Student Name: Charleen Kahapea

Mini Care Plan Instructions

Date: November 1, 2015

Date cared for patient: October 28, 2015

N360 Mini Care Plan

Expected
(complete before assessment)

Found
(complete after assessment)

Nursing
Diagnoses
(NANDA)

1. Pain r/t inflammation or irritation of the gastric

mucosa d/t increased gastric acid
2. Nutritional deficit r/t decreased PO intake AEB
NPO orders
3. Risk for infection r/t possible obstruction AEB
CT results on 10/27.

1. Pain r/t inflammation or irritation of the gastric

mucosa d/t increased gastric acid
2. Nutritional deficit r/t decreased PO intake AEB
NPO orders
3. Risk for infection r/t possible obstruction AEB CT
results on 10/27.

Focus of
physical
assessment

- GI: passing gas, N/V, abdominal pain and

cramping
- Abdomen and stomach: bowel sounds,
distention, firmness, tenderness (rebound
tenderness).

- GI: passing gas, N/V, abdominal pain and cramping

- Abdomen and stomach: bowel sounds, distention,
firmness, tenderness (rebound tenderness).

Need more
information
from patient/
family/
doctor about:

- when was her last bowel movement and its

description. How often she goes?
- last emesis
- feeling of N/V
- abdominal pain assessment
- What did she last eat before feeling ill?
- Did she have any alcohol recently?

- what is the plan for her hospitalization (to do

another X-ray study to see any changes and continue
antibiotics)

Top three
priorities
(goals) for
patient care

1. Pt will express adequate pain management

2. Pt will maintain adequate nutritional intake
through her IV fluids while resting her bowels.
3. Pt will not show signs or symptoms of infection
r/t bowel obstruction/enteritis

1. Pt will express adequate pain management

2. Pt will maintain adequate nutritional intake through
her IV fluids while resting her bowels.
3. Pt will not show signs or symptoms of infection r/t
bowel obstruction/enteritis

Nursing
Interventions

1. Pain assessment
2. Administer pain in timely manner and evaluate
effectiveness
3. Assess for dehydration (decreased skin turgor,
paleness, dry mucous membranes)
4. Maintain orders and administer IV fluids (NS
KCl 20 mEq/L @ 100ml/hr) and monitor for
complications.
5. GI assessment: abdomen distention, tenderness,
pain, firmness, bowel sounds, passing gas, N/V,
diarrhea, constipation)
6. Administer antibiotics as ordered: ciprofloxacin
IVPB @ 200ml/hr

1. Pain assessment
2. Administer pain in timely manner and evaluate
effectiveness
3. Assess for dehydration (decreased skin turgor,
paleness, dry mucous membranes)
4. Maintain orders and administer IV fluids (NS KCl
20 mEq/L @ 100ml/hr) and monitor for
complications.
5. GI assessment: abdomen distention, tenderness,
pain, firmness, bowel sounds, passing gas, N/V,
diarrhea, constipation)
6. Administer antibiotics as ordered: ciprofloxacin
IVPB @ 200ml/hr

Teaching
needed/
provided

- Pain management (prn medication orders and

side effects- N/V and constipation)
- Antibiotic side effects (diarrhea, abdominal
cramping)
- Report if feelings of allergic reactions come
back (she had a reaction to the contrast <denied
allergy to shellfish or iodine> throat tightness,
tingling of the mouth and lips, hard time
breathing)
- calling for assistance for out of bed if she felt
dizzy or unsteady

- Pain management (prn medication orders and side

effects- N/V and constipation)
- Antibiotic side effects (diarrhea, abdominal
cramping)
- Report if feelings of allergic reactions come back
(she had a reaction to the contrast <denied allergy to
shellfish or iodine> throat tightness, tingling of the
mouth and lips, hard time breathing)
- calling for assistance for out of bed if she felt dizzy
or unsteady

Discharge
planning

- Follow up with MD
- Come back if pain or symptoms return (N/V, or
unrelieved abdominal pain)
- Waiting results from imaging study follow up to
determine plan of care.

- Follow up with MD
- Come back if pain or symptoms return (N/V, or
unrelieved abdominal pain)
- Waiting results from imaging study follow up to
determine plan of care.