudid), Ondansetron HCl (Zofran),
Promethazine HCl (Phenergan)
Treatments: NPO diet
Past Surgeries: three bowel resections (before 1980), Nephrectomy (2006), Cholesystectomy (2009)
diagnostic tests: results under the appropriate health pattern.
Client Profile (summarize events leading to the day you cared for client): See previous section of paper titled “Client Profile”
AREA OF HEALTH
SUBJECTIVE DATA
OBJECTIVE DATA
INDIRECT DATA
*Identify source of indirect data
HEALTH/PERCEPTION
D.L. said he is very happy
D.L. functioned
D.L. has many chronic
INTERPRETATION
(effective patterns or
barriers/potential
barriers)
D.L. does have some
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HEALTH MANAGEMENT
General Survey, perceived health
& well-being, self-management
strategies, utilization of
preventative health behaviors
and/or services.
NUTRITIONAL/
METABOLIC
Patterns of food and fluid
consumption,
Weight, skin turgor.
(Skin, Hair, Nails; Head & Neck;
Mouth, Nose, Sinus; swallowing,
Ht., Wt)
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with life and is very blessed
with his family. D.L. said
that although he has had
Crohn’s disease since he
was 28, he thinks it is
managed as best as it can
be. D.L. said he has regular
check-ups. D.L. claims not
to smoke or drink. He said
he is happy with his health
but he just wants them to
figure out what is causing
his pancreatitis.
independently. He
was very pleasant to
talk to and very
knowledgeable of all
his medical
conditions. D.L.
appears wellgroomed. Rated pain
from an 8 to 2
throughout the day.
V/S: 98.6 F, HR 88,
BP 133/76, Resp 16,
93% Rm Air
medical conditions such
as hypertension, Crohn’s
disease,
hypercholesterolemia, etc.
He has had recurrent
episodes of pancreatitis.
(chart)
D.L. said that he is hungry
because he has not eaten
since coming into the
hospital, but he also said he
understands why he cannot
eat anything. He also
complained of dry mouth
and being thirsty. He said
he has Crohn’s disease but
it is controlled well with
Remicaid.
D.L. did not eat
anything during my
shift because he is
NPO except for ice
chips and sips of
water with
medication. D.L. did
not appear
dehydrated despite
being NPO. D.L. did
eat some ice chips
periodically
throughout my shift.
His had elastic skin
turgor, He was able
to swallow his pills
easily.
D.L. has been on an NPO
diet since 10/3/2010 and
has not eaten anything
since that day at lunch.
D.L. was on NS @
75mL/hr to keep him
hydrated. D.L. is 5’11”
and 160 pounds. He is
able to feed himself and
order his own meals once
he is allowed to eat . D.L.
is also taking a
multivitamin. D.L. has
Crohn’s disease. Ca level
is 7.9, which is low.
Glucose is 157, which is a
little high. D.L. is taking
Cholecalciferol, ferrous
sulfate, & multivitamin
(chart)
chronic and recurrent
medical problems, but he
seems very pleased with
his health and is a very
pleasant and kind man.
The main concern right
now is his pain
management.
D.L.’s NPO diet could
contribute to dehydration
and malnutrition, but being
NPO is essential to
performing tests and
procedures that need to be
done to determine what is
causing the pancreatitis.
NS is helping the patient
keep hydrated and the
multivitamin is helping to
minimize malnutrition,
especially since the patient
has Crohn’s disease which
can effect reabsorption of
important vitamins and
minerals. D.L.’s Ca and
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ELIMINATION
Patterns of excretory function &
Elimination of waste; relevant labs,
D.L. stated that he has had
Crohn’s disease since he
was 28 years old.
D.L. was able to
walk to the bathroom
by himself. His
abdomen was firm
and nontender.
Hypoactive BS x4.
(I should have asked
more questions about
when he used the
restroom such as: did
he you just void or
have a bowel
movement? What did
the bowel movement
look like? How often
do you usually have
a bowel movement?
D.L. was not on a strict
I/O count. D.L. has
Crohn’s disease and has
had three bowel
resections.
Cholecalciferol, ferrous
sulfate, multivitamin,
dilaudid, & zofran could
all cause constipation
(chart)
D.L. is independent in his
elimation patterns. He can
walk to the bathroom and
is not incontinent. His
bowel movements should
be monitored to ensure his
Crohn’s disease is being
managed as best as
possible. He should also
be monitored for
constipation due to his
meds.
