Running Head: NURSING PROCESS PAPER

Nursing Process Paper

Clayton Jensen
Professor Heather Bloomfield
NURS* 304 St. Marks clinical site
December 1, 2013

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Abstract

The problem here is the health and care of the patient L.P. (female) of who underwent a
laparoscopic gastric bypass as wells as a cholecystectomy while, at the same time, suffering from
advanced osteoarthritis in her knees and severe obesity. Im not says that her care at the hospital
was lacking in any way. Rather, we are talking about the issue of the care and teaching for her
continued life after the hospital, and what manner to best do just that. First I went ahead and
explained what was already being done because we have to know where we are already to being
anew. Once I had done that I was able to assess what else was needed. In doing so I was able to
come up with 5 of the most important things to help L.P. with in her speedy recovery from the
laparoscopic gastric bypass and cholecystectomy surgeries and on her way to getting her knees
replaced, of which is the reason behind the gastric bypass in the first place. Those five are:
reducing her risk for infection, managing her pain level, improving upon her activity intolerance
and helping her better manage her weight and hypertension. By helping her with these five goals
she will most likely recovery much faster but also boost her moral substantially. A happy patient
is an/a (faster) improving patient.

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I. General information
Pts. Initials: L. P.
Age: 55
Code Status: Full Code

Sex: F

Dates of care: 09/11/2013

Admitting diagnosis and date:

Severe Obesity admitted on 9/10/2013
Surgery (if applicable) and date:
The patient underwent a laparoscopic gastric bypass surgery the day of her admission on
9/11/2013. The patient was also suffering pain due to acute cholecystitis. Due to this she also had
a cholecystectomy performed at the same time as her laparoscopic gastric bypass surgery which
is a very common occurrence, to be performed at the same time.
II. Assessment
Health Perception Health Management
1. Chief complaint
The patients true complaint was that of severe knee pain due to advanced osteoarthritis of both
knees. The osteoarthritis is a result of her severe obesity and other wear and tear. Knowing this
her doctors required that before they are willing to perform the surgery to resolve her
osteoarthritic knee pain they required her to have the laparoscopic gastric bypass surgery to
ensure weight loss, which will promote a better outcome post knee surgery.
2. Review general health
I.
Health problems
o Current
Acute Abdominal pain (laparoscopic gastric bypass surgery and
cholecystectomy)
Arnold-Chiari Malformation
Arthritis of hands and feet
Chronic knee pain (Osteoarthritis)
Depression
Diabetes mellitus
Hypertension
Migraine headaches
Severe Obesity
o Past Medical History
Cholecystitis
Former smoker (Quit 2003)
o Past Surgical History
Ankle repair
Hysterectomy
Skull removal
II.
Allergies
o No Known Allergies

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3. Medications (for each medication the patient is getting)

Medication: Prinivil,Zestril/lisinopril
Dose: PO: 20mg tab/day
Safe dose? Yes
Frequency: QID
Reason for getting: hypertension
Side Effects: CNS: dizziness, drowsiness, fatigue, headache, insomnia, vertigo,
weakness. Resp: cough, dyspnea. CV: hypotension, chest pain, edema, tachycardia.
Endo: hyperuricemia. GI: taste disturbances, abdominal pain, anorexia, constipation,
diarrhea, nausea, vomiting. GU: erectile dysfunction, proteinuria, renal dysfunction, renal
failure. Derm: flushing, pruritis, rashes. F and E: hyperkalemia. Hemat:
AGRANULOCYTOSIS, neutropenia (captopril only). MS: back pain, muscle cramps,
myalgia. Misc: ANGIOEDEMA, fever.
Nursing implications: Bilateral BP, compliance, labs, pt. history, education
w/medication regimen
Medication: Pantoprazole Sodium
Dose: 40 mg IV Q24H (Dilute with 10 ml NS inject IV over no less than 2 min. Flush
line prior to and after with NS, LR or D5W.)
Safe dose? Yes
Frequency: Q24H
Reason for getting: This medication is given for prophylaxis of infections after surgery.
Side Effects: CNS: headache. GI: abdominal pain, diarrhea, eructation, and flatulence.
Endo: hyperglycemia.
Nursing implications: Dilute with 10 ml NS inject IV over no less than 2 min. Flush line
prior to and after with NS, LR or D5W. Do not give with other meds through same site
or tubing. Assess pt routinely for epigastric, abdominal or flank pain.
Medication: Amitriptyline (ELAVIL)
Dose: PO: Take one 50 mg tab at bedtime
Safe dose? Yes
Frequency: QID
Reason for getting: Insomnia and Migraines
Side Effects CNS: SUICIDAL THOUGHTS, lethargy, sedation. EENT: blurred vision,
dry eyes, dry mouth. CV: ARRHYTHMIAS, hypotension, ECG changes. GI:
constipation, hepatitis, paralytic ileus, increased appetite, and weight gain. GU: urinary
retention, Decreased libido. Derm: photosensitivity. Endo: changes in blood glucose,
gynecomastia. Hemat: blood dyscrasias.
Nursing implications: Patients taking high doses or with a history of cardiovascular
disease should have ECG monitored before and periodically during. Assess for suicidal
tendencies, especially during early therapy.

