JACKSON COMMUNITY COLLEGE

NUR 171
SUPPORTIVE EDUCATIVE NURSING

PREPARATION FOR SAFE PATIENT CARE

Student Name
Date

Alexandria Rose
12/12/15

Rev 06.25.2012

DAY ONE PREPARATION - Critical Thinking Summary

Patient Room Number N/A
Age
94
M/F F
CODE Status
Full Resuscitation
Primary Medical Diagnosis / Reason for Admission
Small Bowel Obstruction

Secondary Medical Diagnoses

(List all that impact patients care)

Gastroenteritis, Uterine CA, HTN, Hyperlipidemia, Hypothyroid, Thyroid CA, Partial Thyroidectomy, Glaucoma, Hx Skin CA, Hysterectomy

Nursing Care Plan for PRIORITY Physiological Nursing Diagnosis

Nursing Diagnosis in PES Format
Patient Expected Outcome
Individualized & Prioritized Nursing Interventions
with Referenced Evidence/Rationale
(measurable and with time frame)
P: Acute Pain
Client will report pain is relieved or
1. Assess: Assess pain using COLDSPA acronym. Identify
precipitating or aggravating and relieving factors. Rationale: In
controlled. (Doenges, Moorhouse,
order to fully understand a client's pain symptoms, one should
Murr pg 658).

attempt to obtain self-reports. (Doenges, Moorhouse, Murr pg

659-660).

E: Small bowel obstruction.

S: Constant non-radiating abdominal
pain, emesis, abdominal tenderness,
abdominal guarding, CT shows small
bowel obstruction.

AEB
Client will rate her pain at a
tolerable level within 1 hour after
interventions are initiated on
12/12/15.

2. Intervene: Administer analgesics, as indicated, to maximum

dosage, as needed. Notify physician if regimen is inadequate to
meet pain control goal. Rationale: To maintain acceptable
level of pain for the client (Doenges, Moorhouse, Murr pg 662).

Defining Characteristics Use Ackley text

3. Teach: Instruct client to report pain as soon as it begins.

book did you pick the correct diagnosis?

Rationale: Timely intervention is more likely to be successful in

aleviating pain (Doenges, Moorhouse, Murr pg 661)

Unpleasant sensory or emotional experience

arising from actual or potential tissue
damage, with mild to severe pain lasting less
than 6 months.

4. Discharge Planning: Identify specific signs/symptoms and

changes in pain characteristics requiring medical follow-up.
Rationale: Sudden changes in pain characteristics can indicate
serious complications (Doenges, Moorhouse, Murr pg 662).

Potential Complications
If this patients condition were to
worsen, what would be the most likely
reason?

Tissue death r/t ischemia

Infection (Peritonitis)
Nutrient Malabsorption
Deficient fluid volume
Tumor
Heart Attack
Stroke
Aneurism

SCHEDULE
How will you organize your time?

How will you be vigilant in monitoring

for and preventing this complication?

What will you do if it happens?

Call Bill and report to primary nurse.

Vitals Q3 Hours
Pain scale check with vitals and 30
min post administration of
analgesics
Watching for signs of fluid volume
excess/deficit
Monitoring I&O
Monitor Lab Values (Esp. WBC)
Heat to Toe Assessment Q Shift
Report anything i'm uncomfortable
doing to ensure patient safety.

PROCEDURES
What procedures do you have to do?
Be ready! (Catheters, injections, blood

CARE PATHWAYS
Is the patient on a Care Pathway?
Attach pathway and/or agency PMP.

AM report

I&O Monitoring

Refer to PMP in IPOC

Check Vital Signs

Lovenox Injection

(Report, medications, ambulation, bath,

charting, procedures, etc.)

Pass Meds
Give Breakfast
AM Care
Head-Toe Assessment
Diagnostic Tests if any scheduled
Subjective Interview
Check Vitals
Report

glucose monitoring, dressing changes, etc.)

(What do you need to do Day 1 and Day 2

according to the path or management plan?)