D.L. said he functions
independently when at
home. He said he gets
around fine. He also said
he does not exercise, but he
visits his kids and
grandchildren throughout
the week, which is his
exercise. D.L. said that he
was not moving around as
much as normal due to his
epigastric pain.
D.L. was able to
move about the room
by himself without
any assistance. He
did not grimace or
act like he was in
intolerable pain
while moving
around. He is in very
good shape for his
age. He functions
independently. His
hand grasps were
strong and equal.
MAE. ROM WNL.
V/S: 98.6 F, HR 88,
D.L. was not a fall risk.
His activity status is up as
tolerated. He has walked
to the bathroom to go to
the restroom during his
hospital stay (he hasn’t
used a bedpan or bedside
commode). His ADL’s
are all performed by
himself. He has given his
own baths in the hospital.
D.L. has no record of
dyspnea on exertion.
(chart)
D.L. functions
independently. He is able
to move around, but
keeping his pain under
control should be a priority
for his nurse so that his
pain does not limit his
movement.
Medications, impacting, etc.
(Abdominal - bowel and bladder)
ACTIVITY/EXERCISE
Patterns of exercise & daily living,
self-care activities include major
body systems involved.
(Thoracic & Lung; Cardiac;
Peripheral vascular;
Musculoskeletal,
vital signs)
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BP 133/76, Resp 16,
93% Rm Air
SEXUALITY/
REPRODUCTION
Satisfaction with present level of
Interaction with sexual partners
(Breast; Testes; AbdominalGenitourinary-reproductive)
SLEEP/REST
Patterns of sleep, rest, relaxation,
fatigue
(Appearance, behavior)
COGNITIVE/ PERCEPTUAL
Patterns of thinking & ways of
Perceiving environment, orientation
Mentation, neuron status, glasses,
Hearing aids, etc.
D.L. stated that his first
wife died of cancer. D.L.
said he has three children
with his first wife. D.L.
said he married his second
wife and that she “was a
nice lady.” D.L. said that
he loved his first wife very
much.
We did not discuss
sexual relations or
functioning. D.L.’s
present wife was at
the hospital with him
for the whole day
and waited in the
room for him while
he was getting a test
done. D.L. seemed
to be happy with his
marriage.
D.L.’s first wife died
from cancer. He is
remarried (chart)
D.L. and I did not discuss
sexuality so no conclusions
can be drawn regarding
this matter. However, D.L.
did seem very happy with
his present marriage and
seemed to appreciate his
wife being with him at the
hospital.
D.L. said that he has not
gotten much sleep in the
last couple of nights at the
hospital because of his
pain. He did say that at
home he usually sleeps fine
(I should have asked about
how many hours he slept a
night at home.)
D.L. seemed very
tired during my shift.
When we were
waiting downstairs in
one of the testing
areas, he was trying
to take a nap while
we were just waiting.
(No information was
obtained from indirect
sources regarding
sleep/rest.)
D.L. told me things about
the past such as storied
about his kids or first wife.
D.L. also recalled my
name. He stated who he
was, what day it was, and
D.L. does not wear
hearing aids or
glasses. A&O x3
during my shift.
D.L. could answer
questions easily and
D.L. has been A&O x3
during his entire hospital
stay. (chart)
D.L. seemed very tired due
to lack of sleep from pain.
It should be essential for
the nurses taking care of
him to manage his pain so
that he is able to get more
sleep. D.L. should be
encouraged to take naps
throughout the day even
though taking naps may
not be a normal event
while D.L. is at home.
D.L. has no problems with
cognition. He
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ROLE/RELATIONSHIP
Patterns of engagement with others,
Ability to form & maintain
meaningful
Relationships, assumed roles;
Family communication, response,
Visitation, occupation, community
involvement
SELF-PERCEPTION/ SELFCONCEPT
Patterns of viewing & valuing
Self; body image & psychological
state
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where he was easily.
follow directions.
Long-term & shortterm memory were
intact.
D.L. said he worked at a
stainless steel factory in
Lousiville for 35 years. He
said this was his second
marriage. He said he had
three children with his first
wife who died of cancer.