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Medication: Fluoxetine (PROZAC)

Dose: PO: Take 10 mg Tab daily
Safe dose? Yes
Frequency: QID
Reason for getting: Depression
Side Effects CNS: CNS: NEUROLEPTIC MALIGNANT SYNDROME, SEIZURES,
SUICIDAL THOUGHTS, anxiety, drowsiness, headache, insomnia, nervousness,
abnormal dreams, dizziness, fatigue, hypomania, mania, weakness. EENT: stuffy nose,
visual disturbances. Resp: cough. CV: chest pain, palpitations. GI: diarrhea, abdominal
pain, abnormal taste, anorexia, constipation, dry mouth, dyspepsia, nausea, vomiting, and
weight loss. GU: sexual dysfunction, urinary frequency. Derm: increase sweating,
pruritus, erythema nodusum, flushing, and rashes. Endo: dysmenorrhea. F and E:
hyponatremia. MS: arthralgia, back pain, myalgia. Neuro: tremor. Misc: SEROTONIN
SYNDROME, allergic reactions, fever, flu-like syndrome, hot flashes, sensitivity
reaction.
Nursing implications: Assess for suicidal tendencies, especially during early therapy.
Advise patient, family and caregivers to look for suicidality, especially during early
therapy or dose changes.
Medication: Hydrocodone acetaminophen (LORTAB) 7.5-500 mg/15 mL (solution)
Dose: PO: 15 ml Every 4 hours PRN for pain
Safe dose? Yes
Frequency: PRN
Reason for getting: Pain
Side Effects: CNS: CNS: confusion, dizziness, sedation, euphoria, hallucinations,
headache, unusual dreams. EENT: blurred vision, diplopia, miosis. Resp: respiratory
depression. CV: hypotension, bradycardia. GI: constipation, dyspepsia, nausea, vomiting.
GU: urinary retention. Derm: sweating. Misc: physical dependence, psychological
dependence, tolerance.
Nursing implications: Assess blood pressure, pulse, and respirations before and
periodically during administration.
Medication: Topiramate (TOPAMAX)
Dose: PO: 15 mg 2 times daily
Safe dose? Yes
Frequency: BID
Reason for getting: Migraine Prevention
Side Effects: CNS: CNS: INCREASED SEIZURES, SUICIDAL THOUGHTS,
dizziness, drowsiness, fatigue, impaired concentration/memory, nervousness,
psychomotor slowing, speech problems, sedation, aggressive reaction, agitation, anxiety,
cognitive disorders, confusion, depression, malaise, mood problems. EENT: abnormal
vision, diplopia, nystagmus, acute myopia/ secondary angle closure glaucoma. GI:
nausea, abdominal pain, anorexia, constipation, dry mouth. GU: kidney stones. Derm:
oligohydrosis (increase in children). F and E: hyperchloremic metabolic acidosis.
Hemat: leukopenia. Metab: weight loss, hyperthermia (increase in children). Neuro:

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ataxia, paresthesia, tremor. Misc: fever.

