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: Viktoria Lipke Client’s Initials: HS Date 9-18-07 Diagnoses: Small bowel resection with necrotic small bowel
Assigned Nurse & Unit: 4400 with Alan Smith • How was your learning expanded or reinforced today? In other words, report on what you learned, not on what you did. (Refers to Application of Theory on Level III Clinical Evaluation Tool)
I learned the difference between a central line and a peripheral line also that the one difference among them is that the flush amount for each one. How to properly administer medication through a central line. • What assessments did you make today that led to the client’s priority nursing diagnoses? In addition to the usual assessment data, be sure to include assessments specific for that client and the diagnosis, lab work, telemetry, etc. (Assessment)
After the clients surgery her troponin I level was high indicating that she had a heart attack. This led me to the nursing diagnose of risk for tissue perfusion. The second priority diagnoses being alteration in GI function because the patient has not passed gas/bowel movement which is why she is still NPO which will then lead to the priority diagnoses of alteration in fluid and electrolyte balance. • 1. 2. 3. 4. 5. 6. 7. 8. List the priority nursing diagnoses for your client. (Diagnosis) Safety, potential for injury r/t falls as evidence by patient needs assistance Risk for post-op infection r/t abdominal wound Alteration in GI function r/t pacing gas and bowel movement Alteration in comfort r/t incisional pain as evidence by patient states she’s in pain wants no medication Alteration in fluid and electrolyte balance r/t NPO status as evidence by has no pass gas or bowel movement yet Anxiety r/t disease process as evidence by she has concerns about the future outcome Knowledge deficit r/t post-op routines and home care Risk for tissue perfusion r/t MI as evidence by troponin I level was high
Which relevant goals/outcomes did you establish for these nursing diagnoses? (Goals/Outcomes)
1. Goal: patient will remain free of infection Outcome: she didn’t have a increase in temperature, her wound stayed clean dry and intake, urine was clear to yellow w/out odor, no elevation of WBC. 2. Goal: patient will have a return in bowel function: check abdomen for sounds, swelling and pain Outcome: patient has not have positive bowel sounds, however she has remained free of nausea, vomiting, and abdominal distention 3. Goal: Patient will experience relief or decrease pain/discomfort Outcome: patient felt discomfort however didn’t want pain medication, used other coping mechanisms instead 4. Goal: patient urine output will be at least 30ml/hour Outcome: patient urinated 800ml in 6 hours 5. Goal: patient will be free from falls Outcome: patient had no falls or injury d/t patient called staff for assistance and had staff assistances for every time she got OOB. 6. Goal: patient will be free of fears and concerns Outcome: staff explained all routines, procedures and treatments prior to implementation, we encouraged verbalization of feelings/fears/concerns, and assist patient to identify sources of support: family/ friends 7. Goal: patient will verbalize understanding of follow-up care and home care management Outcome: patient was taught proper education and verbalized understanding. 8. Goal: monitor telemetry strip and troponin I level for evidence of another MI occurring Outcome: patient remained in normal sinus rhythm with no ECG changes reflecting ischemia. • Which interventions were performed to achieve these goals/outcomes? These include skills such as IV's, ECGs, tubes, dressings, etc. Don’t forget the medications that were given to your client. (Intervention and Skill SectionsInterventions are preventions that you would list on a NCP and skills are procedures that you actually did.)
Patient had a central line placed; we used it to administer Heparin to prevent existing clots from getting bigger and new ones from forming. Also we administered lasix to help kidney get ride of excess fluid. Also we flushed the second line. Other medication I administered were: • Valsartan (diovan) which is a angiotensin II receptor • Aspirin to prevent platelet from aggregating • Nitroglycerin patch to promote peripheral vasodilatation • Protonix a proton pump inhibitor, GERD • Lopressor a beta blocker Her ECG remain in normal sinus rhythm with no ECG changes, I changed her
abdomen dressing, which was dry and intact. • Which interpersonal communication interventions did you do with the client and family in order to achieve these goals/outcomes? (Helping Relationship/Communication)
Have a social worker meet the patient to help plan for home care management. We discussed pain management to have pain score of less than 4 so this way she will feel better and look forward to going home. We went other fears and concerns she had about her surgical procedure and disease process. • What client teaching interventions (including meds and primary, secondary, or tertiary preventions) were performed to achieve these goals/outcomes? (Client Teaching/Learning Needs)
I told the patient that it was important to sit in a chair for 45 minutes or more at least 3 times a day, walk in the hallway with a staff assistances BID, this will help decrease gas pain and stimulate the return to normal bowel function. Explained to the patient that the catheter will be removed when she is able to walk to the bathroom. She had to wear leg sleeves to help with circulation and prevent blood clots. Important to perform breathing exercises. It’s important to review information about her diet, medications and activities and exercises before she goes home. Also explained that it’s important to call the doctor if she feels bloated or have stopped passing gas, feels nauseous, has fever or chills, experience redness or burning at the incision site. • What documentation (including report, flow sheets, notes, Clinical Pathways, etc.) was performed in order to achieve these goals/outcomes? (Documentation)
Patient I & O's, daily weight, VS, monitor telemetry strip and document rhythm strip, documented physical assessment on patient. • How did you evaluate the client's response to these interventions? (Evaluation)
Patient communicated with the staff when she need something, felt pain, had questions or concerns. She was overall in a pleasant mood. Patient verbalized understanding of procedures and teaching opportunities. Patient cooperated with the staff when it came to post-op guidelines such as ambulating, OOB to chair, and deep breathing. • How did your understanding increase today? (Critical Thinking) I am more aware of what to assess for with a post-op small bowel resection
patient. I know what to the daily goals and priorities are. • What references did you use today in the care of your client and/or when preparing this DWS? (Nursing Research) Medical encyclopedia: small bowel resection Nurse Alan Smith • Give examples of how you interacted with other members of the health care team when you were providing care to your client. Were you able to organize your care? (Management and Organization)
I worked with my nurse and the tech’s to make sure the client’s procedure & priorities were accomplished. • How did you demonstrate professionalism today? (Responsibility, Accountability, Autonomy, and Ethical Decision Making)
I was on time. I helped my nurse whenever I could help out. I applied my knowledge to the client’s priority diagnoses, goals, and interventions • Don’t forget to include a diary card. (Personal and Professional Growth) I am very concerned if I’m going to succeed in this clinical because I’m struggle on how to pull it all together at clinical and I keep making stupid mistakes that I’m made at myself for because I’m really trying hard and I want to be here. My nurse Alan is great and is helping me a lot. Hopefully I’ll do much better next week.