He said he is remarried. He
said he and his wife visit
the kids and grandchildren
every week. The whole
family meets every Sunday
for lunch after church. He
said he has a boat and he
and his wife like to go out
on it.
D.L. and his wife
seemed to have a
very good
relationship and
interacted
appropriately with
one another. She
stayed with him
throughout my whole
shift. D.L.’s son
came to visit him.
D.L. seemed to think
the world of his
family because he
talked about them a
lot and how lucky he
was to have them all
live so close in
proximity and have
such great
relationships.
D.L. worked at J &L for
35 years. He retired in
1995. He was in the
Navy. Married twice. Has
three children. Children
and wife reported as
visiting D.L. often while
he is in the hospital
(chart)
D.L. seems to have a very
good support system in his
family. He seems to have
many diverse and
meaningful relationships in
his life.
D.L. said despite his
Crohn’s and current
hospitalization, he was very
happy with his health. He
said his Crohn’s is wellmanaged.
I observed D.L.
being very pleasant
and overall happy
despite the pain he
was in.
(No information was
obtained from indirect
sources relating to selfperception or selfconcept)
D.L. was an overall happy
man who was happy with
his current situation in life.
He was happy with his
health management.
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COPING/STRESS
TOLERANCE
Stress tolerance, behaviors, patterns
of coping with stressful events &
level of effectiveness, depression,
anxiety.
VALUE/BELIEF
Patterns of belief, values,
Perception of meaning of life that
guide choices or decision; includes
but is not limited to religious beliefs
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D.L. said he was doing
good, but he just wishes he
could get some more sleep.
D.L. was dealing
with being in the
hospital well. He
seemed happy
overall. However, he
did seem very tired.
(I could have asked
him bluntly how he
was doing with being
in the hospital and
some ways that he
copes with stress.)
His wife being with
him seemed to relax
him. He also seemed
happy to see his son
when he visited
during my shift.
D.L. showed no
signs of depression
or anxiety.
D.L. has no past history
of depression or anxiety.
His behavior since being
in the hospital has been
appropriate (chart)
D.L. is coping with this
hospitalization very well.
The main concern is lack
of sleep which is making
the patient tired. It would
be beneficial to keep
allowing the family to
visit.
D.L. said that he attends
church every Sunday. He
also said he thanks God He
has blessed him with such a
great, supportive, and
loving family. He said he
wanted to participate in
communion when it came
around.
D.L. made subtle
remarks indicating a
faith of some kind.
He referenced God
and church a couple
times. He and his
wife took
communion together
when the priest came
around.
Religion is listed as
Catholic. D.L. is on the
communion list (chart).
D.L. has faith in God and
is dedicated to his Catholic
faith AEB communion,
attending church, etc.
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Lab Information & Interpretation
Lab Test
Result 1
Normal Range
Interpretation
7.9 (L)
9-11 mg/dL
INR
WBC
1.2
23.7 (H)
1-2
5-10,000/mm3
HGB
12.7
12-16 gm/dL
Low value could be due to Ca or vitamin D
deficiency as a result of poor reabsorption due to
Crohn’s disease
WNL
High level due to inflammation, stress, & possible
infection
WNL
HCT
37.5
35-47%
WNL
Ca
9
PLT
115 (L)
150-450 x10 /L
RBC
4.31 (L)
4.5-6 million/mm3
MCV
87
80-95 um
Low value could be from enoxaparin or bleeding
from Crohn’s disease
Low value could be due to enoxaparin, Crohn’s
disease ( because of decreased absorption of
nutrients needed to make RBC), and lack of a
kidney (which produces erythropoeitin that helps
bone marrow make RBC)
WNL
33.9
32-36 g/dL
WNL
0
0
WNL
27,740
0-160units/L
AST
27
0-35 units/L
Extremely high level due to acute and reoccurring
pancreatitis and Crohn’s disease, which is and
instestinal disease
WNL
ALT
46
4-36 IU/L
High level could be due to pancreatitis,
MCHC
Troponin
Lipase
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enoxaparin, & Ondansetron HCl
Alkaline
70
30-120 u/L
WNL
Na
K
Cl
137
4.7
103
136-146 mEq/L
3.5-5 mEq/L
98-107 mEq/L
WNL
WNL
WNL
CO2
25
23-31 mEq/L
WNL
Glucose
157
70-110 mg/dL
CREAT
1.6
0.6-1.2 mg/dL
BUN
23
8-23 mg/dL
High level could be result of taking Coreg, eating
a big lunch before coming into the hospital, or
Promethazine HCl
High level could be due to impairment of the
kidneys due to only having one kidney. Could
also be a result
WNL
Calcification of tail of pancreas.