Nursing implications: Monitor closely for notable changes in behavior that could
indicate the emergence or worsening of suicidal thoughts or behavior or depression.
Medication: Heparin Sodium
Dose: Subcut: 5000 units
Safe dose? Yes
Frequency: Q 8 12 hr
Reason for getting: Heparin will help keep the PICC/other IV sites from forming blood
clots in lumen or on tip of catheters.
Side Effects: GI: drug-induced hepatitis. Derm: alopecia (long-term use), rashes,
urticaria. Hemat: BLEEDING, anemia, thrombocytopenia (can occur up to several weeks
after discontinuation of therapy). Local: pain at injection site. MS: osteoporosis (longterm use). Misc: fever, hypersensitivity.
Nursing implications: aPTT: activated partial thromboplastin time. (1.5-2.5) 90seconds.
(60seconds=normal) - Protamine Sulfate is the antidote
Medication: Novolog (Fast acting insulin)
Dose: Total insulin dose determined by needs of patient; generally 0.51 unit/kg/day;
5070% of this dose may be given as meal-related boluses of rapid-acting in- sulin, and
the remainder as an intermediate or long-acting insulin.
Safe dose? Yes if:
Admin Instructions: NovoLog
Medium-dose algorithm:
Glucose / Insulin Dose
140-170...........1 unit
171-200...........2 units
201-230...........3 units
231-260...........4 units
261-290...........5 units
291-320...........6 units
321-350...........7 units
351-380...........8 units
>380................9 units and call MD
If correction insulin is given at bedtime, obtain a blood glucose level between 2:00 and
3:00 AM to identify possible hypoglycemia. DO NOT give the patient correction insulin
at this time if the glucose is elevated.
Frequency: Dose depends on blood glucose, response, and many other factors.
Reason for getting: Control of hyperglycemia in patients with type 1 or type 2 diabetes
mellitus.
Side Effects: Endo: HYPOGLYCEMIA. Local: erythema, lipodystrophy, pruritis,
swelling. Misc: allergic reactions including ANAPHYLAXIS.
Nursing implications: Assess for symptoms of hypoglycemia (anxiety; restlessness;
tingling in hands, feet, lips, or tongue; chills; cold sweats; confusion; cool, pale skin;
difficulty in concentration; drowsiness; nightmares or trouble sleeping; excessive hunger;

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headache; irritability; nausea; nervous- ness; tachycardia; tremor; weakness; unsteady

gait) and hyperglycemia (confusion, drowsiness; flushed, dry skin; fruit-like breath odor;
rapid, deep breathing, polyuria; loss of appetite; nausea; vomiting; unusual thirst)
periodically during therapy.

Medication: Lantus
Dose: 0.1 0.2 units/kg once daily in the morning or 10 units once or twice daily.
Safe dose? Yes if:
Frequency: Dose depends on blood glucose, response, and many other factors.
Reason for getting: Control of hyperglycemia in patients with type 1 or type 2 diabetes
mellitus.
Side Effects: Endo: HYPOGLYCEMIA. Local: lipodystrophy, pruritis, erythema,
swelling. Misc: allergic reactions including ANAPHYLAXIS.
Nursing implications: Assess patient for signs and symptoms of hypoglycemia (anxiety;
restlessness; mood changes; tingling in hands, feet, lips, or tongue; chills; cold sweats;
confusion; cool, pale skin; difficulty in concentration; drowsiness; nightmares or trouble
sleeping; excessive hunger; head- ache; irritability; nausea; nervousness; tachycardia;
tremor; weakness; unsteady gait) and hyperglycemia (confusion, drowsiness; flushed, dry
skin; fruit-like breath odor; rapid, deep breathing, polyuria; loss of appetite; nausea;
vomiting; tiredness; unusual thirst) periodically during therapy.

All medications (Deglin, 2009)

