ABSN Clinical Assignment
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ABSN Clinical Assignment Worksheet
Please use this sheet to gather your patient information as you provide your patient care. This information will assist you in completing your care plan. Be sure to report ALL ABNORMAL FINDINGS TO THE INSTRUCTOR OR TO THE PRIMARY NURSE AT THE TIME OF FINDING.
I. Patient Information
Patient Initials Mr.B. Gender M Age 75 Date of Admission 6.28.19 Room# 3
DNR Status Full Code Allergies NKA Isolation/Precautions Standard Precaution
Safety concerns Fall risk, risk of infection, Risk of oxygen toxicity
SBAR (morning report from nurse)
S: 75 y/o male with complaints of shortness of breath and pain at incision site
B: POD- 3 days since surgery S/P: open cholecystectomy and Hx of Emphysema
A: T:100.3 F, HR:112, RR:32, BP 142/84, o2 SAT:88%. From the report it is evident that the patient is experience symptoms of Cholecystitis. There could be a great possibility that the patient has infection in the gall bladder. This can be checked in the event that the bile is building up causing cholecystitis, or it is building up within the gall bladder showing signs that it could be infected. In the event that this continues, it is important to check if the gall bladder tissues are still functioning or if they are dead. This usually happens the when the cholecystitis goes untreated for long which can lead to the death of the gall bladder. It is one of the most common type of complications that the patient will undergo, especially given his age, or if he took time to be treated, or if he has other condition like diabetes. The physician will also check whether there is a tear in the patient’s gall bladder, or if it could lead to the burst of the gall bladder. It is also important to check whether there is a perforation in the patient’s gall bladder which could be as a result of the swelling of the gall bladder, death of a tissue or an open infection.
- Torn gallbladder. A tear (perforation) in your gallbladder may result from gallbladder swelling, infection or death of tissue.
R: Continue usage of Salmeterol inhaler, Deep breathing exercise and coughing, using incentive spirometer, encourage turning, and continue pain management
Chief Complaint Pain at incision site, 7/10 on pain scale and shortness of breath attributed to open Cholecystectomy surgery. The shortness of Breath will often occur after incision due to the fact that anaesthesia is going to hamper the way that the patient normally breathes, it will also delay the patient’s urge to cough. Also after the abdominal or chest surgery, it could also hurt the patient when he tries to breathe heavily or is pushing out air, this could also be due to the fact that mucus would keep on building in the patient’s lungs. In any case the patient is going to experience collapse of the lung, or it may not inflate. This would lead to rapid breathing, shortness of breath, heart rate, and which can be realized from blue lips and skin. In this case, it is important for the nurse to use an incentive spirometer to ensure that the breathing is measured through practice of deep breaths and taking it slow as will be reviewed in interventions.
History of Present Illness (What happened to bring the patient to hospital? Pain at incision site and shortness of breath
Admitting Diagnosis Cholecystitis
Signs and Symptoms (what were the signs & symptoms on admission Pain at right upper quadrant / cholecystitis, dyspnoeic respiratory efforts with mild retractions in substernal region, Temperature is 100.3. Scattered coarse rhonchi throughout lung fields and diminished breath sounds in the left lower lung
Interventions or treatments drug and oxygen therapy: O2 at 2LPM via nasal canal every 12 hours via nasal canula, Salmeterol inhaler q12 at home and during hospital (surgeon reordered) , morphine via peripheral IV, turn and perform coughing and deep breathing exercise q2h and use incentive spirometer q1h and monitoring complications of cholecystitis
Surgical procedures performed during this hospitalization Cholecystectomy-Right Upper Quadrant
Past Medical History. Emphysema
Past Surgical History: Appendectomy at 18 y/o
II. Medications
Medications (Use the 1st column only if/when you are administering medications today)
|
Self-Critique Administration Technique |
Medication Name |
Dose |
Frequency |
Action/ Classification |
Indication (why is the patient taking this medication? |
Side effects/nursing interventions/ Considerations |
Patient/Family Education |
|
N/A |
Salmeterol |
50mcg |
Q12h |
Beta2 Adrenergic receptors against bronchospasms |
prevention of bronchospasm |