Moderate inflammation &
edema in region of head of
pancreas. Significant
surrounding fluid & soft tissue
mostly in RUQ. R kidney absent.
no bowel obstruction.
gallbladder absent. liver and
spleen normal.
Findings not known (because left
floor before results came back)
Should yield no
calcification,
inflammation, or
edema. Both
kidneys and
gallbladder should
be present.
Findings compatible with acute pancreatitis
Liver, spleen, and
pancreas should
appear normal with
no enlargement or
edema.
N/A
CT scan of Abdomen
and pelvis
MRCT w/o contrast
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Medication Information & Interpretation
Scheduled Medications
Drug Name
(generic/trade
name)
Carvedilol
(Coreg)
Cholecalciferol
(Vitamin D)
Enoxaparin
(Lovenox)
Drug
classification/action
Why Person
Taking
Patient Dose
(Normal Range)
-antihypertensive
-beta blocker
-blocks beta adrenergic
receptor sites
-decreases HR & BP,
improves CO
-treat hypertension
-25 mg PO 2x/day
with meals (6.25
mg 2x/d, may be
increased q7-14
days up to 25 mg
2x/d)
-fat-soluble vitamin
-requires activation in
liver & kidneys to
create active form of
Vit D3.
-treat & prevent Vit D
deficiency
-needed for Ca
absorption from kidney
-anticoagulant
-antithrombotic
-prevent/treat DVT or
heart attack
-treat Vit D
deficiency
-helps promote Ca
& P normal levels
b/c D.L. has
chronic kidney
disease due to lack
of one kidney
-1000 U BID PO
(400-1000 U/day)
(HIGH dose
probably due to not
just treating Vit D
deficiency, but also
improving Ca & P
normal levels)
-prevent thrombus
formation since
D.L. is not moving
around as much as
-30 mg SQ QD (30
mg once daily)
S/E
-dizziness, fatigue,
weakness,
diarrhea, erectile
dysfunction,
hyperglycemia
Nursing
Implications
-give with food or
meals
-Take apical pulse
before administering:
hold for pulse <60
-may cause increased
BUN, K, blood
glucose, etc.
-monitor I/O & daily
weight
-monitor BP & HR
-dizziness, N, V,
-monitor serum Ca,
anorexia,
P, & alkaline
constipation,
phosphatase levels
bone/muscle pain, periodically
fatigue
-monitor for vit
deficiency: Rickets
-monitor for vitamin
toxicity:
hypervitaminsosis D
-bleeding, pain or -monitor for bleeding
irritation at site,
& hemorrhage
anemia,
-monitor CBC, PLT
thrombocytopenia, count, and occult
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15
-prevents thrombus
formation
Ferrous Sulfate
Multivitamin
(Centrum)
Na Cl 0.9%
(Normal
Saline)
he usually would
(this dose is
especially for
patient with
decreased renal
function due to lack
of one kidney)
-antianemic
-prevent/treat Fe
-iron supplement
deficiency due to
-prevent/treat Fe
increased risk for
deficiency
malabsorption as a
result of Crohn’s
disease
-multivitamin
-treat/prevent
-treat/prevent vitamin
vitamin deficiency
deficiency
due to Crohn’s
disease
-replace Na & Cl lost
-maintain patency
-maintain patency of IV of IV
-hydrate
-hydrate
N, V
-325 mg PO once
-hypotension, N,
daily with meals
constipation, dark
(325 mg once daily) stools, diarrhea,
epigastric pain
-1 tablet PO QD (1
tablet QD)
-IV 75 mL/hr (1.53L/24 hrs)
-constipation,
diarrhea, upset
stomach, black
stoole
-fever,
hypertension
blood periodically
(may cause decrease
in PLT)
-may cause increase
in AST & ALT
-alternate injection
sites daily
-monitor bowel
function for
constipation
-monitor nutritional
status
-give on empty
stomach
-may give with food
if GI upset occurs
-use cautiously in
kidney dysfunction
-monitor I/O,
electrolytes, & pH
balance
PRN Medications
Drug Name
(generic/trade
name)
Amlodipine
Drug Action/
Purpose
-antihypertensive
Why Person
Taking
Normal Dose
Range
-treat hypertension
-10 mg PO QD (5-
S/E
-headache, light-
Nursing
Implications
-assess BP: hold for
Running head: PROCESS PAPER
16
