Nursing Care Plan
Student Name/Date: _Jessica Reetz__________________
Expected Outcomes Nursing Interventions/Rationale Outcome Evaluation
Nursing Diagnosis (Short term (8-48 hr.) reasonable
List all interventions for each nsg. dx (include (Patient outcome noted as met or
(Dx, related to, & as evidenced by) expectations stated in measurable,
patient/family teaching) unmet/responses described)
behavioral terms, i.e., action verbs)
Nausea R/T GI irritation and pain Patient will demonstrate Provide distraction from nausea using Outcome met. Patient was
AEB pallor, cool and clammy understanding by explaining television or music, cold washcloth offered crackers to alleviate
skin, and reports of “feeling sick techniques to decrease or application or conversing with the patient. symptoms and instructed on
to my stomach.” alleviate nause symptoms Watching television, listening to music or distraction techniques
within 24 hours. holding conversations can distract the (television and talking). Patient
patient from symptoms of nausea, in effect remained still most of the day
temporarily forgetting about it. and moved slowly when she
needed to be mobile.
Instruct patient to avoid sudden
movements and remain lying still. Sudden
or continuous movements can trigger
nausea symptoms.
Offer giner ale or clear soda and crackers.
Ginger root has been shown to be an
effective placebo for N/V. Bland foods can
settle the stomach without irritation.
Nursing Care Plan
Student Name/Date: _Jessica Reetz__________________
Expected Outcomes Nursing Interventions/Rationale Outcome Evaluation
Nursing Diagnosis (Short term (8-48 hr.) reasonable
List all interventions for each nsg. dx (include (Patient outcome noted as met or
(Dx, related to, & as evidenced by) expectations stated in measurable,
patient/family teaching) unmet/responses described)
behavioral terms, i.e., action verbs)
Risk for falls R/T orthostatic Patient will remain free of falls Ensure that the bed is kept in the lowest Outcome patially met. Bed was
hypotension, anemia, advanced throughout hospital stay. position with wheels locked and call light always placed in lowest
age, confusion and use of placed within reach. If pt does attempt to position with call light within
antihypertensive medications get up alone, if the bed is in the lowest reach. Patient was assisted with
AEB low RBC lab value position the pt can firmly anchor feet on toileting on awakening. Patient
(anemia), slow, unbalanced gait the floor to aid in standing. If pt should did not use a walker, preferred
and c/o fatigue. fall out of bed, impact is minimized since a wheel chair. Physical therapy
the bed is close to the ground. Call light is involved in working with her.
should be accessible so pt can call for a
nurse to aid her instead of stading up
alone.
Routinely assist patient with toileting,
especially on awakening and before
bedtime. Majority of falls are related to
toileting. Ensuring the pt uses the
bathroom first thing in the morning and
before bedtime can potentially eliminate
the need for getting up to use the
bathroom alone during the night.
Encourage patient to use walking aid. Use
of a walker aids pt in ambulation and can
allow a greater sense of independence if
she doesn’t need a nurse to hold onto her
arm while walking. Patient can work on
strenght building while using a walker.
PACIFIC LUTHERAN UNIVERSITY
SCHOOL OF NURSING
NURSING PROCESS PAPER FOR NURS 340 SITUATIONS - ADULT HEALTH I
Date(s) of care: Week 4 Number of days in hospital: Age of pt (decade): 60s
4 days
Occupation(s)/Significant Social History Allergies: NKDA
Pt lived with husband in a motel. Both
are admitted in the hospital with plans to
be discharged to a SNF. No other family
is reported.
Weight: 160 lbs
Vital Signs Day of Care: ** note vaules and state a reason why it might be abnormal
Day 1: BP 118/60 HR 64 Resp Rate 20 Temp 98.1
O2 Sat 97 RA Pain 4 out of 10
(abdominal pain
probably due to
UGIB, hiatal
hernia, GERD)
Intake & Output previous 24 hrs Intake & Output this shift
I- 3900 cc O- 2000 cc I- 440 cc O- 200 cc
Day 2: BP HR Resp Rate Temp
O2 Sat Pain
Intake & Output previous 24 hrs Intake & Output this shift
Primary (Admitting) Medical Diagnosis: Upper GI Bleed
Secondary Medical Diagnosis: Anemia, large hiatal hernia, asthma, hypokalemia, and schizophrenia.