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4. Pathophysiology for all conditions that the patient is being treated for (getting
medication for and/or getting other treatment for) Describe usual treatment and
complications. Indicate which signs, symptoms, treatments, and complications your patient
is experiencing
How well does the patient understand his/her medications and pathophysiology?
How well does the patient manage his/her treatment regimens at home?
Severe obesity:
This patient is 5 feet 2 inches tall and weighs 292 pounds resulting in a BMI of 53.4. She
is well beyond the classification of obese and its effect there of are obviously difficult on her.
The patient understands fully the importance of her laparoscopic gastric bypass surgery not only
to promote the future surgical repair of her knees but also the importance to her overall health
and future life. We spoke of all the things she does or doesnt do at home with her diet, exercise,
and life style. She spoke of the difficulties of life with all the weight but also said that her ability
to stop eating, exercise, or even just to eat healthily is disturbed. She said she eats not only due to
hunger but also due to depression. Her husband showed that he plays a huge role in her life as
support in everything and she emulated that about him, but despite that support she still struggles
with her eating and depression cycle.
Pathophysiology of Obesity:
Obesity occurs when excess calories are stored as fat. It can result from excess energy
intake, decreased energy expenditure, or a combination of both. The etiology of obesity is
not as simple as excess kilocalorie intake in relation to energy expenditure. Appetite,
which affects food intake, is regulated by the central nervous system and by emotional
factors. The hunger center in the hypothalamus stimulates appetite in response to stimuli
such as hypoglycemia and peptides produced in the gut. As nutrient levels rise, the satiety
center (also in the hypothalamus) sends the message to stop eating. Gastrointestinal
filling and hormonal factors also signal satiety (a sensation of fullness). Appetite may
have little relationship to hunger or physical signals, however, people may eat to relieve
depression or anxiety. Several hormones are involved in regulating obesity, including
thyroid hormone, insulin, and leptin (a peptide produced by fatty tissue that suppresses
appetite and increases energy expenditure). Some studies suggest that leptin resistance is
a cause of obesity. Insulin is associated with body fat distribution. The two major types of
body fat distribution are upper body and lower body obesity. (Baudolf, Burke, LeMone,
2013, p. 590)
Obesity is an exaggeration of normal adiposity and is a central player in the
pathophysiology of diabetes mellitus, insulin resistance, dyslipidemia, hypertension, and
atherosclerosis. Obesity is a major contributor to the metabolic dysfunction involving
lipid and glucose, but on a broader scale, it influences organ dysfunction involving
cardiac, liver, intestinal, pulmonary, endocrine, and reproductive functions. Obesity
contributes to immune dysfunction from the effects of its inflammatory adipokine

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secretion and is a major risk factor for many cancers, including hepatocellular,
esophageal, and colon. Because of the accelerating effects that obesity has on the
worsening of metabolic syndrome and cancer, it has the potential to be profoundly
detrimental to our species if major methods of prevention and/or effective treatment are
not realized. It is essential then to institute major educational efforts aimed at promoting
better eating habits and physical exercise. (Redinger, 2007)
Diabetes Mellitus:
She spoke of her diabetes with a little reserve in her voice. She spoke of trying to manage
her weight in the past to better manager her diabetes but spoke also of the failure at her attempt.
It seemed as though the whole thought of obesity and having diabetes was a difficult topic for
her. She spoke of not always being heavy and how she misses not being held back by it. She
showed high hopes for this laparoscopic gastric bypass surgery to get her to a healthier point that
will allow her to have her old life back.
She spoke of disliking the process of measuring her glucose and giving herself her insulin
but she knows why it is important. She said It keeps me alive whether I like it or not and I have
been doing it this long so I can do it for how ever much longer I need to. To manage her insulin
she is using Novolog as her fast acting insulin and Lantus as her long acting insulin. She
explained to me in detail the times that she has to take it and how she takes it and makes sure she
eats there after. With her explanation of how she is managing her glucose and insulin and the fact
that she has been doing this 20+ years I felt she knew what she was doing. The only thing I
touched on with her was diet and exercise. She was very receptive of the idea of both and with
the help of her laparoscopic gastric bypass surgery she felt very optimistic.
Diabetes Mellitus Pathophysiology:
Type 2 diabetes mellitus (T2DM) is a progressive disease caused by a combination of
complex metabolic disorders that result from coexisting defects of multiple organ sites,
such as insulin resistance in muscle and adipose tissue, a progressive decline in
pancreatic insulin secretion, unrestrained hepatic glucose production, inappropriate
glucagon secretion, and diminished production of gastrointestinal incretins, as well as
other hormonal deficiencies and impairments.
In patients with T2DM , the normal mechanisms that contribute to the regulation of
glucose levels break down. The two core defects leading to T2DM are insulin resistance
and progressive -cell dysfunction. A secondary cause of increasing plasma glucose
levels is excessive hepatic glucose production. Insulin is needed for glucose uptake by the
muscles and peripheral tissues and to decrease hepatic glucose production. As muscle,
fat, and other tissues become less responsive to insulin, the -cells try to keep up by
producing more and more insulin. Some people may even have bouts of hypoglycemia
when there is excessive insulin circulation in the blood stream due to marked insulin
resistance. This hypoglycemia is a marker of insulin resistance and is viewed as a
precursor of T2DM. As the impairments of insulin resistance progress, the -cells
produce less insulin than necessary for optimal glucose control. Accompanying abnormal
insulin secretary patterns also are present. Beta-cell dysfunction becomes progressively
worse over time. Research has shown that by the time T2DM is diagnosed, at least 50%
of -cell function has been lost.'' At the same lime, the liver produces more glucose than
the body can use, causing a further increase in plasma glucose levels. Insulin is needed to