Besylate
(Norvasc)
-Ca channel blocker
-causes vasodilation
resulting in decreased
BP
10 mg once daily)
headedness,
dizziness, fatigue,
peripheral edema,
fainting,
hypotension,
flushing, reflex
tachycardia,
change in
liver/kidney
function
-confusion,
sedation,
constipation,
hypotension,
urinary retention,
tachycardia
Hydromorphon
e HCl
(Dilaudid)
-opioid analgesic
-antitussive
-decrease moderate to
sever pain
-suppress cough
-decrease pain from
pancreatitis
-2 mg IV push q3h
prn (1.5 mg q3-4h
prn, dose may be
increased as
needed)
Ondansetron
HCl (Zofran)
-antiemetic
- serotonin (5-HT3)
antagonist
-decrease nausea and
vomiting
-treat nausea &
vomiting associated
with pain and
pancreatitis
-4 mg IV q6h prn
(4 mg q6-8 h)
-headache,
diarrhea,
dizziness, fatigue,
constipation
Promethazine
HCl
(Phenergan)
-antiemetic
-antihistamine
-sedative/hypnotic
-treat N & V
associated with
pain and
-12.5 mg IV q6h
(12.5-25 mg q4h
prn)
-confusion,
disorientation,
sedation
SBP <120
-monitor I/O & daily
weight
-may be given with
another hypertensive
drug
-serum liver enzymes
should be checked
periodically
-monitor BP, P, &
Resp before and
during therapy: resp
<10, decrease dose by
25-50%
-watch CO2 levels
-antecdote: narcan
-when IV, dilute with
5 mL of sterile H2O
or NS
-give 2 mg or less
over 205 minutes
-may cause increase
in bilirubin, AST, &
ALT levels
-monitor for N, V,
abdominal distension,
& BS
-infuse over 20
minutes
-monitor BP, HR, &
Running head: PROCESS PAPER
-phenothiazine
-relieve histamine
excess, decrease N&V,
and sedate
17
pancreatitis
Resp
-assess patient’s level
of sedation
-assess for N&V
before & after
-may cause increased
glucose
Nursing Care Plan
I chose “acute pain” as my primary diagnosis because of the fact that D.L. was in so much severe, constant pain. I chose
“impaired comfort” as my second diagnosis because of the fact that D.L. was having to endure so many uncomfortable things at one
time such as pain, nausea, and hunger. I first chose “risk for impaired nutrition: less than body requirements” as my second diagnosis,
but I could not think of ways to ensure he had adequate nutrition since they did not want him to have anything in his stomach so that
they would be able to perform any tests or procedures on him as quickly as they could.
Nursing Diagnosis 1: Acute Pain r/t epigastric and right lower
quadrant pain AEB…
-severe epigastric and RLQ pain
-pancreatitis
-pain levels ranging from 2-8
-Dilaudid ordered for pain prn
Outcomes: Two Patient-centered goals
1. Client will report a pain level verbally acceptable to him by the
Nursing Diagnosis 2: Impaired comfort r/t pain and inability to
eat AEB…
-NPO except for ice chips & sips of water for medication
-has not eaten since 10/3/2010
-hypo-active BSx4
-severe pain in epigastric area
-pain levels ranging from 2-8
-patient c/o being tired because of lack of sleep due to pain
Outcomes: Two Patient-centered goals
1. Client wi2. Client will report decreased pain and increased
Running head: PROCESS PAPER
end of my shift.
2. Client will consistently report a pain level of <4/10 during
hospital stay.
Interventions w/Rationale
1. Assess pain level q3h and pain characteristics
-identifies patient specific need of pain relief
-accurate pain assessment is necessary to implement proper &
efficient pain management techniques
2. Administer pain medication (Dilaudid) as scheduled/prn
-pain medication given when needed and on time decreases the
chance of the pain becoming severe (severe pain often take more
medication and a longer time for the medication to take affect)
3. Encourage alternative pain relief measures such as
repositioning, splinting abdomen with a pillow, deep breathing
exercises, not sitting or standing constantly, etc.