PATHOPHYSIOLOGIES
Primary Diagnosis Pathophysiology
Small Bowel Obstruction
Intestinal obstruction occurs when intestinal contents cannot pass through the GI tract. The obstruction may occur in the small intestine
or the colon and can be partial or complete, simple or strangulated. A partial obstruction usually resolves with conservative treatment,
whereas a complete obstruction usually requires surgery. A simple obstruction has an intact blood supply, and a strangulated one does
not. (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg . 982)
Reference Med/Surg or Patho text (less than 5 years old):
o Textbook S&S - Colicky abdominal pain, nausea, vomiting (possibly projectile), abdominal distention. Constipation and
decreased flatus may occur later on (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg. 983).
o Patients S&S - Abdominal pain, nausea, vomiting, abdominal distention.
Primary Diagnosis Pathophysiology
HTN
Persistent systolic BP of 140mm Hg or more, diastolic BP of 90mm Hg or more, or current use of anti-hypertensive medication. HTN
can be caused by a specific, correctable underlying cause (secondary), or it can be idiopathic (primary). Abnormalities of any of the
mechanisms involved in the maintenance of normal BP can result in HTN (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg. 712).
Reference Med/Surg or Patho text (less than 5 years old):
o

Textbook S&S Persistent systolic BP of >140mm Hg, diastolic BP >90mm Hg, or current anti-hypertensive medication use.
Also fatigue, dizziness, palpitations, angina, or dyspnea (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg. 713).

Patients S&S - Persistent systolic BP >140mm Hg and is taking an anti-hypertensive medication.

Secondary Diagnosis Pathophysiology

Gastroenteritis
Inflammation of the mucosa of the stomach and small intestine. Acute gastroenteritis is defined as sudden diarrhea accompanied by
nausea, vomiting, and abdominal cramping. Viruses are the most common cause. Most cases are self-limiting, however older adults and
chronically ill patients may be unable to consume sufficient fluids orally to compensate for fluid loss. If dehydrations occurs, IV fluid
replacement may be necessary (Lewis, Dirksen, Heitkemper, Bucher 2014 pg 975)
Reference Med/Surg or Patho text (less than 5 years old):
o

Textbook S&S Nausea, vomiting, abdominal cramping, dehydration (Lewis, Dirksen, Heitkemper, Bucher 2014 pg 975)

Patients S&S - Nausea, vomiting, abdominal pain, Hx of gastroenteritis.

Use additional sheets as necessary to complete all pertinent medical diagnoses.

Secondary Diagnosis Pathophysiology

Uterine Cancer
The most frequent invasive cancer of the female reproductive tract. It occurs most commonly in post-menopausal women. Hormonal
changes of menopause stimulate endometrial cell proliferation, inhibit apoptosis, and promote angiogenesis. Progesterone counteracts
the effects of estrogen. Hypertension is a risk factor, as it alters estrogen metabolism and increases levels. (Porth 2015, pg. 1032).
Reference Med/Surg or Patho text (less than 5 years old):
o

Textbook S&S - Abnormal, painless bleeding, cramping, pelvic discomfort, postcoital bleeding, enlarged lymph nodes (Porth
2015, pg. 1032).

Patients S&S Hx of uterine cancer.

Secondary Diagnosis Pathophysiology

Hyperlipidemia
A medical condition characterized by an elevation in any or all lipid profiles and/or lipoproteins in the blood. Hyperlipidemias can be
classified as either primary or secondary. Primary hyperlipidemias are probably genetically based, but the genetic defects are known for
only a minority of patients. Secondary hyperlipidemia may result from diabetes, thyroid disease, renal disorders, liver disorders, and
Cuching syndrome, as well as obesity, alcohol consumption, estrogen administration, and other drug-associated changes in lipid
metabolism (Porth 2015, pg. 404).
Reference Med/Surg or Patho text (less than 5 years old):
o

Textbook S&S - For a female, cholesterol >200mg/dL, triglycerides > 150mg/dL, LDL <50mg/dL, HDL >100mg/dL, lipoprotein
>30mg/dL, or lipoprotein-associated phospholipase A2 >342ng/mL (Porth 2015, pg. 699-700).

Patients S&S Hx of hyperlipidemia.