Mucus producing, cough, difficulty breathing, tightness in chest, vomiting Assess lungs sounds and note any signs of wheezing or rashes. Nurse should compare lab reports to check for increase in serum glucose concentration or decrease in potassium concentrations |
Instruct patient to follow the instructions on how to use salmeterol as ordered. Patient should be educated to take medication as directed. Missed doses should be taken as soon as possible and resume regular schedule. Doses should not be doubled up upon. Patient should notify Health care provider immediately if difficulty in breathing persists after using Salmeterol |
|
Comfortable |
Morphine |
5mg |
q3h prn IV |
Opioid Analgesics Binds to opiate receptors in the CNS |
For RUQ pain due to incision/impaired tissue integrity |
Nausea, dizziness, vomiting, confusion constipation, frequent respiratory complications due to age-75 y/o- elderly tend to be more sensitive to opioid analgesics Assess bowel function routinely and level of consciousness, BP, pulse, and respirations before and intermittently during administering of medication. |
Advised patient of the severity of medication which can lead to overdosed if failure to follow the prescribed dosage. Patient should understand when and how to ask for the medication. Advised patient that no alcohol consumption or CNS depressant should not be taken while using this medication. Avoid driving or engaging in any high alert activities until responsive to medication. Patient should seek assistance if the need arises to ambulate or smoke. |
|
Comfortable |
Oxygen |
2 LPM Via NC |
continuous |
Supplemental oxygen |
Aid in breathing disorders |
Side effects include Headaches, tiredness, dry or bloody nose, skin irritations, oxygen toxicity . Ensure oxygen safety-checking breakers no malfunction hospital equipment that can spark fire. Inform Patient’s family and visitors of importance of oxygen safety precautions and hang signs above oxygen device and Pt’s door to indicate oxygen in use. To detect tissue integrity it will be important to do lab inspection for anormaly in the biliary tract or adjacent poor perfusion, which if not done can amplify ischemia or bladder necrosis. |
Instruct patient that any adjustments to oxygen should be ordered from health care providers to ensure correct flow rate, and duration of oxygen therapy is used No smoking while oxygen in use or use neat heat soured. Patient should ensure there is adequate oxygen in inhaler/tank. |
|
N/A |
D5 ½ NS |
75ml/hr |
continuous |
Hypertonic Solution |
Provides free water for the kidneys, facilitating renal excretion of solutes Commonly use in early postoperative period, treat volume deficit |
Monitor for any changes in baselines-(lab)electrolytes imbalance before and after infusion. Potential side effects poor skin turgor, tachycardia, weak pulse, and hypotension Nurse has to assess respiration rate, breath sounds and heart rate signs and observe for extra heart sounds such as S3 . Nurse should observe for any bounding pulse, pulmonary crackles, dyspnea, shortness of breath |
Explain to patient that Dextrose in Normal Saline is Useful for daily maintenance of body fluids and nutrition, and for rehydration Advised Patient to inform inability to urinate and dehydration |
Source for medications:Vallerand, A. H., Sanoski, C. A., & Quiring, C. (2019). Davis’s Drug Guide for Nurses. 16th Ed. Philadelphia, PA: F.A. Davis Company.
III. IV Lines
|
IV Line: Peripheral, PICC, Central |
Insertion Site location and description |
Type of solution or Normal Saline Lock |
Care provided: flush, dressing change, etc. |
|
Peripheral |
Right forearm |
Hypertonic- D5 1/2NS |
N/A |
IV. Labs/Diagnostics tests
- Labs
|
Test |
Result (indicate only abnormal findings) |
Normal Range |
What is the connection? How does this lab test relate to the PT’s diagnosis or treatment? |
|
WBC (CBC) |
3000 |
4,500-10,000 cells /mcL |
Potential infection from surgical incision |
|
Albumin |
2.0 g/dl |
3.4 to 5.4 g/dL |
Could indicate inflammation/infection to incision site |
- Diagnostic tests (x-ray, etc.)
|
Test |
Result |
What is the connection? How does this test relate to the pt.’s diagnosis or treatment? |
|
CT Scan |
Detection of abscess |
Breakdown of skin due to surgical incision |
|
Ultra Sound |
Indication of Skin impairment |
Pain at incision site and T 100.3. Indicates fever to fight off infection. |
V. Assessments (Today’s assessment)
a. Level of consciousness- Alert and oriented x3
b. Pain Assessment:
History of Pain?__Yes Location_RUQ Baseline Score_7/10
Pain Medication/s Morphine 5mg via IV q3h PRN Time last dose of pain med given at: 7am
c. Vital Signs: HR 112 BP 142/84 T 100.3 SaO2 88% 2LPM via NC RR 32 Pain 7/10
Pain Reassessment 2
d. Tissue perfusion (capillary refill, edema, peripheral pulses, etc.)