Surgery: Open heart surgery (heart valve replacement) 8 years ago.
History of Present Illness: Patient was visiting husband in the hospital. Nurse noticed that pt exhibited broken speech, weakness, and dizziness.
Patient was pale and had bruising, and when asked about it she couldn’t remember how she got them. Patient was then admitted to the hospital.
Definition and Pathophysiology of admitting diagnosis?
If the patient had a surgery to treat the diagnosis, explain the surgery and why it was appropriate for this diagnosis.
Upper GI bleeding (UGIB) can be caused by several factors. Most commonly, bleeding is caused by ulcers in the stomach or duodenum, which is
commonly associated with H. pylori or NSAID use. NSAIDs and aspirins cause irritation to the gastric mucosal membrane. UGIB can also be
caused by chronic esophagitis associated with GERD, bleeding varices, and Mallory-Weiss tears. UGIB is usually characterized by black, tarry stool
(melena) or coffee ground-like emesis, since the blood is digested as it travels through the GI tract. Blood accumulation in the GI tract is irritating
and and increases peristalsis.
No evidence of surgery was found, but an upper GI endoscopy was performed which revealed a large hiatal hernia. Do not know if future surgery
planned as patient was released this day.
Risk Factors (list risk factors noted in the book; circle or underline those that apply to your patient; if you add one that is not listed in the
book, please indicate this):
Advanced age, gender (F), H. pylori infection, NSAID, aspirin, corticosteroid, or anticoagulant use, alcohol use, smoking
Signs and Symptoms (list the signs and symptoms that are usually associated with this diagnosis as noted in the book; circle or underline
those that apply to your patient; if you add one(s) that is/are not listed in the book, please indicate this):
Hematemesis, hematechezia, melena, dizziness, syncope, clammy skin, tachycardia, dyspnea, hypotension, pallor, abdominal pain.
Secondary diagnosis: Give a definition and brief patho explaining how each secondary diagnosis can affect or be affected by the primary
diagnosis/hospitalization.
Anemia is the reduction in RBC count, a decrease in quality or quantitiy of hemoglobin, or a decrease in hematocrit. The many types of anemias are
classified by their causes or the changes that affect the size or shape of the red blood cell. Anemias are always secondary to or a manifestation of a
another disease process. In this case, I believe the patient’s anemia is probably iron-deficiency anemia caused by the chronic blood loss due to UGIB
and GERD.
Hypokalemia is a potassium deficiency, less than 3.5 mEq/L. Potassium is lost from the ECF, and the concentration gradient favors the change by
moving potassium from the ICF to the ECF to maintain the ratio, but causing body potassium depletion. GI disorders can cause potassium loss.
Hiatal hernia is “the protrusion (herniation) of the upper part of the stomach through the diaphragm and into the thorax” (Huether 2004). A sliding
hernia is when the stomach slides into the thoracic cavity through the esophageal hiatus. A paraesophageal hiatal hernia is when the curve of the
stomach protrudes through a secondary opening in the diaphragm and stays alongside the esophagus. Hernias are usually associated with other GI
disorders such as ulcers, which this patient suffers from.
Diagnostic Tests and/or Procedures:
ECG, Upper GI endoscopy, Chest X-ray
*Laboratory Data from admission to most recent (plus significant lab work, i.e.: PT/PTT
Tests Admission Recent TG/MHS Norms Interpretation of results: Specific for this pt? If unknown ?
