Course Number and Name
Course: NURS 101L
NURSING CARE PLAN TEMPLATE
NURS 101L, NURS 210L-AB, NURS 211L, NURS 316L, NURS 317L
Student
Elisia Silva Goncalves
Date
03/09/2020
Instructor
Molina
Course
NURS 101L
Patient Initial
SC
Unit/ Room#
303
DOB
03/09/1968
Code Status
Full Code
Height/Weight
4’11”, 190 lbs
Allergies
Demerol (rash)
Temp (C/F Site)
Pulse (Site)
Respiration
Pulse Ox (O2 Sat)
Blood Pressure
Pain Scale 1-10
98.6°F (axillary)
75 bpm (not noted)
20 bpm
100% (room air)
125/96 (supine)
3
(no non-pharmacologic interventions noted)
History of Present Illness including Admission Diagnosis &
Chief Complaint (normal & abnormal) supported with Evidence Based Citations
Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations
Chief Complaint: abdominal pain
Patient complained of generalized abdominal pain that was constant, sharp, cramping, and tender when palpated. Patient was observed to be crying, and rated pain 10/10 upon admission. Patient had performed a self-enema to relieve constipation and reported experiencing pain 15 minutes prior to going to the Emergency Department via ambulance.
Admission Diagnosis: bowel perforation
· colostomy performed in LUQ, 2.8 cm stoma
Bowel perforations may occur as a result of damage or breakdown to the mucosal layers of the gastrointestinal tract. This develops an opening along the organ, leading to leakage of digestive contents (e.g. stomach acid or fecal matter) into the peritoneum. Can result from inflammation/infection, obstruction, invasive surgeries/procedures, or trauma (Jones & Zabbo, 2019).
A colostomy is a surgically created opening (stoma), diverting bowel elimination from the colon through the abdominal wall, and into an external pouching system for collection. This surgery can be temporary or permanent. Can be located in the ascending, transverse, descending, or sigmoid portion of the colon. Performed when elimination of stool through the rectum is prevented due to disease, or obstruction/damage to the colon (Johns Hopkins Medicine, n.d.-b).
CNS: Patient fully conscious, oriented x4. Head normocephalic, with full range of motion. Deep tendon reflexes +2/normal. EENT: Face, eyes, ears symmetrical. Pupil size 4mm each, bilaterally reactive. Oral mucosa moist and intact. SKIN: intact, color appropriate for ethnicity, skin turgor – recoils immediately MS: upper and lower extremities full ROM, vascular perfusion WNL CV: heart rhythm and sound WNL, no signs of cardiac symptoms RESP: pattern/effort WNL, no cough, patient currently on room air GI: abdomen soft, bowel sound present x4, passing flatus. Colostomy bag LUQ, semi-formed stool; stoma intact, red, moist GU: urine yellow, no odor, symptoms WNL (Taylor et al., 2018)
Pain Assessment: 3 – mild; abdomen – LUQ (Taylor et al., 2018)
Glasgow Coma Scale: eye response – 4/spontaneous eye opening; motor response – 6/obeys commands fully; verbal response – 5/alert and oriented
· total score – 15/15
· patient fully awake, alert, and oriented (Taylor et al., 2018)
Braden Scale for Predicting Pressure Sore Risk: sensory perception – 4/no impairment; moisture – 4/rarely; activity – 4/walks frequently; mobility – 4/no limitation; nutrition – 4/excellent; friction and shear – 3/no apparent problem
· total score – 23/23
· not at risk for developing pressure injuries (Taylor et al., 2018)
Morse Fall Scale: no history of falling – 0; no secondary diagnosis – 0; IV access – 20; normal gait, bedrest, wheelchair – 0; orientated to own ability – 0
· MFS score – 20
· no risk, no fall interventions needed (Morse Fall Scale, n.d.)
Relevant Diagnostic Procedures/Results & Pertinent Lab tests/ Values (with normal ranges),
include dates and rationales supported with Evidence Based Citations
Past Medical & Surgical History,
Pathophysiology of medical diagnoses
(include dates, if not found state so)
Supported with Evidence Based Citations
Diagnostic Procedures:
3/7/20
· abdominal x-ray: large amount of intraperitoneal air and multiple bowel fluid levels suggest bowel perforation
Lab Results:
3/9/20
· Hematology: WNL, blood type B+
· Chemistry: potassium, calcium borderline low
· patient not eating, insufficient nutrient intake
· PTT, PT, INR: WNL
· Urinalysis: yellow, no odor
· All other lab results not stated are normal/WNL
(Taylor et al., 2018)
Past Surgical History:
5 years ago – appendectomy
· An emergency surgical procedure to remove the appendix due to inflammation/infection, known as an appendicitis (Johns Hopkins Medicine, n.d.-a).
