Nutrition and Endocrine
Bowel sounds present and normal in all 4 quadrants, last
bowel movement 03/21/18 at 1200, no evidence of
dysphagia, 5’6 inches, 178 lbs., BMI of 28 % (obese)
nauseated, and vomiting, last time vomited at 03/27/18
at 0700, cardiac diet, renal diet, npo except medication
Hospital medication: Ondansetron Injection 4mg
(blocks specific receptor sites 5-HT3, which are
associated with nausea and vomiting in the
chemoreceptor trigger zone, centrally and at specific
sites peripherally), Mylanta oral susp 30ml by mouth
daily (Flatulence), Metoclopramide 5mg tablet by
mouth daily (Enhances response to acetylcholine of
tissue in upper GI tract, which causes the contraction of
gastric muscle; relaxes pyloric, duodenal segments;
increases peristalsis without stimulating secretions;
blocks dopamine in chemoreceptor trigger zone of
CNS)(GERD), Levothyroxine 75 mcg one tablet by
mouth daily (Increases the metabolic rate of body
tissues), amlodipine 5mg one tablet by mouth
daily(inhibits calcium ion influx across cell membrane
during cardiac depolarization)
Inference: last bowel movement 03/21/18 at 1200,
nothing by mouth except medication as a result of
constipation
Comfort and pain
Pain level 8 (0-10) on 03/27/18 at 1400, tolerable is 5,
patient complaints of pain in all 4 quadrants of the
abdomen, abdomen is tender to touch with distention,
Treatment: tramadol 50mg one table by mouth daily
(binds to u-opioid receptors inhibits reuptake of
norepinephrine, serotonin) (for pain) , Acetaminophen
tablet 650 one tablet by mouth as needed every 8 hours
for mild to moderate pain (limit is 2000 mg) (may block
pain impulses peripherally that occur in response to
inhibition of prostaglandin synthesis)
Inference: abdomen is tender to touch, pain level 8 out
of 10 leading to acute pain
Cardiovascular
Heart sounds normal S1 and S2, no bruit heard over carotid
artery, denies any chest pain RBC on 03/23/18 3.06 (L)
(4.7-6.1), 03/24/18 2.57 (L), 3/25/18 2.99 (L), 3/26/18 3.05
(L), HGB 03/23/18 9.3 (L)(14-18), 03/24/18 7.9 (L),
03/25/18 2.99 (L) 03/26/18 3.05 (L), HCT 27.3 (L)(42.0-
52.0), 03/24/18 23.0 (L), 03/25/18 26.6 (L), 03/26/18 27.6
(L), RDW 03/23/18 15.9 (H)(11.5-14.5) 03/24/18 16.4 (H),
03/25/18 16.6 (H), 03/26/18 16.6 (H), blood pressure on
03/27/18 at 0700 103/65 (N) (100-140), pulse 90 (N) (60-
100), temperature 98.0 (N) (96.4-99.0)
Inference: RBC on 03/23/18 3.06 (L) (4.7-6.1), HGB
03/23/18 9.3 (L)(14-18), HCT 27.3 (L)(42.0-52.0),
03/24/18 23.0 (L), RDW 03/23/18 15.9 (H)(11.5-14.5)
leading to impaired gas exchange
Patient is a 54 year old Hispanic male admitted on 03/16/18 due to
complications of cirrhosis of the liver. CC nausea, and vomiting,
abdominal pain in all 4 quadrants. Full code, insurance private, no
spiritual or religious considerations, Allergies: Lisinopril, Norco, PMH
Hospital: hyperlipidemia, mood disorder with depressive feature,
essential hypertension, obesity, GERD, Liver cirrhosis,
hypothyroidism, severe protein calorie malnutrition, transaminale
elevation, ascites, persistent vomiting, hyponatremia. Non-Hospital:
Fatty liver, Vit B12 deficiency, Vitamin D deficiency, insomnia,
erectile dysfunction, undifferentiated connective tissue disease,
Taynaruds disease, anxiety disorder, cognitive deficit in attention, or
concentration, palpitations, severe alcohol use disorder, enteritis,
orthopnea, abdominal pain, sepsis without acute organ dysfunction,
partial small bowel obstruction. Home medication: Ondansetron 8mg
dissolve one tablet in mouth every 8 hours as needed for nausea and
vomiting (a competitive serotonin type 3 receptor antagonist),
Oxycodone-Acetaminophen 10-325mg, take one tablet by mouth every
8 hours as needed for moderate pain and one-half tablet every 8 hours
as needed for mild pain. Mouthwash diphenhydramine-lidocaine visc-
Mylanta- nystatin- sorbitol oral susp swish and spit 15 ml by mouth
every 6 hours as needed for mouth or throat pain, potassium chloride
10 meq SR one tablet by mouth daily only with Lasix ( a white crystal
or crystalline powder used as an electrolyte replenished, in the tx of
hypokalemia), Levothyroxine75mcg one tablet by mouth daily
(Thyroxine is synthesized via the iodination of tyrosine and the
coupling of iodotyrosine in the thyroglobulin), Furosemide 40mg take
one tablet by mouth daily (inhibits water reabsorption in the nephron
by blocking the sodium-potassium –chloride cotransporter in the thick
ascending limb of the loop of Henle), Spironolactone 50mg take 2