Ordered Results Results Abnormal: ↑ Elevated ↓Low
Hematology Studies Hematology Studies
WBC 6.8 11.9 4.0-12.0 TH/mm3 WNL
RBC 3.15 3.19 4.0-5.5 mil/m3 ↓ level d/t anemia and GI bleed
Hbg 9.6 9.8 12.0-16.0 g/dL ↓ level may be d/t anemia and GI bleed
Hct 30.9 29.6 37-47% ↓ level may be d/t anemia and GI bleed
MCV 92.1 92.8 WNL
MCH 30.5 30.7 WNL
MCHC 33.1 33.1 WNL
RDW 14.8 15.4 ↑ level may be d/t anemia
Plt 238 286 150-450 th/mm3 WNL
WBC Differential VSR VSR WBC Differential
Neuts 59.5 74.1 45-77% WNL
-Segs/PMN’s
-Bands
Lymphs 26.2 17.5 12-44% WNL
Monos 10.1 6.8 4.0-13.0% WNL
Eosin 3.8 1.3 0 -5.0% WNL
Basos 0.4 0.3 0-1.5% WNL
Abs neuts 4.1 8.8 1.8-7.8 th/mm3 ↑ level may be d/t stress or inflammation (possibly r/t
GERD)
Abs lymphs 1.8 2.1 0.8-3.3 th/mm3 WNL
Abs monos 0.7 0.8 0.2-1.0 th/mm3 WNL
Abs eosin 0.3 0.2 0.0-0.4 th/mm3 WNL
Abs basos 0.0 0.0 0.0-0.2 th/mm3 WNL
Platlet/RBC studies Platelet & RBC Specific Studies
Plt estimate ADEQ
Aniso
Poly
Poik
Ovalocytes
RBC frags
Reactive lymphs
Serum Chem Serum Chemistries
Na+ 142 142 135-148 mEq/L WNL
K+ 3.4 4.2 3.6-5.3 mEq/L ↓ level may be d/t deficient dietary intake, GI disorder
(UGIB)
Cl- 107 113 97-107 mEq/L ↑ level may be d/t anemia
CO2 29 27 24-33 mEq/L WNL
HC03 24-33 mEq/L
BUN 19 9 8-24 mg/dL WNL
Creatinine 0.7 0.6 0.8-1.5 mg/dL WNL
Glucose 95 108 65-120 mg/dL WNL
Additional Chemistries Additional Chemistries: Enzymes
SGOT/AST 41 ↑ level may be r/t antihypertensive meds and coumadin use
Alk Phos 48 WNL
SGPT/ALT 34 WNL
Serum Protein 5.1 ↓ level may be d/t malnutrition, inflammatory disease
(GERD)
Serum Albumin 2.8 ↓ level may be d/t malnutrition, inflammatory disease
(GERD)
Globulin (calc) 2.3 WNL
A:G 1.2 WNL
Calcium 8.6 8.5 WNL
Phosphorous
Magnesium 1.7-2.2 mg/dL
Triglyeride
Cholesterol??
Amylase
Lipase
Prealbumin 18-45 mg/dL
C-reactive 0-0.1 mg/dL
protein
Coagulation Studies
PT 20.9 9.2-13.0 sec ↑ level d/t coumadin use
INR 1.46 2.10 0.0-3.5 WNL
Normal mean
PTT 21-31 sec
Normal mean
Urinalysis
Color Yellow Normal finding
Appearance Clear Normal finding
Sp Gr 1.024 1.003-1.030 WNL
PH 6.5 WNL
Urine Protein Trace N Transient proteinuria can be caused by emotional stress
Urine Glucose Neg N Normal finding
Ketones Trace N May be d/t anorexia or fasting
Bilirubin Neg N Normal finding
Occult blood Trace N
Urobilinogen 4 <1.1 EU
Leukocyte 2+ N Possible UTI
esterase
Nitrite Neg N Normal finding
Other
References:
Ackley, Betty J., Ladwig, Gail B. (2006). Nursing Diagnosis Handbook: A Guide to Planning Care. St. Louis, MO:
Mosby Elsevier
Huether, Sue E., McCane, Kathryn L. (2004). Understanding Pathophysiology. St. Louis, MO: Mosby Elsevier
Lewis, S. L., Heitkemper, M. M., Dirksen, S. R., O’Brien, P. G., Bucher, L. (2007). Medical-Surgical
Nursing: Assessment and Management of Clinical Problems. St. Louis, MO: Mosby Elsevier
Student Name:__Jessica Reetz____________ *MEDICATIONS Allergies: __NKA____________
MEDICATION Classification INDICATION COMMON SIDE NURSING IMPLICATIONS
Name, Dose, Route Why is your pt. taking? EFFECTS (look for (specific to your patient; include specific pt teaching
what applies most to points if applicable)
your patient)>
Atenol (Tenormin) 50 mg; oral Antihyperten ↓ BP, ↓ HR, Fatigue, weakness, Montitor BP, ECG, pulse, I & O’s and daily weights.