e. Oxygenation: Room air Oxygen via 2 LPM Face Mask Nasal Cannula. and/or Breathing treatment/s. Salmeterol Inhaler
Breath sounds Coarse, Rhonchi, diminished breath sounds at left lower lung
f. Treatments:
g. Glucometer: Time. N/A Result N/A Action/s N/A
h. Nutrition: Prescribed diet: CLD Appetite Fair Dysphagia: N/A
Abdominal assessment Normal active normal sounds, Incision RUQ-colored and warm, slight redness
Height: 5” 11” Weight: 165lbs BMI: 23
i. Intake and Output: Sips of Ginger ale for past 4 hours, vomited small amounts of clear liquids twice
j. Activity: Muscle strength 2 Bed rest NO OOB to Chair YES Ambulatory ad lib YES
Turn and reposition YES Ambulatory with assistance YES
k. Skin care: Assessment Warm to touch, swollen, tender, red in color, pus, dressing on RUQ
l. Wound care (include location, size, description and treatment of wound) (what does it look like today?)
|
RUQ |
7 inches long |
Discolored, pus, swollen |
Warm to touch, red, tender |
m/ Drainage tubes (what is today’s assessment?)
|
Type of tube |
Drainage description |
Amount of drainage |
Care required |
|
N/A |
N/A |
N/A |
N/A |
n. Physical Assessment (use the systems review assessment to make sure you have information about each system and assessment component at the beginning of your day and when you’re ready to give report)
|
System |
Findings |
|
Neurological: Orientation PERRLA Awareness Speech Sensory Perception Strength Gait |
Alert and Oriented x3 WNL WNL WNL WNL WNL +2 WNL |
|
Respiratory: Respiratory rate/rhythm/effort Chest symmetry Breath sounds Cough/sputum? Pulse Ox Supplemental Oxygen |
32 Breaths per minute SOB, dyspneic respiratory efforts, shallow Mild retraction in substernal region Course rhonchi and diminished breath sounds Yes, no sputum 88% SpO2 2LPM via NC |
|
Cardiovascular: Apical pulse Radial pulse Heart sounds (S1/S2) Pedal pulses Capillary refill time Temperature/color of extremities Edema (location/scale +) |
Increase in Temperature 112 112 WNL 112 Less than 3 secs Warm to touch None present |
|
Abdominal: Inspection Auscultation of Bowel sounds Palpation Prescribed diet Appetite Bowel pattern Bladder Urinary elimination Any Pain (?) |
Impairment at surgical incision site Incision RUQ, disintegrated dressing Normoactive WNL CLD Fair 1-2 twice daily, diarrhea, 5 loose stools Nondistended 2-3 time , 1/O-measured urine output RUQ, 7/10 |
|
Skin: Color Temperature Moisture Turgor Abnormalities (ie, ecchymosis, petechiae) Cyanosis Pressure injury (stage/location) Lesions/rashes/wounds (describe) |
Disintegrated Red/Yellow 100.3 Yes Normal Cellulitis None None None Incision of RUQ abdomen, Skin breakdown |
|
Musculoskeletal: Range of motion Gait Assistive devices Activity Transfer ability Strength of extremities |
Some impediment WNL 1.0 None Some dependence required Some dependence required 2 |
|
IV Therapy: Location/type Site assessment |
Peripheral IV D5 1/2NS at 75ml/hr Right forearm Intact |
|
Psychosocial: Mood Affect Support systems Spirituality Cultural preferences Developmental stage |
Presence of anxiety Anxious Cooperative Wife Christianity Italian Ego Integrity vs. Despair |
Phillips School of Nursing at Mount Sinai Beth Israel
New York, New York
Category of human function: Fluid Gas Transport
Nursing Diagnosis: Ineffective airway clearance r/t retained secretions
Goals: At the end of the 6th shift, the patient will demonstrate mobilization of pulmonary secretions as evidence by RR:25 and O2 SAT:90% at 2 LPM via N
INTERVENTIONS |
RATIONALES |
EVALUATION |
For 8.9 and 10- What’s the rationale for these interventions? |
|
Current V/S: T:99.8 RR:24 92bpm O2 SAT:90% at 2LPM via NC BP 126/82 Pain 4/10 at rest, 6/10 w/movement Patient exhibit decreased work of breathing using accessory muscles Breath sounds were normal At the end of the shift, the goal was met in Mr.B.. ability to demonstrate mobilization of secretions as evidence by RR decreased from 32 to 24 breaths per minute via 2LPM NC and O2 SAT increased from 88% to 90%. Also, Mr. B was able to perform coughing exercise and eliminate some secretions. |
Source: Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2015). 9TH Ed.Medical-surgical nursing:
Assessment and management of clinical problems. St. Louis, MO: Elsevier/Mosby.