Secondary Diagnosis Pathophysiology

Hypothyroidism
Deficiency of thyroid hormone that causes a general slowing of the metabolic rate, and can be classified as primary or secondary. Primary
hypothyroidism is caused by destruction of thyroid tissue or defective horone synthesis. Secondary hypothyroidism is caused by pituitary
disease with decreased TSH secretion or hypothalamic dysfunction with decreased thyrotropin-releasing hormone secretion.
Hypothyroidism may also be transient and related to thyroiditis or discontinuance of thyroid hormone therapy (Lewis, Dirksen,
Heitkemper, Bucher, 2014 pg. 1201).
Reference Med/Surg or Patho text (less than 5 years old):
o

Textbook S&S - Low T3/T4 levels, fatigue, lethargy, personality/mental changes, impaired memory, slowed speech, decreased
initiative, somnolence, depression, weight gain, decreased cardiac output, SOB on exertion, anemia, increased serum cholesterol
and triglyceride levels, dry skin, hair loss, hoarsness, constipation, cold intolerance, and possible myxedema (Lewis, Dirksen,
Heitkemper, Bucher, 2014 pg 1202).

Patients S&S Hx of Hypothyroidism.

Secondary Diagnosis Pathophysiology

Thyroid Cancer
Thyroid cancer is the most common form of endocrine system cancer. The four main types of thyroid cancer are papillary, follicular,
medullary, and anaplastic. Papillary is the most common. It grows slowly and spreads initially to lymph nodes in the neck. Follicular
tends to occur in older patients. It first metastasizes into the cervical lymph nodes, then spreads to the neck, lungs, and bones.
Medullary is diagnosed by genetic testing, and it is associated with early metastasis. Anaplastic is the most rare, yet the most advanced
and aggressive. It is the least likely to respond to treatment. (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg 1204)
Reference Med/Surg or Patho text (less than 5 years old):
o

Textbook S&S painless, palpable nodule or nodules in an enlarged thyroid gland. Firm, palpable cervical masses, elevated
serum calcitonin, or elevated thyroglobulin. (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg 1204)

Patients S&S Hx of thyroid cancer.

Secondary Diagnosis Pathophysiology

Glaucoma
A group of disorders characterized by IOP and the consequences of elevated pressure, optic nerve atrophy, and peripheral visual field
loss. It can be classified into two groups, open and closed angle. Open angle glaucoma is when the outflow of aqueous humor is
decreased in the trabecular network. The drainage channels become clogged, which results in damage to the optic nerve. Closed angle
glaucoma is due to a reduction in the outflow of aqueous humor that results from angle closure. This is caused by the lens bulging
forward as a result of the aging process. (Lewis, Dirksen, Heitkemper, Bucher, 2014 pg 398).
Reference Med/Surg or Patho text (less than 5 years old):

Textbook S&S Gradual peripheral vision loss, tunnel vision. Acute angle: sudden, excruciating periorbital pain, nausea,
vomiting. Angle closure: blurred vision, colored halos around lights, ocular redness, eye or brow pain (Lewis, Dirksen,
Heitkemper, Bucher, 2014 pg 398-399).

Patients S&S Hx of glaucoma.

Secondary Diagnosis Pathophysiology

Skin Cancer
Skin cancer can be classified as either nonmelanoma or melanoma. Nonmelanoma's are more common, and are linked to cumulative
exposure to UV radiation. Melanomas are more commonly seen on areas of the body that are intermittently exposed to the sun, such
as the back or lower legs. These cancers typically start off as a localized change in skin color/texture, and if not treated may
metastasize to other places in the body. (Porth 2014, pg 1174).
Reference Med/Surg or Patho text (less than 5 years old):
o

Textbook S&S Localized change in skin color or texture. Usually black or brown, differing in size and shape, slightly raised,
may be surrounded by erythema, inflammation, or tenderness (Porth 2014, pg. 1174).

Patients S&S Hx of skin cancer. (Not specified which type, but skin irregularity was excised from the patient's back)

MEDICATION SUMMARY
ALLERGIES and usual reaction
No Known Allergies
Generic/Brand
Normal Dose
Name and
Class

Patients Dose
Times to Give

Drug Action

Why ordered
for this patient?

