NURSING CARE PLAN
HEALTH HISTORY:
Admission chief complain and history of present illness:
male patient 58 year old admitted to surgical male ward. before two weeks ago patient complain from slight pain after eating an heavy meals but patient was not give this pain any important. and before four days ago patient said he was not defecate during three days continuously, and patient said when he eat any thing immediately he vomit it and this situation continuo until yesterday when sever crampling pain( not relief by rest or change position )present after dinner associated with sever vomiting. this lead patient to come to hospital (emergency) at 7:30 pm then he was admitted to surgical male ward as case of intestinal obstruction
History of past illnesses:
Before two year patient was do an right inguinal hernia repair
And before 3month ago patient admitted to hospital as case of RTA . no other disease with patient , no HTN or DM.
PHYSICAL EXAMINATION:
General appearance:
Pulse rate: 72 B/M Temperature: 37.3 cº
B.P: 130/80 R.R :17 /M
Pallor, fatigued and extremely ill
patient oriented to time place and persons
Respiratory System:
Respiratory rate: 17 Breath per minute
Respiratory rhythm: regular
No wheezing and no crackles
dry cough .no sputum
patient can’t take deep breathing because he feel pain in surgical area
heart :
no murmurs , normal s1,s2 sounds
nervous system :
patient conscious , patient oriented to time , place , persons . no peripheral sensation loss .
Musculoskeletal system:
no involuntary movement , no activity limitations, No stiffness in neck .
renal system:
normal urination pattern . no pain during urination, no past dropping ,no leg edema .
abdomen :
normal color , no cyanosis , no accumulation fluid in abdomen , no umbilicus herniation , 17 cm surgical incision. no bleeding from surgical site , no discharge from surgical incision , pain around surgical area .
gastrointestinal :
no heart burn , vomiting after eating , no dysphagia , no defecation until this moment from four days ago .
Diagnostic test :
Nursing note Normal range Range Name Num
elevated
4.2-6.4 mmol/L 8mmol/l Glucose 1
normal 4-11*10^3/m 10.8 WBC 5
Normal 4.5-6*10^6m 5.1 RBC 6
Normal 150-450*10M 293 PLT 8
low 135-148meq/l 134 Na 9
low 2-2.6mmol/l 1.5 Ca 10
low 3.5-5.3meq/l 3.2 K 11
79 creatinin 12
pt 13
ptt 14
5.6 urea 15
Medication
Nursing
Con. Side effect Dose Classification Action Name Num
Headache, dizziness 500mg/100ml Antibiotic Bactericidal: inhibits DNA synthesis flagyle 1
Headache, dizziness, lethargy 1gm \ IV Antibiotic
Cephalosporin 3rd inhibits synthesis of bacterial cell wall clofram 2
Maintain airway , monitor vital signs, Nausea, vomiting, dizziness, Respiratory depression, apnea 50mg I.M\q8h Narcotic agonist analgesic agonist at specific opioid receptors in the CNS to produce analgesia pethidine 3
Have protamine sulfate (heparin antidote) on standby in case of overdose. Hemorrhage; bruising; thrombocytopenia 5000iu\q12h Anticoagulant Inhibits thrombus and clot formation heparin 4
Diagnostic procedure : CBC , abdomen x-ray .
Nursing Assessment :
Subjective data:
Patient said : he feel pain in surgical area not relief by change position increase by coughing, walking and setting (pain scale7 from 10 ).
Patient said : he doesn’t know about this disease that happened with him and he doesn’t know about the diet.
Patient said : he doesn’t know how to care surgical site
Patient said : he afraid from death and hospitalization
Patient said : he doesn’t drink because he afraid from vomiting
Patient said :his weight is decreased about 2 kg in last month
Objective data:
Pulse rate: 72 B/M Temperature: 37.3ºc
Pallor, fatigued and extremely ill
Respiratory rate:17 Breath per minute
Respiratory rhythm: regular breathing, conscious, Low level of knowledge about disease.
Patient oriented to time, persons, and place.
Patient now restricted from food just fluids and soup. Surgical incision is about 15 cm, no bleeding and incision is clean.
glucose elevated , k, ca, na are low
Patient takes medication (illustrated in the table above) .
Nursing Diagnoses:
Nursing Diagnoses 1:
Pain related to intestinal obstruction, distention, and surgical incision as manifested by patient verbalization
Planning :
Goal : Relieving Pain Postoperatively
Ex. outcome : patient well able to verbalize has less pain (decreased from 7 to 4 on pain scale) at the end of my shift.