6 years ago – right inguinal hernial repair
· Surgical process of moving a hernia (tissue protruding though a weakened area in the abdominal wall) from the groin area and back into the abdominal cavity. The weak abdominal wall muscles where incision is made are closed with sutures and reinforced with synthetic mesh (UCSF Department of Surgery, n.d.).
9 years ago – cholecystectomy
· The surgical removal of the gallbladder typically to treat gallstones, or inflammation in the gallbladder or pancreas (Mayo Clinic, 2019).
Past Medical History:
All immunizations up to date (Centers for Disease Control and Prevention, 2020).
Erikson’s Developmental Stage with Rationale
And supported by Evidence Based Citations
Socioeconomic/Cultural/Spiritual Orientation
& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations
Generativity vs. Stagnation
Occurs during middle adulthood, ages 40-65 years. Developmental stage with focused on care and the sense of productively contributing to the continuity of society (generatively) vs. the trivialization of one’s activities (stagnation). Is the person making their life meaningful by guiding future generations? Activities include working, teaching/mentoring others, volunteering in the community, and raising children (Feldman, 2016).
Religion/Spirituality: Catholic
Economic Background: bank teller with a bachelor’s degree
Social Background: white male, primary language English; widowed, father of three (3) adult children (one son and daughter listed as emergency contacts), lives alone
· potential for low self-esteem and social isolation
· anxiety or fear of asking children for help
· failure to thrive from loss of spouse, or living alone
Safety Screening: patient did not mention concern for personal safety; no physical signs of abuse or neglect
Substance use: patient consumes alcoholic drinks twice (2) a week
No advanced directives listed
(Taylor et al., 2018)
Potential Health Deviations, Predisposing & Related Factors; (At least two) Include three independent nursing interventions for each
(“At Risk for…” nursing dx)
Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale
supported with Evidence Based Citations
At risk for impaired skin integrity
· cut out 1/8-inch margin in adhesive backing for ostomy pouch to prevent trauma to stoma tissue
· monitor healing during ostomy care by inspecting skin for redness, inflammation, texture changes
· clean area with warm water, pat dry, use a skin moisturizer to hydrate skin and prevent breakdown
At risk for constipation or diarrhea
· assess usual defecation pattern
· determine presence of bowel activity through auscultation
· review diet and fluid intake – fiber can provide bulk, fluids determine stool consistency
· encourage daily physical activity, exercise
(Ladwig et al., 2020)
Consults & Discharge Referrals:
· psychiatrist consult – patient expressed negative feelings about body image and lack of desire to thrive
· social worker – if patient refuses to be compliant with colostomy care, may need to discharge to rehabilitative facility since they live alone
Orders:
Vital Signs every 4 hours
Labs – CBC, BMP in the morning
· check WBC, if elevated could indicate infection
· BMP to check for fluid/electrolyte imbalances while adjusting to diet after surgery
Diet – as tolerated
· as patient recovers from surgery, normal bowel activity will return
· want to promote balanced diet for metabolism and reduce risk for diarrhea and constipation
Colostomy Care – ostomy assessment every shift, monitor for potential complications; change ostomy bag when soiled and prior to discharge
· regular care reduces risk of skin integrity and monitors for infection
Provide Patient Education – colostomy care
· encourages sense of control for patient
· prepares patient for self-care when discharge
Continuous Activity – up ad lib
· to prevent pressure injuries/maintain skin integrity
· promote bowel movement/decrease risk for constipation
(Ladwig et al., 2020; Taylor et al., 2018)
Diagnostic
Label
Related to
Contributing
Factors
As evidenced by
Signs and
Symptoms
Priority Nursing Diagnosis
(at least 2)
Written in three-part statement
Planning
(outcome/goal)
Measurable goal during your shift
(at least 1 per Nursing diagnosis)
Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching
(at least 4 per goal)
Rationale Each must be
supported with Evidence Based Citations
Assessment
Goal Met, Partially Met,
or Not Met
& Explanation
Disturbed body image related to daily care of fecal material, as evidenced by verbalization of negative opinions of having a “poop bag” attached to person.
(Ladwig et al., 2020)
Patient will demonstrate social involvement and begin to accept situation by observing care of, or touching colostomy bag.
Ask patient psychosocial questions related to medical situation during nursing assessment.
Consideration of providing counseling.
Review the medical necessity behind surgical procedure, maintain positive approach during care.
Assess patient’s level of social support.
Verbalization of patient’s feelings can help identify the patient’s progress and risk for body image disturbance.
Can Help patient with acceptance of a temporary medical situation and promote will to thrive.