tablets by mouth daily (antagonist of aldosterone, acting primarily
through competitive binding of receptors at the aldosterone-dependent
sodium-potassium exchange site in the distal convoluted renal tubule),
Pantoprazole 40 mg TBEC DR one tablet by mouth twice daily (prton
pump inhibitor that suppresses the final step in gastric acid production
by forming a covalent bond to two sites of the H+ K+-ATPase enzyme
system at the secretory surface of the gastric parietal cell), Tramadol
50mg one tablet by mouth every 8 hours as needed for pain
(norepinephrine and serotonin reuptake blockade in the CNS) (For
pain), Folic Acid 1 mg tablet by mouth daily (water soluble B complex
vitamin), Hydroxyzine Pamoate one to two capsules by mouth every 6
hours as needed for anxiety or at bedtime as needed for sleep
(competes with histamine for binding at H1-receptor sites on the
effector cell surface, resulting in suppression of histaminic edema, flar,
and purities), Amlodipine 5mg take two tablets by mouth daily
(decreases arterial smooth muscle contractility and subsequent
vasoconstriction by inhibiting the influx of calcium ions through L-
type calcium channels) Cyanocobalamin 1000mcg one tablet by mouth
daily (Vit B 12), EDD pending awaiting doctors’ orders
Oxygen and pulmonary
Respirations 18 per minute (N) (12-20) on
03/27/18 at 0700, 02 saturation 93% at room
air on 03/27/18 at 0700 Shortness of breath
with moderate exertion, 2 liters of oxygen via
nasal cannula as needed for shortness of
breath
Inference: 02 saturation 93% at room air on
03/27/18 at 0700 Shortness of breath with
moderate exertion, 2 liters of oxygen via
nasal cannula as needed for shortness of
breath resulting from impaired gas exchange
Mobility
Unable to ambulate without assistance,
weight baring as tolerated, uses bedside rails,
gait imbalance due to lower extremity
weakness, no history of falls, Morse 60 High
risk (<25)
Inference: Unable to ambulate without
assistance, gait imbalance, lower extremity
weakness, resulting from acute pain
Fluid and electrolyte
Skin warm and dry to touch, , PICC line in right arm (20),
nausea and vomiting, no redness or inflammation noted by IV
site, Input 1350 ml Output 470 ml Net 880 ml (yellow, clear)
NA 03/23/18 133(L)(135-145), 03/24/18 133(L), 03/26/18
134 (L), K 03/23/18 3.2 (L)(3.5-5.0), 03/24/18 2.9 (L), CL
03/23/18 100(L) (101-111), 03/24/18 98(L), 03/25/18 98(L),
03/26/18 98(L), Mg 03/25/18 1.6 (L) (1.7-2.8), Hospital
Medication: Furosemide 40mg take one tablet by mouth daily
(inhibits water reabsorption in the nephron by blocking the
sodium-potassium –chloride cotransporter in the thick
ascending limb of the loop of Henle), potassium chloride 40
meq SR one tablet by mouth daily ( a white crystal or
crystalline powder used as an electrolyte replenished, in the tx
of hypokalemia), Spironolactone 100mg one tablets by mouth
daily (antagonist of aldosterone, acting primarily through
competitive binding of receptors at the aldosterone-dependent
sodium-potassium exchange site in the distal convoluted renal
tubule),
Inference: Input 1350 ml Output 470 ml Net 880 ml (yellow,
clear) NA 03/23/18 133(L)(135-145), 03/24/18 133(L),
03/26/18 134 (L), K 03/23/18 3.2 (L)(3.5-5.0), 03/24/18 2.9
(L), CL 03/23/18 100(L) (101-111), 03/24/18 98(L), 03/25/18
98(L), 03/26/18 98(L), Mg 03/25/18 1.6 (L) (1.7-2.8)
resulting from excess fluid volume
Nursing Diagnosis (According To Nanda And By Priorities): Need According To Maslow (I.E., Physiological/Oxygen)
1. Excess fluid volume related to increased isotonic fluid retention as evidence by Input 1350 ml Output 470 1.physiological
ml Net 880 ml, NA 03/23/18 133(L)(135-145), 03/24/18 133(L), 03/26/18 134 (L), K 03/23/18 3.2 (L)(3.5-
5.0), 03/24/18 2.9 (L), CL 03/23/18 100(L) (101-111), 03/24/18 98(L), 03/25/18 98(L), 03/26/18 98(L), Mg
03/25/18 1.6 (L) (1.7-2.8),
2. Constipation related to decrease in normal frequency of defecation accompanied by difficult or incomplete 2.phsiological
passage of stool and or passage of excessively hard, dry stool as evidence by last bowel movement 03/21/18 at
1200, and npo except medication
3. Acute pain related to an unpleasant sensory and emotional experience associated with actual or potential 3.physiological
tissue damage, or described in terms of such damage as evidence by Pain level 8 (0-10) on 03/27/18 at 1400,
tolerable is 5, patient complaints of pain in all 4 quadrants of the abdomen, abdomen is tender to touch with