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"shut off" liver glucose production. With less circulation insulin and marked insulin
resistance, the liver continues to make glucose in an unrestrained manner. All 3 defects
insulin resistance, insulin secretion dysfunction from -cells, and excessive liver
production of glucose contribute to hyperglycemia and the development of T2DM. (Barr,
2008)
Osteoarthritis:
The patient was very adamant about telling me why she had to undergo her laparoscopic
gastric bypass surgery. She made sure I knew that it was being performed first for her ability to
get her future knee surgeries to resolve her knee pain and second to reduce her weight and better
her overall health. With that statement by her she really put in perspective how much pain she
was actually in due to her knees. She said it has debilitated her extremely and due to that it has
magnified her weight gain and also her depression. Post surgery she did manifest a lot of
enthusiasm to loose the weight and said she couldnt wait to be rid of her knee pain.
Osteoarthritis pathophysiology:
OA is the most commonly occurring of all forms of arthritis, and a leading cause of pain
and disability in older adults (CDC, 2008). This disease is characterized by progressive
loss of joint cartilage, synovitis (inflammation of the synovium lining the joint), joint
pain, stiffness, and loss of joint motion (Porth & Matfin, 2009). OA may be idiopathic
(without known cause) or secondary (associated with known risk factors), although it
may be difficult to differentiate between primary and secondary OA.
In OA, proteoglycans and collagen are lost from the cartilage as a result of enzymatic
degradation. The water content of the cartilage increases as the collagen matrix is
destroyed. With the loss of proteoglycans and collagen fibers, the cartilage becomes
yellow or brownish gray and loses its tensile strength. Surface ulcerations occur, and
fissures develop in deeper layers of the cartilage. Eventually, large areas of articular
cartilage are lost, and underlying bone is exposed. The bone thickens in exposed areas,
reducing its ability to absorb energy in joint loading. Cysts can also develop in the bone
as synovial fluid leaks through damaged cartilage. Cartilage-coated osteophytes (bony
outgrowths often called joint mice) change the anatomy of the joint. As these spurs or
projections enlarge, small pieces may break off, leading to mild synovitis (inflammation
of the synovial membrane). (Baudolf, Burke, LeMone, 2013, p. 1353-1354)
Hypertension:
The patient showed a consistent high blood pressure throughout the whole day I was
there with her assisting in her care. This was probably largely due to her pain level due to the
surgery. We did provider her antihypertensive medication (Lisinopril) consistently and on time
her but she still held a consistent 135/90 140/90 blood pressure throughout the day. We notified
the physician and he said to just keep an eye on her for now and provide her with more pain
medication to possibly remedy the hypertension though pain reduction.
She said that the higher blood pressure wasnt all that normal considering she had taken
her antihypertensive medication. She didnt seem to worry about it all that much and suspected it
would decrease as with the pain decrease and possibly it would lower when she was finally home
considering she doesnt care for hospitals all that much. She said that she has cut sodium out of
her diet a lot due to her hypertension but not completely. I spoke of the dash diet with her and