sives, beta MI prevention bradycardia, mental
blockers, status changes,
antianginals hypotension
Pantoprazole (Protonix) 40 Antiuler GERD, ↓ gastric acid, Hypergylycemia, Monitor for occult blood in stools & emesis, assess for
mg; oral agents, prevention/treatment of abdominal pain, gastric pain.
proton pump ulcers headache
inhibitor
Prednisone 40 mg; oral Cortico- Asthma HTN, depression, Monitor I & O’s, daily weights. Admister with meals
steroid, anti- eccymoses, nausea to minimize GI irritation. Do not take with grapefruit
asthmatics juice. Do not stop medication suddenly, gradually
taper off.
Tiotropium (Spiriva) 18 mcg; Broncho- ↓ incidence/severity of ↑ HR, dry mouth Assess respiratory status (rate, breath sounds)
Inhaln dilator bronchospasm d/t COPD
Hydromorphone (Dilaudid) Opioid Pain relief Constipation, sedation, Assess pain prior to and 1 hour after administration.
2 mg; oral analgesics nausea, respiratory Monitor respiratory rate, BP, pulse, LOC.
depression
Enoxaparin (Lovenox) 70 mg; Anticoagulant Prevention of DVT Anemia, nausea, Assess for signs of bleeding, hemorrhage. Monitor
subcutaneous edema, bruising CBC and platelet count. Do not rub injection site.
Risperidone (Risperdal) 3 mg; Anti- ↓ symptomps of Insomnia, sedation, Monitor mental status, mood changes, orthostatic BP,
oral psychotics psychoses or bipolar constipation, nausea, pulse. Watch pt to ensure medication is swallowed.
mania dry mouth, dizziness Advise pt to change positions slowly.
Warfarin (Coumadin) 6 mg; Anticoagulant Prevention of thrombo- Bleeding, dermal Assess pt for s/s of bleeding and hemorrhage. Monitor
oral embolic events necrosis, nausea PT/INR.
DISCHARGE PLANNING GUIDE
Anticipated discharge: _Today_________________ Pt. Diagnosis: _Upper GI bleed_______
Discharge to: __SNF___________
Functional Assessment
Independent Assist (specify) Total Care
eating X
bathing X Stand by assist (SBA)
dressing X
toileting X SBA
transferring X SBA
ambulating X SBA
taking medications correctly X Needs
supervision and
reminding due to
schizophrenia
house keeping X Pt fatigues
easily and has
schizophrenia
X Pt fatigues
preparing meals easily and has
schizophrenia
The care of the patient and the plan for discharge require a multidisciplinary approach. It is often the nurse who contacts the members of the multidisciplinary team to assist in the
care of the patient.
Multidisciplinary Team Referral in hospital Needs after discharge
State specific involvement in plan of Listed are examples. Please delete the
care or the patient needs that examples and state the specifics that
requirement involvement relate to your patient.
Social Work/Case Manager Social work is involved to handle
placement of client and husband to a
SNF
Respiratory therapist
Physical therapist PT involved in increasing mobility Pt will be supplied with a walker
and activity
Occupational therapist
Visiting Nurse
Home Health care worker
State how the discharge needs identified above will be addressed. Please consider the following and write a short statement to assure the patient’s needs are being met for a
safe discharge:
Prior to hospitalization, patient lived with husband in a motel. Husband was the primary caretaker, but his advanced age and current ailment and disability will no longer allow him to care
for them properly. Arrangements have been made to place them both in a skilled nursing facility as the patient is no longer able to completely care for herself. With proper supervision to
ensure she continues to take her meds and increases her activity, she seems like she will be able to adjust well.
What specific teaching does the patient need for a safe discharge?
Patient should be taught to take it easy and not overexert herself. She should know when she needs to notify the staff at the SNF if she is experiencing any s/s relating to her GI
disorder. Patient was malnourished when admitted to the hospital and should learn the value of good nutrition to maintain and promote healthy living. If she is well nourished,
perhaps her energy level will increase and she will fatigue less easily and won’t need assistance ambulating, bathing or toileting.
Patient should be aware of the medications she will continue to take after discharge. She is already aware of the effects of coumadin. Patient should also continue to take her
Risperdal and should follow up periodically with psychotherapy.
