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ABSN Clinical Assignment

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)


Administration Technique

Medication Name





Indication (why is the patient taking this medication?

Side effects/nursing interventions/


Patient/Family Education





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




q3h prn


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.                




Via NC


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.            


D5 ½ NS



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. 


Right forearm

Hypertonic- D5 1/2NS


IV. Labs/Diagnostics tests

  1. Labs


Result (indicate only abnormal findings)

Normal Range

What is the connection? How does this lab test relate to the PT’s diagnosis or treatment?



4,500-10,000 cells /mcL

Potential infection from surgical incision


2.0 g/dl

3.4 to 5.4 g/dL

Could indicate inflammation/infection to incision site

  1. Diagnostic tests (x-ray, etc.)



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?)


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. 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)








Sensory Perception



Alert and Oriented x3









Respiratory rate/rhythm/effort

Chest symmetry

Breath sounds 


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


Apical pulse

Radial pulse

Heart sounds (S1/S2)

Pedal pulses

Capillary refill time

Temperature/color of extremities

Edema (location/scale +)

Increase in Temperature





Less than 3 secs

Warm to touch

None present



Auscultation of Bowel sounds


Prescribed diet


Bowel pattern


Urinary elimination

Any Pain (?)

Impairment at surgical incision site

Incision RUQ, disintegrated dressing





1-2 twice daily, diarrhea, 5 loose stools


2-3 time , 1/O-measured urine output

RUQ, 7/10






Abnormalities (ie, ecchymosis, petechiae)


Pressure injury (stage/location)

Lesions/rashes/wounds (describe)










Incision of RUQ abdomen, Skin breakdown


Range of motion


Assistive devices


Transfer ability

Strength of extremities 

Some impediment 




Some dependence required

Some dependence required


IV Therapy:


Site assessment

Peripheral IV D5 1/2NS at 75ml/hr

Right forearm





Support systems


Cultural preferences

Developmental stage

Presence of anxiety






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




  1. Assess V/S including respiratory efforts and auscultate lungs to identify normal or adventitious breath sounds to ensure  no abnormality  and force effort to inspire and expire and chest rises and lowers same time
  2. Encourage patient to perform DBE, using incentive spirometer 10xq2h while they are awake
  3. Administer O2at 2LPM via NC, and encourage usage of  Salmeterol inhaler 50 mcgq12h
  4. Perform chest physical therapy 
  5. Position PT upright position q2h
  6. Reinforce education on oxygen use and safety while at home
  7. Document any baseline changes. Note if any interventions work and document patient teaching.
  8. Check for pain at site
  9. Check for increase or decrease of tissue in the bladder. 
  10. Assess the patient’s level of dress.

For 8.9 and 10- What’s the rationale for these interventions?

  1. Adventitious breath sounds and  Alteration in respiratory pattern indicate if patient is in respiration distress, or presence of mucus plug 
  2. Promote proper lung expansion and to assess PT use of accessory muscle or adopt breathing pattern to facilitate  effective gas exchange. 
  3. The use of oxygen help promotes mobilization of pulmonary secretions, improve ventilation and expansion of chest and improve oxygen saturation.
  4. CPT helps to mobilize secretions due to bronchial
  5. Sitting upright helps promotes upward diaphragmatic movement and increase lung expansion 
  6. Important for PT to use the required amount of oxygen and be cautious not to overuse to prevent toxicity .PT should refrain from using oxygen to use around heat sources or smoking while on oxygen therapy. 
  7. Documentation is vital to aid health professionals to have a guideline to enable them to track and monitor patient care and efficiently make individualized plan to evaluate if treatment is effective. 

Current V/S:




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




  1. check for mucosal membrane damage, integumentary, corneal or subcutaneous tissue damage.
  2. Due to frequent dressing changes it is necessary for the nurse to apply Montgomery straps
  3. When change dressing apply zinc oxide, sterile petroleum jelly or powder around incision
  4. Note any change in temperature, onset fever and tachycardia or presence of hematoma
  5. Note sensitivity to incision site. How did the patient react when in contact while wound changes? Facial expression or resistance?
  6. Document any baseline changes. Note if any interventions work and 

Interventions have to correlate with  Are the interventions listed above appropriate to the Nursing diagnosis #4 and goal  to be met?

  1. What are some interventions for diagnosis of tissue integrity and list matching rationale for each given. 
  1. The patient depicts difficulty in moving  and cannot change position while in bed or seated
  2. Changing dressing frequently can cause skin trauma. Thus, to avoid easily alteration of skin the Montgomery straps will help to minimize skin irritations.
  3. This will enable the skin around incision to be dry and clean. Also, act as a barrier to prevent skin breakdown.
  4. Monitor of incision site will keep alert to ensure no presence of blood and fistula formation
  5. Should be able to note improvements to incision site when in contact while dressing changes
  6. This will enable the patient to gain more muscle strength to be able to ambulate with less dependency
  7. Documentation is vital to aid health professionals to have a guideline to enable them to track and monitor patient care and efficiently make individualized plan to evaluate if treatment is effective. 

Current V/S:



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


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


Endoscopic retrograde cholangiopancreatography (ERCP)

Percutaneous transhepatic cholangiography

Liver function studies

White blood cell


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

Source of Information for Textbook Picture: 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.