Nursing Interventions :
change patient position to let flatus get out to decrease intraluminal pressure
Have the patient splint the incision site with hand or pillow when coughing to lessen pain and protect site from increased intraabdominal pressure. Splinting and proper positing reduce the stress on the incision area.
Provide therapeutic environment—proper temperature and humidity, ventilation, visitors to decrease the tension on patient .
Put patient in comfort position to decrease pressure on surgical incision
Explaining pain relief methods, such as Breathing exercises, heat application, and progressive relaxation because Breathing exercises and relaxation techniques decrease oxygen consumption, respiratory rate, heart rate, and muscle tension, which interrupt the cycle of pain–anxiety–muscle tension
Administer analgesics, as doctor ordered .
Evaluation :
· Goal met . patient verbalize has less pain (decreased from 7 to 4 on pain scale)
Nursing Diagnoses 2 :
Altered Nutrition, Less Than Body Requirements, related to nausea, vomiting as manifested by patient.
Planning :
Goal : promote nutritional status
Ex. outcome : patient will be able to maintain good nutrition balance at the end of my shift .
Nursing Interventions :
· Administer IV fluids, TPN if ordered to promote hydration and nutrition.
· Begin liquids when patient is no longer NPO. Advance diet as tolerated. Diet should be high caloric, high protein. Frequent, small feedings may be indicated.
· Monitor intake and output and weight daily to determine caloric status.
· provide small, frequent feedings to prevent distention of intestine.
Evaluation :
Goal not met . patient doesn’t maintain good nutrition balance because he afraid from vomiting and one shift aren’t enough to maintain patient nutrition status
Nursing Diagnoses 3 :
Impaired Skin Integrity related to invasive procedure as manifested by surgical incision .
Planning :
Goal : improving Skin Integrity
Ex. outcome : patient will be free from impairment skin integrity
Nursing Interventions :
· Perform hand washing before and after contact with patient to prevent contamination .
· Inspect dressings routinely and change it if necessary
· Record amount and type of wound drainage
· Turn the patient frequently and maintain good body alignment.
· Keep suture line clean, never vigorously rub near suture line .
· Avoid hot water and harsh soaps. Patients should bathe in lukewarm water using mild soap (Dove); avoid bubble bath; rinse well and pat skin dry with towel.
Evaluation :
Goal not met because wound healing need more than one shift care to maintain skin integrity
Nursing Diagnoses 4 :
Knowledge deficit about disease and about wound care
Planning :
Goal : Educating the Patient
Ex. outcome : patient will be have good knowledge about disease and about wound care at the end of my shift .
Nursing Interventions :
Encourage questions to answer about illness .
Describe illness and relate symptom of hernia .
Answer questions honestly and completely at appropriate level .
Teach patient how to care wound and how to promote healing .
Explain all procedure and treatment and the rational for them .
Teach patient about wound care and abut early sings of infection .
Evaluation :
Goal met . Patient have good knowledge about disease and about wound care
Nursing Diagnoses 5 :
Risk for Fluid volume deficit related to impaired fluid intake, vomiting, as manifested by patient verbalization.
Planning :
Goal : Maintaining Electrolyte and Fluid Balance
Ex. outcome : patient will be free from signs of dehydration or electrolyte imbalance during my shift.
Nursing Interventions :
Measure and record all intake and output to maintain fluid balance
Administer IV fluids as doctor order to prevent dehydration
Monitor electrolytes, urinalysis, hemoglobin, and blood cell counts and report any abnormalities to identify any abnormalities in early stages and treat it .
Monitor vital signs; a drop in blood pressure may indicate decreased circulatory volume due to blood loss from surgical procedure .
Evaluation :
Goal met . patient now free from signs of dehydration or electrolyte imbalance.
Nursing Diagnoses 6 :
Risk for Infection related to surgical incision
Planning :
Goal : Prevent Infection
Ex. outcome : patient will be free from sign and symptom of infection during my shift
Nursing Interventions :
Check dressing for drainage and incision for redness and swelling.
Instruct patient to avoid touching incision to minimize wound contamination and injury.
Assess and accurately document condition of incision site each shift.
Keep suture line clean (may shower unless contraindicated by health care provider; avoid tub bathing until wound heals); never vigorously rub near suture line, pat dry.
Monitor for other signs/symptoms of infection: fever, chills, malaise, diaphoresis.
Administer antibiotics as order
Evaluation :
Goal met : patient now free from sign and symptom of infection .
comments recommendation :
Good wound care faster wound healing
Take medication as doctor order on time
when appear any abnormal signs must be go to doctor not treat in home without doctor order .
Encourage regular health maintenance visits to clinic.
موضوع: nursing care plan / intestinal obstruction 
17/11/2009, 02:33
