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Chelsey Miyake

1. Altered Body Composition related to


electrolyte imbalances

2. Pain
Patient stated general abdomen tenderness
(intermittent)
Upon admission, patient stated tenderness was 8/10
11/25/14 general abdomen tenderness 2/10
11/26/14 general abdomen tenderness 1/10
Patient refused pain medication
PRN Morphine prescribed for pain

NG Tube to intermittent suctioning


NPO (11/25/14)
Clear Liquid (11/26/14)
Full Liquid (11/27/14)
IV D5NS KCl 35ml/hr
K+: 3.1 (11/23/14), 3.3 (11/24/14)
d/c IV when intake is adequate
Tx: Potassium chloride 2 tab

3. Elimination
Creatinine: 0.3 (11/23/14), <0.3 (11/25/14)
BUN: 5 (11/25/14)
2 BM 11/25/14 (per patient small, soft, brown and
small runny and brown)
Tx: ambulation, full liquid to soft, low fiber diet.

Chief Medical Diagnosis:


Small bowel obstruction

4. Imbalance Nutrition: Less than Body


Requirements

Priority Assessment:
Abdominal assessment (observation
flat/round, bowel sounds, tenderness,
enlarged organs), pain, I&Os, nausea or
vomiting, tolerance to diet, electrolytes

BMI: 17.44
NPO (11/25/14)
Clear Liquid (11/26/14)
Full Liquid (11/27/14)
Patient discharged on full liquid diet

5. Knowledge Deficit

6. Anxiety

Patient had frequent questions while conducting my


head to toe assessment
Patient wondered why there were little vegetables on
possible foods to eat for low-fiber

Patient states feeling nervous about trying solid food


Dietitian suggested advancing to soft foods
tomorrow; patient stated she preferred to wait 1-2
more days

Nursing Outcomes and Interventions


Desired Outcomes
Altered Nutrition/Fluid & Electrolyte Imbalance related
small bowel obstruction:
1. Patient maintains normal serum electrolyte levels

Interventions
Altered Nutrition/Fluid & Electrolyte Imbalance:
1. Daily weight
2. Assess new lab values (albumin, protein, electrolyte
panel, 24h urine, nitrogen balance, glucose,
chemistries, H&H)
3. Assess for signs and symptoms of electrolyte
imbalance (hypokalemia, hyponatremia,
hypocalcemia, hypomagnesaemia,
hypophosphatemia)
4. Monitor I&O
5. Encourage adequate intake
6. Administer electrolyte replacement therapy as
prescribed
Pain

Pain related to small bowel obstruction:


2. Patient uses pharmacological and
nonpharmacological pain-relief strategies to maintain
an acceptable pain level of less than 3

1.
2.
3.
4.
5.

6.
7.

Assess pain characteristics (quality, severity,


location, onset, duration and precipitating factors)
Auscultate bowel sounds
Assess the patients expectation for pain relief
Offer repositioning to assist with pain management
(use of nonpharmacological pain management)
Observe or monitor signs and symptoms associated
with pain, such as BP, HR, temp, color and moisture
of skin, restlessness and ability to focus
Assess patients knowledge of or preference for the
array of pain relief strategies available
Evaluate patents perception of dietary impact on
abdominal pain

Impaired Elimination related scarred tissue (adhesions) in


small bowel:
3. Patient will be able to pass bowel movements on a
regular schedule

Elimination
1. Monitor I&Os
2. Encourage the patient to ambulate
3. Encourage daily fluid intake of 2000 to 3000 ml/day,
if not contraindicated medically
4. Encourage the patient to keep a food diary
5. Evaluate fear of pain with defecation
6. Consult dietitian regarding proper diet

Imbalanced Nutrition: Less than Body Requirements


related to malabsorption:
4. Patients nutritional status improves, as evidenced
by weight gain or stabilization of weight; controlled
diarrhea; and normal serum electrolyte, vitamin and
mineral profiles

Imbalanced Nutrition: Less than Body Requirements


1. Document patients actual weight (do not estimate)
2. Assess for skin lesions, skin breaks, tears, decreased
skin integrity and edema of extremities
3. Assess serum electrolytes, calcium, vitamin k and
B12 folic acid and zinc levels of determine actual or
potential deficiencies
4. Consult dietitian
5. Encourage use of vitamin and mineral supplement as
ordered
6. Assess patterns of elimination: color, amount,
consistency, frequency, odor and presence of
steatorrhea

Knowledge Deficit:
5. Patient verbalizes understanding of disease and
management

Knowledge Deficit
1. Asses patients understanding of SBO and necessary
management
2. Discuss risk factors
3. Discuss management.
4. Discuss surgical interventions
5. Consult dietitian regarding dietary restrictions
6. Discuss interventions to help manage/prevent future
obstructions

Anxiety:
6. Patient describes a reduction in the level of anxiety
experienced

Anxiety
1. Assess the patients level of anxiety
2. Determine how the patient uses defense mechanisms
to cope with anxiety
3. Maintain a calm manner while interacting with the
patient
4. Remind the patient that anxiety at a mild level can
encourage growth and development and is important
in mobilizing changes
5. Encourage the patient to ask questions/ seek
assistance from health care provider
6. Assist the patient with different coping techniques