Items to check
before giving;
when to hold

Two common
side effects

You know med

is working
when:

Enoxaparin
[Anticoagulant]

40mg SC q24h
x6-11 days

30mg SC q24h

Binds to
antithrombin III and
accelerates
activity, inhibiting
thromin factor Xa

DVT Prophylaxis

Stool occult
blood
Platelet count

Anemia
Hemorrhage

No DVT formation

Latonoprost
Opthalamic

1gtt in eye(s)
qpm

1gtt in both eyes

qHS

Increases
aqueous humor

Glaucoma

No herpes
simplex present,

Burning/stinging
photophobia

Decreased IOP

[Prostaglandin
Analog]
Levothyroxine
[Thyroid
Hormone]
Pantoprazole
(Protonix)
[Proton Pump
Inhibitor]
Hydralazine
[Vasodilator/
Nitrate]

outflow
50-200mcg PO
qd

56mcg IV push
qd

Synthetic isomer
of thyroxine

Hypothyroidism

20-40mg PO qd

40mg IV push qd

Inhibits gastric
parietal cell
hydrogenpotassium ATPase

GERD

10-50mg PO qid

10mg IV push
q6h prn

Directly dilates
peripheral
vessels

HTN

Hydromorphone
(Dilaudid)
[Opioid Agonist]
Metoclopramide
(Reglan)

0.2-0.6mg IV Q23h prn

0.5mg IV push
Q3h prn

Binds to opioid
receptors

Abdominal pain

10mg IV x1

10mg IV x1 prn
for
nausea/vomiting

Dopamine
receptor agonist

Nausea/Vomiting

Morphine
[Opioid
Agonist]

2.5-5mg q3-4h
prn

2mg IV push
STAT q5min prn

Binds with
opioid
receptors
within CNS

Severe acute
pain

Ondansetron
(Zofran)
[Anti-emetic]

0.15mg/kg IV q8h
prn

4mg IV push q6h

prn

Selectively
antagonizes
serotonin 5-HT3
receptors

Nausea/Vomiting

Ocular
inflammation
Baselike TSH, T3,
and T4,
ECG
Question nausea,
question diarrhea

Tachycardia
Diarrhea

TSH, T3 and T4
levels WNL

Headache
Diarrhea

Relieved GERD
symptoms

Headache
Tachycardia

Blood pressure
WNL

Dizziness
Headache

Client states
relief of pain

Restlessness
Lethargy

Client denies
nausea vomiting

Pain level,
Respirations
(hold if <12)

Dizziness
Constipation

Client states
relief of pain

Nausea/Vomiting

Headache
Constipation

Nausea/Vomiting
relieved.

Blood pressure
(hold if SBP<90)
Pulse (Hold if
<60)
Pain Level
Respirations
(hold if <12)
Skin turgor,
Abdominal
distention

LAB VALUES SUMMARY

Diagnosis #1
Diagnosis #2
Diagnosis #3
Small Bowel
Obstruction
Hyperlipidemia

Medical
Diagnosis
List laboratory and
diagnostic tests
found in your text
for admitting and
secondary medical
diagnoses.

CBC with
diff/indicies
Blood Chemistry
ABGs
Serum Electrolytes
UA

Serum Lipase

Test

Normal
Value

ANALYSIS OF LAB VALUES

Admitting
Follow up
Cause of
date / value
date / value
abnormal
finding

RBC

4.2-5.4
million/mcL

3.79
million/mcL

Hemoglobin

WNL

Hematocrit

WNL

Platelets

WNL

Test further to
determine the
cause, and
educate on ironrich foods.

