Lakeview College of Nursing
Clinical Preparation Assignment
N210 
Student Name: Katey Goodpaster Date: October 9, 2011 Adm. Diagnosis: Small Bowel Obstruction (SBO) Allergies: Heparin (Bovine)
                                                                                                                                                                                                                                        (5 pts)

Patient Initials: EE Age: 97  Date of Admission: 10/4/2011

Gender:   M     F    Ethnicity: Caucasian

Occupation: Retired – used to work for a furniture company

Education: Junior year of high school

Where do I live?  House     Farm     Apt.    Asst. Living    (circle one)
                             
             Nursing Home   Other_______________________

I live alone

Do I have any other family?  Children and Grandchildren (Most live in St. Louis, but one daughter lives in the same neighborhood)

Adm. Date: 10/4/2011 Adm. History: (What brought me to hospital?)			
 Daughter brought the patient to the hospital after complaining about sharp abdominal pain with the addition of severe nausea, vomiting and gall stones.

I have had these procedures while I have been here: 

PICC line replacement, Went in for surgery on 9/9

I need help with:   Hygiene      Moving        Eating       Dressing

I need help:         Not at All        Some           Lots             Totally

I have a     DNR       POA       Living Will       None

Activity Level:

The patient is able to get up with little assistance. Once up, patient can walk around on own with walker. Outside of hospital, pt. can still drive and has an activity level high enough to live at home on own.

Medical History: Hypercholesterolemia, CAD, Arthritis, Osteoporosis, Vertigo, CKD, Peripheral vascular disease, Pacemaker, Aortic valve replacement, Macular degeneration (left eye), Hypertension

Surgical History: CABG, Aortic valve replacement, Cardiac defibrillator placement, Appendectomy, Cataract removal, Blepharoplasty

What equipment am I using?  (Circle all that apply)

Incentive Spirometer     Foley    NG     IV 

  Cast   Splint    Drain     Telemetry     Oxygen

 Chest Tube    Trach      Ostomy       Dressing

TED/SCS      Walker/Crutches      Wheelchair

Other Triple Lumen and Nasogastric tube    

         I am rating my pain as a    
       ____3____/10     I describe it as:
-Slight abdominal pressure 
-Occasional sharp leg cramps

All data is collected and is recorded using the appropriate terminology.  All sections are complete. 
Any data that is not collected is adequately explained in the blank spaces ie NA or unavailable. 

LAB DATA (List all pertinent/current lab/diagnostic values and highlight which one(s) are abnormal)      			  (1pts)                                                                               
TEST	NORMS	BEFORE	NOW	TEST	NORMS 	BEFORE	NO W	TEST	NORMS	BEFORE	NOW	

WBC	
4-11		
10.01	
RBC	
3.5-5.2		
3.76	
K	
3.6-5.0	
1.9	
3.7	
DIFF: 
Monocytes
Lymphocytes
Neutrophils
Eosiniphils
Basophils			
8.2
26.0
62.1
2.9
0.8	

HGB

 HCT	

12-18

37-51		

12.1

37.6	

NA	

135-145		

149	
PT			
NA	
PLT			
173	
CL	
101-111		
115	
INR			
NA	
APTT			
NA	
CA	
8.5-10.5		
8.6	

GLUCOSE	
90-120		
150	
A1-C			
NA	
CO2	
21-31		
27.7	

CHOLESTROL	
<200		
271	
BUN	
6-20		
27	
MG	
		
NA	

TRIGLYCERIDE	
54-162		
203	
CREATININE	
		
0.75	
TSH			
NA	

HDL/LDL
			
58	
BNP				OTHER				
OTHER
				OTHER				OTHER				
DIAGNOSTICS:  Test & Results                                                                                                                                                                     
   Chest X-Ray: 8/6 – Post PICC line replacement                                      Other:                                                                         Other:
     
     EKG:                                                                Other:                                                                         Other:

PATHOPHYSIOLOGY:  4 parts, answer all 4 questions in a thorough manner using own words and appropriate medical terminology, use additional paper if necessary.

1. Identify the primary disease(s) that will be explained in this paper.     (1pt)
Small Bowel Obstruction (SBO)

2. Describe the pathology of this disease; include any causative factors/etiologies that can be identified.     (5 pts)
	With small bowel obstruction, there is a barrier in the way that obstructs the intestines’ contents to pass through. When this occurs, discharge becomes backed up within the intestines, which causes abdominal pain, nausea vomiting, etc. Some causes of small bowel obstructions are postoperative adhesions, hernias, Crohn disease, appendectomy, upper gastrointestinal surgeries, etc. Low levels of potassium and gallstones may cause SBOs, as well. Some symptoms and symptoms that are associated with SBO are severe nausea and vomiting, abdominal pain, constipation, etc. 

3. Relate the abnormal labs and diagnostics to the disease process.  If all tests are WNL then indicate which values 
    are important to monitor and explain why.       (3 pts)
	The patient’s previous low potassium level is the first indication of the SBO. These levels are the most vital to monitor to ensure that there are not further bowel obstructions occurring. Because of the previous medical history of the patient, it is also important to monitor cholesterol, triglycerides, and glucose levels so that further blockages do not occur. Increased BUN levels show that there is kidney impairment, which could be a result of this patient previously having Chronic Kidney Disease (CKD). Therefore, the nurse should be precautious with Acetaminophen meds. Slightly elevated Na and Cl levels are most likely due to the D5 medication being given.