Supporting patient can help develop strategies to cope with the emotional stress.
A determent of patient’s speed of recovery and emotional health.
Goal not met:
· patient refused to open eyes or listen to any positive outlooks on situation. Patient used vulgar language about their perception of themselves. Patient asked to be left alone.
Deficient knowledge related to lack of exposure to new ostomy, as evidenced by lack of participation.
(Ladwig et al., 2020)
Patient able to explain the purpose of the colostomy procedure.
Patient able to explain and perform colostomy care on self satisfactorily.
Assess and evaluate patient’s emotional/cognitive/physical wellbeing.
Use client-centered approach. Have patient participate during ostomy care.
Consider use of printed material (e.g. brochures) and electronic methods (e.g. videos, images, diagrams) during teaching.
Repeat education and practice frequently.
Patient must be willing to cooperate in order to learn effectively.
Engages with client as an active learner. Promotes sense of control.
Serves as additional sources of information. Alternative formats of patient education may resonate with patient better.
Reinforces learning.
Goal partially met
· patient was able to verbally explain why they received a colostomy and its purpose. Patient acknowledge that they knew the colostomy bag is a temporary procedure, however expressed that they felt cursed by this event. Patient consequently was unwilling to participate during care and wished for the nurse to leave as soon as possible.
MEDICATION LIST
Medications (with APA citations
Class/Purpose
Route
Frequency
Dose (& range)
If out of range, why?
Mechanism of action
Onset of action
Common side effects
Nursing considerations
specific to this patient
docusate
(Jones & Bartlett Learning, 2020)
Pharmacologic class: stool softener, surfactant
Therapeutic class: laxative
Oral
Daily
50 mg capsule
1) acts as surfactant that softens stool by decreasing surface tension between oil and water in feces
2) increases electrolyte and water secretion into colon, forming a softer fecal mass
syncope, abdominal cramps, distension, nausea/vomiting, diarrhea, perianal irritation
increase fiber intake, hydration
ketorolac tromethamine
(Jones & Bartlett Learning, 2020)
Pharmacologic class: NSAID
Therapeutic class: analgesic
IV
Every 8 hours, PRN
30 mg
blocks cyclooxygenase and inhibits prostaglandin synthesis, thus reducing inflammation and relieves pain
GI bleeding, prolonged bleeding time, hepatic failure, renal failure, exfoliative dermatitis
1) take with food, remain upright for 30 minutes to decrease irritation of lower esophagus
2) avoid alcohol, increases stomach irritation
ondansetron hydrochloride
(Jones & Bartlett Learning, 2020)
Pharmacologic class: selective serotonin (5-HT3) receptor antagonist
Therapeutic class: antiemetic
Oral
Every 6 hours, PRN
4 mg tablet
blocks serotonin receptors in the chemoreceptor trigger zone (CTZ) in the CNS and peripherally at vagal nerve terminals in the intestine, thus reducing nausea and vomiting
headache, fatigue, diarrhea/constipation, abdominal pain, arrhythmias
monitor nausea, bowel sounds/activity, gastric distention
References
Centers for Disease Control and Prevention. (2020, February 03). Recommended child and adolescent immunization schedule for ages 18 years or younger, United States, 2020. https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent-shell.html#vaccines-schedule
Feldman, R. S. (2016). Development across the life span, 8th edition. Pearson Education.
Johns Hopkins Medicine. (n.d.-a). Appendectomy. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/appendectomy
Johns Hopkins Medicine. (n.d.-b). Colostomy. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/colostomy
Jones & Bartlett Learning. (2020). Nurse’s drug handbook, 19th edition. Burlington, MA.
Jones, M. W., & Zabbo, C. P. (2019, October 11). Bowel perforation. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK537224/
Ladwig, G. B., Ackley, B. J., Makic, M. B. F., Martinez-Kratz, M., & Zanotti, M. (2020). Mosby’s guide to nursing diagnosis, 6th edition. St. Louis, MO: Elsevier.
Mayo Clinic. (2019, August 09). Cholecystectomy (gallbladder removal). https://www.mayoclinic.org/tests-procedures/cholecystectomy/about/pac-20384818
Morse Fall Scale. (n.d.). Network of Care. Retrieved March 9, 2020, from https://networkofcare.org/library/Morse%20Fall%20Scale.pdf
Taylor, C., Lynn, P., & Bartlett, J. L. (2018). Fundamentals of nursing: The art and science of person-centered nursing care, 9th edition. Philadelphia, PA: Wolters Kluwer.
UCSF Department of Surgery. (n.d.). Inguinal hernia. https://generalsurgery.ucsf.edu/conditions–procedures/inguinal-hernia.aspx
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