Investigate further. If
it's infection, educate
pt that adequate
vitamins A, C, and
zinc are needed to
fight it.
Investigate further. If
it's infection, educate
pt that adequate
vitamins A, C, and
zinc are needed to
fight it.

prn)

4.0-10
thousand/mcL

11
thousand/mcL

Acute hemolysis
or infection

Monocyte
Absolute

0.0-0.8
thousand/mcL

1.1
thousand/mcL

Infection or
carcinoma

WNL

Potassium

WNL

Chloride

WNL

CO2

WNL

BUN

WNL

Creatinine

WNL

Albumin

WNL

Calcium

WNL
WNL
WNL

Protein
MCHC

Implications
for care

Hemolytic
anemia or
nutritional deficit

WBC (diff

Sodium

Diagnosis #4

Ketones
Urine
Blood Urine

Leukocyte
Esterase
Urine
Protein
Urine
RBC Urine

Bacteria
Urine
Glucose
Level
GFR
Estimated
Non African
American
ALT-SGPT
AST/SGOT

NEG
NEG

Abn +2

Hemolytic
anemia or
disease of the
bladder

R/O hemolytic
anemia. Monitor
urine for
increased
amounts of
blood.

NEG

NEG

Abn TRACE

Stress, or
nephrosis

Investigate renal
health.

0-2/HPF

10-20/HPF

Hemolytic
anemia or
disease of the
bladder

R/O hemolytic
anemia

Diabetes

Do more
definitive tests
to check for
diabetes

N/A
60-100mg/dL

127mg/dL

WNL

WNL
WNL

ANALYSIS OF LAB VALUES Day 2

List all other pertinent normal or abnormal lab values.

Test

Normal
Value

Admitting
date / value

Follow up
date / value

RBC

4.2-5.4
million/mcL

3.79
million/mcL

3.51
million/mcL

Hemoglobin

12-16gm/dL

12.0gm/dL

11.1gm/dL

Malnutrition
r/t SBO and
NPO

Hematocrit

36-48%

37%

34.2%

Malnutrition
r/t SBO and
NPO

Platelets

WNL

WNL

WBC (w/ diff 4-10

prn)
thousand/
mcL

11
thousand/mcL

Monocyte
Absolute

1.1
thousand/mcL

8.5 thousand/ Acute

mcL
hemolysis or
infection,
but
improving.
1.1 thousand/ Infection or
mcL
carcinoma.

Sodium

WNL

WNL

Potassium

WNL

WNL

Chloride

WNL

WNL

CO2

WNL

WNL

127mg/dL

120mg/dL

BUN

WNL

WNL

Creatanine

WNL

WNL

Albumin

WNL

WNL

Glucose
Level

0.0-0.8
thousand/
mcL

60100mg/dL

Cause of
Abnormal
finding
Malnutrition
r/t SBO and
NPO

Possibly r/t
time taken,
after sugary
meal, etc.

Implications
for care
Continue
monitoring
levels.
Administer IV/NG
nutrition if
necessary.
Continue
monitoring
levels.
Administer IV/NG
nutrition if
necessary.
Continue
monitoring
levels.
Administer IV/NG
nutrition if
necessary.

Continue
current care,
as condition
is improving.
Investigate further. If
it's infection,
educate pt that
adequate vitamins A,
C, and zinc are
needed to fight it.

Continue
monitoring BS
for elevation.

Calcium

8.510.1mg/dL

8.8mg/dL

7.9mg/dL

Protein

WNL

WNL

MCHC

WNL

WNL

Malnutrition
r/t SBO and
NPO

Continue
monitoring
levels.
Administer IV/NG
nutrition if
necessary.

Student Name ________Alexandria Rose________Date___12/12/15__Time______0700_____

Patient Age/Sex __94/F__ Medical Diagnosis __Small Bowel Obstruction__ Code Status
MENTAL STATUS
LOC and orientation X3
Appearance
Cognition
PAIN
Location, severity, quality, radiation,
duration, precipitating/alleviating
factors, associated symptoms
HEAD AND NECK
Hair and skin
Eyes: sclerae, conjunctivae, pupil
reactivity
Eyes: vision/aids
Ears: lesions, hearing/aids
Nose: symmetry, mucosa, drainage
Mouth: mucosa, tongue, dentation,
lesions
Swallowing/ Appetite
Trachea position
JVD at 45 degrees
UPPER EXTREMITIES
Skin
Pulses (brachial, radial)
Capillary refill
Strength/ROM
Turgor/edema
CHEST/BACK
Shape
Respiratory effort/SpO2
Cough/sputum
Lung sounds anterior and posterior
Skin condition/integrity
Heart sounds
Apical pulse rate/rhythm (auscultate
full min)
ABDOMEN/PERINEAL AREA
Contour, symmetry
Bowel sounds in 4 quadrants
Tenderness
Urinary pattern/color

Full Code

Pt is A&Ox 4, to person, place, time, and situation.