4. Relate the medications to the disease process or patient situation; include any precautions to be aware of when administering.        (3 pts)
	The Potassium replacement medications are vital to ensure that K+ levels do not reach low levels and cause SBOs. Because of the nausea that coincides with SBO, anti-vertigo medications were ordered. It is important that the nurse uses precautions with falling due to dizziness, and dehydration and constipation.

MEDICATIONS:                                                                                                                                                                               (6 pts)                  
List all medications ordered for your patient. Complete first four columns prior to clinical; last column MUST be completed at end of clinical session.
Include PRN meds only if they are administered during clinical time. 
Name, prescribed dose and frequency; plus usual dose and frequency of administration. 	Classification & mechanism of action. [Use your drug reference]	Why is medication ordered for THIS patient?	 Nursing Precautions/ Considerations needed to safely administer this medication. 	 Evaluate medication effectiveness for THIS patient (patient response).	

1.0.45%  NaCl with KCl mEg 1000 mL IV daily

2.D5 0.45% NaCl with KCl 20 mEg IV daily

3.Diphenhydramine (Benedryl) 12.5 mg IV
Daily PRN

4.Ipratropium Bromide 0.03% (Atrovent) nasal spray daily PRN

5.Labetalol (Normodyne trandate) 20 mg IV daily

6. Metoclopramide (Reglan) 10 mg IV daily PRN

7.Metoprolol (Lopressor) 2.5 mg IV daily

8. Morphine 2.0 mg IV daily PRN

9. Ondansetron (Zofran) 4.0 mg/2.0 mL IV daily PRN

1.Potassium replacement

2.Potassium replacement

3.Antihistamines 

4.Nose preparation

5. Alpha/Beta adrenergic blocking agents

6.Intestinal motility stimulants

7. Beta adrenergic blocking agents

8. Analgesic, narcotic

9. Anti-vertigo	

1.Low Potassium levels (Causing SBOs)

2.Low Potassium levels (Causing SBOs)

3.Nausea

4.Nasal discharge

5. Hypertension

6.Nausea, vomiting control

7. Hypertension

8. Pain

9. Nausea/ vomiting	

1.Increase blood pressure

2. Increase blood pressure

3.Dizziness, Anaphylaxis

4.Bronchitis

5.Nasal congestion

6.Fatigue

7. Bradyarrhythmia

8. Nausea

9. Constipation	

1.Effective, K+ levels  increased (went from 1.9 to 3.7)

2.Effective, K+ levels  increased (went from 1.9 to 3.7)

3.Effective, decrease or no post nasal drip

4.Effective, decrease or no post nasal drip

5.Effective, Blood pressure decreased (went from 168//90 to 156/69)

6. Effective, no vomiting and little nausea

7.Effective, Blood pressure decreased (went from 168//90 to 156/69)

8. Effective, went from severe pain (10) to slight, occasional pain (3).

9.Effective, no vomiting, little nausea. Previously severely vomiting.	

Priority Nursing Diagnosis: Imbalanced nutrition related to large amounts of output with evidence by foley and NG discharged amounts.				 (Use NANDA format)	
														
What does the patient/client need to accomplish?
GOALS/OUTCOMES

Measurable patient centered goals 
are identified realistic and contain 
time element.  	What can the nurse do to help resolve the problem?
IMPLEMENTATION
Nursing Interventions

Specific nursing actions can easily be linked to the outcomes.  The interventions are realistic and appropriate to the patient's current status.	Why will the nurse do these actions?

SCIENTIFIC RATIONALE
Be sure to include source using APA format

Rationales for each intervention contain comprehensive scientific reasoning that succinctly identifies why the intervention was selected.  Citation is provided.	How did the patient/family respond to the nurse’s actions? 
EVALUATION
Client Response 

Includes all the following: 1.Client’s response to the intervention(s),
 2. Status of goals and outcomes, (ie goal met, in progress or revised) 3. Modifications to the plan of care.	

By the end of week, this patient’s blood pressure will no greatly increase due to stress because it could cause further problems.

	

Nurse will teach stress relief and coping strategies to the patient so that the blood pressure does not increase with stressful situations.	

The nurse will do these actions to avoid tachycardia and to ensure regulation of hypertension.	