distention

Plan (Outcome Criteria) Interventions (With Rationale) Evaluation

Clients Na, potassium, and chloride lab
values will be within normal range by 1700 on
03/27/18
1) Administered potassium chloride 40 meq SR one tablet by Goals not met
mouth daily
Rational: a white crystal or crystalline powder used as an
electrolyte replenish in the treatment of hypokalemia
2) Assessed cardiac rate and rhythm once every 2 hours
Rational: Hypokalemia and hyperkalemia can result in
electrocardiogram changes that can lead to cardiac arrest,
and ventricular dysrhythmias
3) Assess intake and output and daily weight
Rational: Weight gain is a sensitive and consistent sign of
fluid volume excess
4) Administered parenteral fluids as ordered and monitor their
effects
Rational: Rapid resuscitation with fluids can cause adverse
effects on kidney function and electrolyte balance
5) Teach client/family the signs of low potassium and the risk
factors
Rational: Sings and symptoms of low potassium include
muscle weakness, nausea, vomiting, constipation, and
irregular pulse
Client will have a bowel movement by 1700 on 1) Administered Ondansetron Injection 4mg for nausea Goal not met
03/27/18 Rational: Stop nausea and vomiting to allow other
medication to stay into system and take into effect and
have therapeutic effects
2) Assess usual pattern of defecation and establish the extent
of the constipation problem
Rational: A detailed and accurate assessment of the patient
enables the nurse to plan interventions, monitor outcomes,
and evaluate care, ensuring no unnecessary treatment is
rendered
3) Teach client taking opioids that constipation is a common
side effect.
Rational: many patients on opioids do not understand their
cause of constipation and medication side effect
4) Collaborate with physician about as needed laxative
Rational: The thorough and comprehensive assessment of
patients on opioids experiencing constipation will also
allow a bowel function approach for laxative prescribing
rather than one based on the opioid dose alone
5) Assess by palpating for abdominal distention, percuss for
dullness, and auscultate bowel sounds.
Rational: In clients with constipation the abdomens is often
distended and tender; and stool in the colon produces a dull
percussion sounds
Client pain level will be within or below tolerable range (0-5) 1) Administer a non-opioid analgesic for mild to moderate pain an add an opioid Goals Met
by 1700 on 03/27/18 analgesic if indicated for moderate to severe acute pain
Rational: Non-opioids, such as acetaminophen and nonsteroidal anti-
inflammatory drugs, are first line analgesics for the treatment of mild and some
moderate acute pain, while opioids are included for the treatment of moderate to
severe acute pain
2) Administer stool softener and stimulant to prevent/treat opioid related
constipation and ask about other opioid related side effects including nausea,
pruritus, lack of appetite, and changes in rest and sleep
Rational: In a study of postoperative orthopedic clients, more than half of the
clients experienced one or more opioid related side effects
3) Assess the clients pain flow sheet and medication administration record to
evaluate effectiveness of pain relief, previous 24-hour opioid requirements, and
occurrence of side effects
Rational: systematic tracking of pain is an important factor in improving pain
management and making adjustments to the pain management regiment
4) Teach the client use of nonpharmacological methods to supplement
pharmacological analgesic approaches to help control pain, such as distraction,
imagery, music therapy, simple massage, relaxation and application of heat and
cold
Rational: although more evidence is needed to conclude effectiveness,
nonpharmacological methods can be used to complement pharmacological
treatment of pain
 5) Teach the client to use the self-report pain tool to rate the intensity of past or
current pain. Ask the client to set a comfort function goal by selecting a pain level
on the self-report tool that will allow performance of desired or necessary
activities of recovery with relative ease. If the pain level is consistently above the
comfort function goal, the client should take action that decreases pain or notify a
member of the health care team so that effective pain management interventions
may be implemented promptly
Rational: The use of comfort function goals provides the basis for the direction
and medication of the treatment plan