-increases patient’s sense of control
-relaxation decreases muscle tension, which would decrease pain
4. Ensure quiet, comfortable, and relaxing environment by turning
down lights, minimizing noise, closing the door, making sure
wife is in the room, etc.
-decreases anxiety and increases mood of patient
EBP Citation:
Black, J., & Hawks, J.H. (2005). Medical surgical nursing:
clinical management for positive outcomes. (7th Ed) St. Louis,
MO: Elsevier Saunders.
18
restfulness before my shift is over.
Interventions w/Rationale
1. Administer pain medication (Dilaudid) as scheduled/prn
-managing the client’s pain will help them to be comforted
2. Manage the client’s nausea by administering the scheduled/prn
medications (Phenergan, Zofran)
-Nausea is very uncomfortable and managing the nausea will help
the patient to feel relieved and relaxed
3. Develop a therapeutic relationship with the patient, especially
regarding pain and comfort. (Ex: encourage patient to express
pain, teach self-management, provide support & understanding of
pain)
-a nurse who actively gets the patient involved with their own
planning, interventions, and assessment of comfort and pain
levels enhances the patient’s potential to be comforted
4. Explain that the reason the patient is not allowed to eat
anything is so that the doctors can perform necessary tests such as
an MRCP, CT scan, etc. in order to try and determine what is
causing the pancreatitis so that they can better treat the problem.
-a patient who understands the reasoning behind doctor’s orders
they are not happy with makes it easier for them to accept and
comply with the orders. It is especially important to reiterate that
although the orders may not be pleasant, the overall reasoning is
to help the patient.
EBP Citation:
Carpenito-Moyet, L.J. (2006). Nursing diagnosis: application to
clinical practice. (11th Ed.) Philadelphia, PA: Lippincott.
Craven, R., & Hirnle, C.J. (2007). Fundamentals of nursing:
Running head: PROCESS PAPER
Carpenito-Moyet, L.J. (2006). Nursing diagnosis: application to
clinical practice. (11th Ed.) Philadelphia, PA: Lippincott.
Craven, R., & Hirnle, C.J. (2007). Fundamentals of nursing:
human health and function. (6th Ed.) Philadelphia, PA: Lippincott.
Evaluation:
Goal 1: Goal met. Pain level was assessed to be an 8/10. Dilaudid
was administered. Patient encouraged to lie down to rest and
relax. Tried to make environment as comfortable as possible:
closed door to minimize noise and distraction, made sure wife
was in the room, & turned down lights. Reassessed pain after 45
minutes and pain was down to a 4/10, which the patient stated
was much better than before.
Goal 2: Goal not met. I did not see the patient through to his
discharge from the hospital, so this goal is not able to be
evaluated.
19
human health and function. (6th Ed.) Philadelphia, PA: Lippincott.
Evaluation:
Goal 1 & 2: Goals met. Phenergan and Dilaudid were
administered in order to control pain and nausea. The patient
verbalized his understanding of why he wasn’t allowed to eat
anything. I was able to spend a lot of time talking to him using
therapeutic techniques and was able to understand his frustration
and also just get to know him better. By the end of my shift, his
pain level went down to a 4/10 and he was able to take a nap.
Running head: PROCESS PAPER
20
Reference
Baumgart, D.C. (2009). The diagnosis and treatment of Crohn’s disease and ulcerative colitis. Deutsches Arzteblatt International,
106(8), 123-33. Retrieved from Ebsco Host.
Black, J., & Hawks, J.H. (2005). Medical surgical nursing: clinical management for positive outcomes. (7th Ed) St. Louis, MO:
Elsevier Saunders.
Carpenito-Moyet, L.J. (2006). Nursing diagnosis: application to clinical practice. (11th Ed.) Philadelphia, PA: Lippincott.
Craven, R., & Hirnle, C.J. (2007). Fundamentals of nursing: human health and function. (6th Ed.) Philadelphia, PA: Lippincott.
Deglin, J.H., & Vallerand, A.H. (2007). Davis’s drug guide for nurses. (11th Ed.) Philadelphia, PA: FA Davis Company.