Pt appears appropriate for situation.
Cognition is intact.
Pt denies any pain.

Hair is white and thinning. Skin pale pink, dry and

intact.
Sclera are white, conjunctiva are pale pink. PERRLA.
Pt states she wears glasses, but forgot them at home.
Pt states she is hard of hearing. Pt wears bilateral
hearing aids, but left them at home.
Nose is symmetrical, with no drainage. NG tube with
suction patent in R nare. A total of 650ml of green bile
has been suctioned since insertion.
Buccal mucosa is pink, moist, and intact. No sores
noted. Pt has multiple dental fillings on top and bottom
teeth. Dentation intact. Tongue is pink, moist and
intact. No lesions noted.
Pt states her appetite at home is good. Since
hospitalization, she has been NPO. Pt denies difficulty
swallowing.
Trachea is midline.
No JVD noted at 45 degrees.
Skin is pink, warm, dry, and intact.
Brachial pulse is +2 bilaterally, regular rate/rhythm.
Radial pulse is +2 bilaterally, regular rate/rhythm.
Capillary refill is <3 seconds bilaterally.
Hand grasp is strong and equal bilaterally.
Skin turgor is loose. Minimal tenting noted.
AP Diameter is 2:1, symmetrical.
No accessory muscle use noted. Pt is 97% on RA with a
respiratory rate of 16/min.
Pt denies cough.
Lung sounds clear and vesicular in all lobes.
Skin is pink, warm, dry, and intact.
S1>S2 in aortic and pulmonic areas. S1=S2 at Erbs
point. S1>S2 at tricuspid and mitral areas.
Apical pulse is 77bmp, regular rate and rhythm.
Abdomen is flat, symmetrical.
Bowel sounds hypoactive in all 4 quadrants.
No tenderness to palpation or facial grimmacing noted.
Pt denies urinary difficulty. Urine is dark yellow.

Bowel pattern/character/last BM
Perineum (if appropriate)
LOWER EXTREMITIES
Skin color/integrity
Edema
Pulses (femoral, popliteal, PT, DP)
Capillary refill
Strength/ROM
EQUIPMENT
Pumps
Tubes
DURING SHIFT
Vital signs/time

Pt has not had BM since admission.

N/A
Skin is pink, warm, dry and intact
+2 bilaterally ankle edema noted.
Posterior tibial and dorsalis pedis both +1 bilaterally,
regular rate and rhythm.
Capillary refill is <3 seconds bilaterally.
Plantar flexion and dorsiflexion are strong and equal
bilaterally. Negative Homan's sign.
N/A
Pt has NG tube with suction in R nare.

Vitals obtained at 0700

BP: 173/76
HR: 77
RR: 16
O2 Sat: 97% RA
Temperature: 99.0 degrees F, oral

Blood glucose monitoring

results/insulin

N/A

Intake and output

Intake as of 1100 for 12/12/15 is 756ml

Output as of 1100 for 12/12/15 is 300
Pt is NPO. Pt denies nausea.
Pt has D5 .9 with 20 of K+ running at 75 ml/hr IV in her
R hand.
RBC, hemoglobin, and hematocrit are decreasing.
Daughter and son visit frequently.
Pt was educated on the need to keep the NG tube in
until bowel sounds return to normal activity.

Food intake/Appetite/Nausea
IV solution and rate/hourly checks
Significant lab results
Support system/SO involvement
Patient education completed

NURSING DIAGNOSIS
Acute pain r/t small bowel obstruction aeb constant non-radiating pain, emesis, abdominal
tenderness, abdominal guarding, CT shows small bowel obstruction.