Potter, P. A., A., S. P., Perry, A. G., Ostendorf, W., & Hall, A. (2017). Fundamentals of nursing. St. Louis: Elsevier.
Category of human function: Sensory- Perceptual and Comfort, Rest, Activity, and Mobility
Nursing Diagnosis: Impaired tissue integrity as evidence by Information needed here?? What should I put here?
Goals: A the end of 6th shift surgical incision site will show recovery of the skin tissue by reduction in swelling and pain as evidence by pain 7/10 to 4/10 as a result of administering morphine 5mg IV q3h PRN
INTERVENTIONS |
RATIONALES |
EVALUATION |
Interventions have to correlate with Are the interventions listed above appropriate to the Nursing diagnosis #4 and goal to be met?
|
|
Current V/S: RR:24 92bpm O2 SAT:90% at 2LPM via NC BP 126/82 Pain 4/10 at rest, 6/10 w/movement Patient was able to tolerate dressing changes more signalling less sensitivity to incision site. No development of abscess, drainage or tear. Goal met, less wound dressings due to improvements of skin alteration. Swelling and redness decreased. Date recorded on the development of the patient and rate of reduced swelling and redness reduction. Check for vital signs if they are at recommended rate |
Source: Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. (2015). 9TH Ed.Medical-surgical nursing:
Assessment and management of clinical problems. St. Louis, MO: Elsevier/Mosby.
Potter, P. A., A., S. P., Perry, A. G., Ostendorf, W., & Hall, A. (2017). Fundamentals of nursing. St. Louis: Elsevier.
Textbook Picture for Nursing Care Plan
Patient’s Initials: Mr. B Student: Ria Ajibade
Health Problem: Cholecystitis Date: 7.1.19
|
Textbook picture of Health Problem |
Comparison of Patient and textbook picture |
|
Etiology, Risk Factors No bilirubin reaching small intestine to be converted to urobilinogen. No bile salts in duodenum, preventing fat emulsion and digestion. The bile in the gallbladder also becomes supersaturated with cholesterol. Lack of or decreased absorption of Vitamin K, resulting in decreased Production of prothrombin Some risk factors increases with age in both men and women. Although women are prone to get gallstone. Risk also higher in Native American or Hispanic descent. |
Patient is 75 years old Patient is a Male History of Emphysema History or abdominal surgery- appendectomy Patient is Italian |
|
Signs & Symptoms Severe pain, fever, and jaundice. nausea Vomiting. restlessness, diaphoresis Manifestations of inflammation include leukocytosis and fever. Physical findings include right upper quadrant tenderness and abdominal rigidity. |
Pain at RUQ Mild fever Restlessness |
|
Possible Complications Complications of cholelithiasis and cholecystitis include gangrenous cholecystitis, subphrenic abscess, pancreatitis, cholangitis (inflammation of biliary ducts), biliarycirrhosis, fistulas, and rupture of the gallbladder, which can produce bile peritonitis. In older patients and those with diabetes,gangrenous cholecystitis and bile peritonitis are the most common complications of cholecystitis. |
Post op at incision site at RUQ- 7/10 Complain of feeling extremely hot and tired Mild fever- temperature: 100.3F Abnormal respirations and ineffective breathing due to Secretions: 32 breaths per minute At risk for infection and abscess due to skin impairment Increased BP 142/84 Low sp02: 88% |
|
Usual Diagnostic Tests History and physical examination Ultrasound Endoscopic retrograde cholangiopancreatography (ERCP) Percutaneous transhepatic cholangiography Liver function studies White blood cell |
CBC CT scan Ultra Sound |
|
Medical-Surgical Treatment Laparoscopic cholecystectomy Incisional (open) cholecystectomy IV fluids Opioid medication |
Open cholecystectomy IV fluids Opioid medication |
|
Erikson's Theory: Theoretical developmental stage and the task for the stage Check for patient vital sign -This is wrong the correct answer is Ego Integrity Vs. Despair |
Patient's actual developmental stage and tasks engaged in. Ego Integrity since the patient is very diverse, well oriented, and able to converse well. He can give a brief detailed explanation about his health and personal life. The patient has a great family support system wife, children and grandchildren visit him regularly |
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