Evaluation
Altered Nutrition/Fluid & Electrolyte Imbalance:
During clinical, I monitored my patients lab values and assessed for signs and symptoms of
electrolyte imbalances. The patients weight was not monitored daily. I tried to maintain adequate
monitoring of the patients intake and outtake; however she was very independent and would go to the
restroom on her own. I made it a point to check throughout the day if she had a bowel movement. The
patient had an fair appetite considering she did not have much options on a clear and full liquid diet. The
patient was very verbal in expressing her likes and dislikes regarding her meals. I encouraged intake by
offering to call dietary and exchange juices for her. The patient was also prescribed additional potassium
supplements because she was slightly hypokalemic. This outcome was met.
Pain
During my head-to-toe assessment I completed a focus GI assessment on the patient. Her
stomach was flat, soft and tender. The patient described the pain as intermittent and moved throughout
her lower quadrants. I asked the patient to describe the amount of tenderness on scale of 0 to 10. Upon
admission, the patient informed me that her stomach had pain of 8/10. The first clinical day the
tenderness as at a 2/10 and the second day it went down even further to a 1/10. The patient was satisfied
with the pain and did not require any pain medication. The patient was positive for bowel sounds in all 4
quadrants. The patients vitals were within normal range of her baseline. The patients perception of
dietary impact was met when the dietitian came to discuss her diet advancement with her. Overall, this
outcome was met.

Elimination
As stated before, the patients intake and outtake was monitored as best as we could. Ambulation
was encouraged; the patient was very well informed about ambulation being beneficial to her situation.
Fluids were encouraged, but it could have been reinforced further with the dietitians teaching. The
patient did not have fear of defecation, just fear of future impactions. The patients diet was evaluated by
dietitian. This outcome was partially met.
Imbalanced Nutrition: Less than Body Requirements
The patient was not weighed during my shift. During my assessment there no breaks in skin
integrity noted, however the patient did have caf-au-lait spots related to her neurofibromatosis diagnosis.
I would have liked to know her albumin levels because she was NPO for a couple of days, but that lab
was not tested. A dietitian was consulted. The patient stated that she did want to gain some weight
during the dietitian consult. She also mentioned she takes supplements at home regularly to help make up
for the nutrients she does not received due to her restricted diet. I was unable to assess her bowel
movements, but the fact that she was passing gas and stool was an improvement of her condition. This
outcome was partially met.
Knowledge Deficit
The patient was a good understanding of small bowel obstruction, which may be due to her
frequent bowel obstructions this year. I was able to assess her understanding of her risk factors and
management. She also had a good understanding of surgical interventions because of her previous
experience. The dietitian was consulted. The patient already had a good idea of interventions to manage
and prevent future obstructions. This outcome was met.
Anxiety
The patient was very determined to be discharged early. However, when she learned she was
going to be discharged on a full liquid diet she seemed a little anxious. I believe she was anxious or
nervous that she may advance too soon and end up with another obstruction. The patient took the
initiative and vocalized any questions that she had. I did not observe any defense mechanisms and I
remained calm and interacted with the patient in a calm manner throughout the clinical day. This outcome
was met.
Discharge Plan/Patient Teaching
The patient was planning to return home upon discharge. This was the patients third
hospitalization this year for a small bowel obstruction. The patient had scarred tissue or adhesions in her
small intestine which put her at high risk for future obstructions. The patient did not go into too much
detail about the living environment or the type of dwelling she lives in. After the doctor put in the
discharge orders, the patient called her sister to pick her up from the hospital. Her sister will also play a
part in her support system.
The patient was very independent. She required little to no assistance with her ADLs. The patient
was able to ambulate independently with no assistance, shower independently and feed with no
assistance. She will continue to complete her ADLs at home with no assistance. The patient required no
special equipment. She had no surgery to remove her small bowel obstruction for her current
hospitalization. I was unable to find the type of treatment she received upon admission, however I did
notice in her electronic chart that she had 8 bowel movements her second day at the hospital.

On the day of discharge, I had the opportunity to observe the dietitian give the patient teaching on
her diet advancement. The dietitian provided pamphlets with lists of possible food to eat for soft, lowfiber foods. While listening to the dietitians input, the patient took additional notes. She also asked
questions about incorporating her everyday foods that she eats normally at home. Although the patient
noted what the dietitian had said she seemed determine to eat foods that could be made easily and eaten
on the go. The patient described herself as a busy body and was always on the go. This could be a barrier
to learning because the patient may not adhere to the dietitians advice due to the limited food selection.
The patient also mentioned she was anxious about advancing her diet because she did not want to have
another bowel obstruction. This could serve as another barrier to learning.
Before discharge there were multiple topics that needed to be discussed. The primary nurse had
to go over discharge instructions. This included to follow-up with the patients doctor in one week, to
continue her current medications, and the signs and symptoms to report and when to seek help. The
dietitian also needed to consult with the patient. She had to discuss when to advance her diet from full
liquids to a soft, low-fiber diet and what types of foods she should avoid.

References:
Gulanick, M., & Myers, J.L. (2011). Nursing care plans: Nursing diagnoses, interventions and outcomes,
(7th ed.). St Louis: Mosby.