SOAP NOTE (on above nursing diagnosis only)

S: Pt was admitted complaining of severe, constant abdominal pain. Pt now rates pain at 0/10.
O: Vital signs: BP 173/76, HR 77, RR 16, Temperature 99.0 degrees F, O2 Sat 97% RA. Pt was
diagnosed with a small bowel obstruction by X-ray. Pt had an NG tube with suction inserted on
12/10/15 and is NPO. NG tube returned a total of 650ml of green bile since insertion. No

abdominal distention noted, bowel sounds are hypoactive, and pt denies abdominal tenderness.
Skin is pink, warm, dry, and intact. No lesions noted. Bilateral +2 ankle edema noted.
A: Patient is improving. Pain has subsided and the NG tube suction has returned progressively
smaller amounts of urine, indicating improved functioning of the GI tract.
P: Continue nursing care. Progress toward having a BM and getting the NG tube removed.
END OF SHIFT CHECK-OUT
Patient safe and comfortable
I&O documented
____Alexandria
Student signature

Rose SN____

Meds administered
MAR signed

Reported off to RN and instructor

DAY TWO PREPARATION

EVALUATION
Did you choose the appropriate nursing diagnosis for Day One?

Yes No

What would have been a better choice?

Were your objectives and interventions appropriate?

Yes No

What would have been more appropriate?

Nursing Care Plan for SECOND PRIORITY Nursing Diagnosis

Nursing Diagnosis in PES Format
Patient Expected Outcome
Individualized & Prioritized Nursing
(Measurable and with time
Interventions with Referenced
Evidence/Rationale
frame)
P: Risk for decreased cardiac output.

Client will identify signs of cardiac

decompensation, alter activities, and
seek help appropriately upon
discharge (Doenges, Moorhouse,
Murr pg. 172).

E: Hypertension

S: Persistent Systolic BP >140 and

currently taking antihypertensive
medication.

Defining Characteristics (from book did

you pick the correct diagnosis?)
Palpitations, increased peripheral vascular
resistance, inadequate blood pumped by the
heart to meet the metabolic demands of the
body (Doenges, Moorhouse, Murr pg. 172).

1. Assess: Assess vital signs/hemodynamic

parameters, including cognitive status. Not vital sign
response to activity or procedures and time required
to return to baseline. Rationale: Provides baseline
for comparison to follow trends and evaluate
response to interventions (Doenges, Moorhouse,
Murr pg. 174).
2. Intervene: Administer blood or fluid replacement,
antibiotics, diuretics, inotropic drugs,
antidysrhythmics, steroids, vasopressors, and/or
dilators as indicated. Evaluate response. Rationale:
Evaluate response to determine therapeutic,
adverse, or toxic effects of therapy (Doenges,
Moorhouse, Murr pg. 175).

AEB: Client will verbally recite

specific signs of cardiac
decompensation, as well as
measures to take in such an
event.

3. Teaching: Provide for diet restrictions (low

sodium, bland, soft, low-calorie/fat diet with frequent
small feedings) as needed. Rationale: To maintain
adequate nutrition and fluid balance (Doenges,
Moorhouse, Murr pg. 177).
4. Discharge Planning: Discuss significant
signs/symptoms that require prompt reporting to
healthcare provider (muscle cramps, headaches,
dizziness, skin rashes). Rationale: These may be
signs of drug toxicity, third spacing, severe
dehydration, etc (Doenges, Moorhouse, Murr pg.
177).

Student Name _________Alexandria Rose___________ Date __12/12/15___

Patient Age/Sex ___94/F____ Medical Diagnosis ______Small Bowel Obstruction______ Code Status
_ Full Code____
MENTAL STATUS
LOC and orientation X3
Appearance
Cognition
PAIN
Location, severity, quality, radiation,
duration, precipitating/alleviating
factors, associated symptoms
HEAD AND NECK
Hair and skin
Eyes: sclerae, conjunctivae, pupil
reactivity
Eyes: vision/aids
Ears: lesions, hearing/aids
Nose: symmetry, mucosa, drainage
Mouth: mucosa, tongue, dentation,
lesions
Swallowing/ Appetite
Trachea position
JVD at 45 degrees
UPPER EXTREMITIES
Skin
Pulses (brachial, radial)
Capillary refill
Strength/ROM
Turgor/edema
CHEST/BACK
Shape
Respiratory effort/SpO2
Cough/sputum
Lung sounds anterior and posterior
Skin condition/integrity
Heart sounds
Apical pulse rate/rhythm (auscultate
full min)
ABDOMEN/PERINEAL AREA
Contour, symmetry
Bowel sounds in 4 quadrants
Tenderness
Urinary pattern/color
Bowel pattern/character/last BM
Perineum (if appropriate)
LOWER EXTREMITIES
Skin color/integrity
Edema

Pt is A&Ox4 to person, place, time, and situation.