Goal is still in progress. If by end of week, goal is not met, then nurse will reevaluate stress relief strategies to ensure stable blood pressure to avoid further implications.	
	                             (2pts)                                                                    (2 pts)                                                                                (2 pts)                                                                                    (2 pts)

PHYSICAL ASSESSMENT DATA (collect own data on clinical day)     (Use Taylor Chapter 25 & N201 materials as resources)              (5 pts)
All subjective & objective data is collected and recorded using appropriate terminology. Data not collected or requiring elaboration is explained in the blank spaces.  
Pulse Ox %:
97	BP:
156/69	Pulse:
Rate: 81
Rhythm: +2	Respirations:
Rate: 20
Rhythm: non-labored (RRR)	Temp:
98.2
Route: Oral	Pain:
Rating:      3   /10    Characteristics:          	Ht: 1.524 (5’0”)
Wt: 70.308 kg (155lb)	
NEUROLOGICAL: 
 MAE:   Y        N           PERLA:    Y         N
Strength Equal:   Y      N   if no -   Legs   Arms    Both 
Orientation, Mental Status, Speech, Sensory, LOC, 	
Alert and conscious x 3 

	
MUSCULOSKELETAL: 
Neurovascular status, ROM, Supportive devices/strength

ADL Assistance    Y   N       Fall Risk:    Y   N
Fall Score_____2_________
Activity/Mobility Status:    Independent (up ad lib)     
            Needs assistance with equipment   
            Needs support to stand and walk	

Can walk up and down halls with walker
Grip strengths are equal on hands
Needs one assist for getting up
Equal lateral sensations	
CARDIOVASCULAR: 
Heart sounds:  S1, S2, S3, S4, murmur etc.
Peripheral Pulses, Capillary refill: ___2 sec.______
Neck Vein Distention:   Y   N      Edema  Y    N
Location of Edema____abdomen________________	 
Presence of S1 and S2, no gallops, murmurs or rubs (no S3 or S4)	
RESPIRATORY:
Accessory muscle use:    Y     N
Breath Sounds: Location, character	
Breath sounds were non labored (regular rate and rhythm)

GASTROINTESTINAL:
Diet at home : No specific diet              Current Diet:   NPO

Auscultation: Bowel sounds, other sounds
Last BM, character &  freq of stools 
Palpation: Pain, Mass etc
Inspection: distention, incisions, scars, drains, wounds
Ostomy:    Y       N         Nasogastric:    Y      N  
Feeding tubes/PEG tube   Y      N      Type:___________	

Pain when palpate abdomen
Ice chips until discontinued
NPO (strict)
No bowel movements
Bowel sounds diminished in lower quadrants of abdomen
No food since Tuesday
IV site right brachial 
	
INTEGUMENTARY: 
Skin color, character, turgor, rashes, bruises, wounds: character, drainage, approximation etc.
Braden scale: ____3_____
Drains present:  Y         N       Type_______________	
Skin color and pigmentation relative to ethnic background
Bruising at left brachial	
EENT: 
Ears: no hearing aids                     Eyes: no glasses/contacts
Nose: slight discharge        Teeth: no dentures, all real teeth            
                             	
Nose has discharge due to seasonal allergies
Previously received blepharoplasty and cataract removal (L eye)	
GENITOURINARY: 
Color, character, quantity of urine, pain, 
Dialysis   Y      N 
Inspection of genitals
Catheter:  Y    N      Type: urinary	
Urine is clear and yellow
Low output levels

PSYCHOSOCIAL/CULTURAL:
Educational level

Developmental level       

Coping methods          

Health Beliefs
Occupation (previous if retired)

Religion & what it means to pt.

Personal/Family Data    (Think about home environment, family structure, and available family support)	
Finished Junior year in high school
Children and Grandchildren in Champaign and St. Louis (lived only about 3 min. away from 1 daughter and family – very close with them)
Entire family is very supportive
Widower (lives alone)
Used to work at a furniture store
Still drives and very active
No sign of depression, seemed very friendly and content
Has living will

Journal

     1. Schedule
0630 arrive and review patient’s data
0700 get report
0715 introduction and interview
0745 Clean teeth, face and hands 
0830 return to continue interview
0900 take vital signs
0920 start with morning hygiene 
1000 Sit patient in chair with TED and change linens while finishing interview
1035 Leave patient for nap
1115 Ask any additional questions and say goodbyes
2. My schedule was far off track because the patient got scheduled for a 0900 surgery earlier that morning. Therefore, I did not get as much time as expected with my patient. As soon as I received report, I did my introduction, took vitals and started on her bed bath and hygiene, while performing the interview process. 
3. Today, I learned how to start a morphine medication, which was interesting to watch.
4. Since I did not spend as much time as expected with my patient, I did not perform many of the tasks taught in lab or lecture. On another SN’s patient, I saw her try to put in an IV, which coincided with what we have been working on in lab.
5. If today was repeated, I would spend more time with my patient, which was not possible. I followed my nurse around some of the time, and the things I learned were very helpful, so I would have liked to shadow him more closely.
6. Today I saw caring demonstrated by my patient. Right before she left for surgery, she gave me her flowers to put by the nurses’ station because she expressed she had a great experience on the floor and everyone treated her with a great deal of respect. Also, I saw caring being performed by another student nurse while trying to put an IV in. The SN talked the patient through the administration of the IV so that the patient did not get nervous.
7. I saw respect being demonstrated by my nurse. Every learning process that was available, he would come and make it a point to teach me important tasks. He constantly reminded me about how he used to be in the same place, and wanted us to have a great learning experience.

Reference

Lippincott, Williams, Wilkins (2008). Nutrition diagnosis. Handbook of Nursing Diagnosis. Woltens 			        Kluwer health.