Pt is dressed appropriately for the situation.
Pt makes statements that indicate cognition is intact.
Pt states pain is 0/10.

Skin is pink, warm, and intact.

Sclera are white bilaterally. Conjunctiva are pink, moist,
and intact. PERRLA.
Pt uses hearing aids and glasses, but is not currently
wearing either.
Nose is symmetrical and midline. Mucosa is pink, moist,
no drainage.
Buccal mucosa is pink, moist, and intact. No lesions
noted. Dentation is intact, multiple fillings noted.
Pt denies difficulty swallowing. Pt has appetite, but is
currently NPO.
Trachea is midline.
No JVD noted at 45 degrees.
Skin is pink, warm, and intact. No lesions noted.
Brachial and radial pulses both +2, regular rate and
rhythm bilaterally.
Capillary refill is <3 seconds.
Grasp strength is strong and equal bilaterally. Pt has full
ROM.
Skin turgor is loose. Minimal tenting noted.
AP diameter is 2:1.
No accessory muscle use noted.
No cough noted.
Lung sounds clear to auscultation in all lobes.
Skin is pink, warm, and intact.
S1>S2 in aortic and pulmonic areas. S1=S2 at Erbs
point. S1>S2 at tricuspid and mitral areas.
Apical pulse is 71bpm, regular rate and rhythm.
Abdomen is flat and symmetrical.
Bowel sounds hypoactive x4 quads.
No tenderness to palpation noted.
Urine is concentrated yellow. No odor noted.
Pt has not had BM since before admission.
N/A
Skin is pink, warm, and intact.
Bilateral ankle edema noted.

Pulses (femoral, popliteal, PT, DP)

Capillary refill
Strength/ROM
EQUIPMENT
Pumps
Tubes
DURING SHIFT
Vital signs/time

Dorsalis pedis +1, regular rate and rhythm bilaterally.

Capillary refill is <3 seconds.
Plantar flexion and dorsiflexion strong and equal
bilaterally.
None.
None.
Vitals obtained at 0700
BP: 183/64
HR: 71
RR: 16
O2 Sat: 95% RA
Temperature: 98.2 degrees F, oral

Blood glucose monitoring

results/insulin

N/A

Intake and output

Food intake/Appetite/Nausea

N/A
Pt is NPO. Pt states she has an appetite. Pt denies
nausea.
Pt has D5 .9 with 20 of K+ running at 75 ml/hr IV in her
R hand.
Hgb: 11.1gm/dL
Monocyte Absolute: 1.1thou/mcL
Glucose 120mg/dL
Daughter and son visit daily.
Pt educated on why bowel sounds need to be present
before she can stop being NPO.

IV solution and rate/hourly checks

Significant lab results
Support system/SO involvement
Patient education completed

NURSING DIAGNOSIS
Risk for decreased cardiac output r/t hypertension aeb persistent systolic BP >140 and currently
taking antihypertensive medication.

SOAP NOTE (on above nursing diagnosis only)

S: Pt rates pain as 0/10. Pt states she feels better and wants to start eating.
O: Vital signs: BP 183/64, HR 71, RR 16, Temperature 98.2 degrees F, O2 Sat 95% RA. Pt had NG
tube removed on 12/12/15. Bowel sounds are hypoactive. Pt has not had BM since before
admission. Pt appears relaxed.
A: Pt is progressing well toward discharge.
P: Continue nursing care. Monitor bowel sounds and alert patint to report any changes or BM.

END OF SHIFT CHECK-OUT

Patient safe and comfortable
I&O documented
________Alexandria
Student signature

Meds administered
MAR signed

Rose SN_________

Reported off to RN and instructor