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explained that sodium doesnt need to be cut out completely, even though it wouldnt hurt, but if
she were to incorporate not only sodium decrease but also a decrease in fat, saturated fat,
cholesterol, and higher in potassium, magnesium, and calcium she would see better results with
her hypertension. I also explained that hypertension has no symptoms, and if untreated
hypertension may lead to many health problems, including damage to blood vessels that may
lead to heart failure.
She there after thanked me for the information and said she looked forward to trying the
recommendations with her diet to battle her hypertension.
Hypertension Pathophysiology:
Hypertension is defined as systolic blood pressure of 140 mmHg or higher, or diastolic
pressure of 90 mmHg or higher, based on the average of three or more readings taken on
separate occasions (NHLBI, 2004).
Primary hypertension is thought to develop from complex interactions among factors that
regulate cardiac output and systemic vascular resistance. These interactions may include
the following:
Excess sympathetic nervous system with overstimulation of- and -adrenergic
receptors, resulting in vasoconstriction and increased cardiac output.
Altered function of the renin-angiotensin-aldosterone system and its responsiveness
to factors such as sodium intake and overall fluid volume. The renin-angiotensinaldosterone system affects vasomotor tone and salt and water excretion. Chronically
high levels of angiotensin II lead to arteriolar remodeling, which permanently
increases SVR. In approximately 20% of people with primary hypertension, renin
levels are lower than normal. Increased sodium intake increases the blood pressure in
these patients. Low plasma renin levels are more commonly seen in African
Americans than in Whites. Another 15% of patients with hypertension have higher
than normal plasma renin levels. For these patients, salt intake has less of an effect on
blood pressure (Huether & McCance, 2008). Most people with hypertension have
normal levels of renin activity.
Other chemical mediators of vasomotor tone and blood volume such as atrial
natriuretic peptide (factor) also play a role by affecting vasomotor tone and sodium
and water excretion. Vascular endothelium itself produces hormones (endothelins)
that also affect vasomotor tone. Endothelin-1 is a potent vasoconstrictor (Huether &
McCance, 2008).
The interaction between insulin resistance, hyperinsulinemia and endothelial function
may be a primary cause of hypertension. Excess insulin has several effects that
potentially contribute to hypertension: (1) sodium retention by the kidneys, (2)
increased sympathetic nervous system activity, (3) hypertrophy of vascular smooth
muscle, and (4) changes in ion transport across cell membranes (Huether& McCance,
2008).
The result is sustained increases in blood volume and peripheral resistance. The
cardiovascular system adapts to increased blood volume by increasing cardiac output.
Autoregulatory mechanisms in the systemic arteries react to the increased volume,
causing vasoconstriction. The increased systemic vascular resistance causes hypertension.
(Baudolf, Burke, LeMone, 2013, p. 1020-1021)

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Arnold-Chiari Malformation:
Prior to my interaction with the patient I made a point to understand what this
malformation was. This is a malformation of the skull leaving not enough room for the brain to
reside in. As a result of this lack of space the brain is therefore forced down the only extra space
there is, down through the foramen magnum and into the spinal cord space. She spoke of the
issue as if it were old news considering she has had it her whole life. As a result of this issue she
suffers severe migraines and lack of sleep. She said the only thing she feels can really do to deal
with these issues is to remember to take her medications (Topiramate (TOPAMAX) and
Amitriptyline (ELAVIL)). She did have an operation on her skull a long time prior (unknown
date) to alleviate the pressure on her brain. She said this did help but the symptoms werent
subdued completely but rather only diminished a small amount. She said, I have learned to deal
with the pain.
Arnold-Chiari Malformation Pathophysiology:
Chiari malformations are usually caused by structural defects in the brain and spinal cord.
These defects develop during fetal development. Due to genetic mutations or a maternal
diet that lacked certain nutrients, the indented bony space at the base of the skull is
abnormally small. As a result, pressure is placed on the cerebellum. This blocks the flow
of the cerebrospinal fluid. That's the fluid that surrounds and protects the brain and spinal
cord. Much less commonly, Chiari malformations can occur later in life. This can happen
when an excessive amount of cerebrospinal fluid is drained away because of injury,
infection and/or exposure to toxic substances
There are four types of Chiari malformations: (This patient exhibits type III)
Type III - This is the most serious form of Chiari malformation. It involves the protrusion
or herniation of the cerebellum and brain stem through the foramen magnum and into the
spinal cord. This usually causes severe neurological defects. Type III is a rare type.
(WebMD, n.d.)
Depression:
The patient has had a long history of depression. She feels it is largely do to her health
and has gotten worse with age as well. She described it as I was once running towards a light at
the end of the tunnel of which I cant see anymore because I couldnt seem to run fast enough to
chat up to it. In other words not only has the baggage of my health weighed me down but also
the light was moving away from me like it does with everyone as we age. With the laparoscopic
gastric bypass surgery and the upcoming surgery on her knees she said that the light is starting to
be a little bit more visible.
She said she has been taking her antidepressants for about 10 years now and they did the
trick at the start. She suspects they still help but she feels either the medications arent strong
enough or her depression is getting worse. Reason being is that she still feels depressed at times
despite taking her medication.
Pathophysiology of depression:

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It's not known exactly what causes depression. As with many mental illnesses, it appears
a variety of factors may be involved. These include:
Biological differences. People with depression appear to have physical changes in
their brains. The significance of these changes is still uncertain, but may eventually
help pinpoint causes.
Neurotransmitters. These naturally occurring brain chemicals linked to mood are
thought to play a direct role in depression.
Hormones. Changes in the body's balance of hormones may be involved in causing or
triggering depression. Hormone changes can result from thyroid problems,
menopause or a number of other conditions.
Inherited traits. Depression is more common in people whose biological family
members also have this condition. Researchers are trying to find genes that may be
involved in causing depression.
Life events. Certain events, such as the death or loss of a loved one, financial
problems, and high stress, can trigger depression in some people.
Early childhood trauma. Traumatic events during childhood, such as abuse or loss of
a parent, may cause permanent changes in the brain that make you more susceptible
to depression.
(Staff, 2012)
Nutritional/Metabolic
1. Fluids ordered for this patient:
Out of surgery she was NPO for a day and by the end of my shift she was able to drink
clear liquids only.
2. IV fluids and rates:
Normal Saline (0.9% saline)
3. Diet which has been ordered for the patient:
An all liquid diet
4. Is the patient getting tube feedings?
No
5. Finger stick blood sugar testing?
Every 2 hours on the day of my shift 9/11/13 (6:30 am to 5:00 pm) (The glucose readings
were - 132, 149, 119, 135, 121, 153)

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6. Labs: Explain possible reason(s) for and the significance of lab values in regard to
nutrition:
Comprehensive metabolic panel
Collected: 09/10/13 0357 - Updated: 09/10/13
Specimen Type: Blood
Sodium - 139 mmoL/L
ALT - 28 U/L
Potassium - 3.5 mmoL/L
Alkaline Phosphatase - 83 U/L
Chloride - 108 mmoL/L (H)
Albumin - 1.7 g/dL (L)
CO2 - 19.0 mmoL/L (L)
Total Bilirubin - 0.40 mg/dL
Anion Gap - 12
Glucose - 114 mg/dL (H)
BUN - 10 mg/dL
GFR - > 60 mg/dL
Creatinine - 0.6 mg/dL
Protein - 5.2 g/dL (L)
Calcium - 7.8 mg/dL (L)
Magnesium - 2.1 mg/dL
AST - 23 U/L

Why does the patient have his/her diet order?

Due to the trauma inflicted on her GI the doctor wants to put as little workload on the GI
until it starts to become more active and starts to accept the surgery. The intestines are a
very touchy organ and will shut off with the smallest of disturbances and will take its
time to start back up. So by ordering an all-liquid diet for the time being the doctor is
preventing any that could go wrong post surgery like dumping syndrome (extreme
diarrhea) or a bowel obstruction of any kind. Based off of her labs she will need to
eventually increase her protein and calcium intake with her new diet. This will promote
better and faster healing, more energy and stronger bones.

How well is the patient eating?

The patient is eating everything that is given to her for breakfast lunch and dinner. She
especially likes the Jell-O.

Can the patient feed him/herself?

Yes

Is the patient getting enough nutrition?

Yes

Does the patient need to have a change in his or her diet order?
The only change would be to get her back on to regular food as soon as possible, but that
will only happen when the doctor feels that her bowels are ready for it.

Does the patient have an NG tube? If so, is it to suction and how much drainage is
coming out?

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NO
**List all nursing diagnoses related to nutrition/metabolism for this patient:
Impaired tissue integrity, readiness for enhanced nutrition, readiness for enhanced selfhealth management, risk for falls, risk for impaired skin integrity, risk for infection, risk
for injury, risk for unstable blood glucose level, risk for Imbalanced nutrition: less than
body requirements
Elimination
1. Does the patient need to have I & O documented?
Yes
2. Will the patient need to use a bedpan or bedside commode?
Yes

3. Labs: Explain possible reason(s) for and the significance of lab values in regard
to elimination:
Bowel elimination pattern
Date of patients last bowel movement:
o 9/9/2013
Did the patient have constipation or diarrhea?
o Diarrhea
If so, what did you do about it?
o I personally didnt do anything. She had the diarrhea because of the preoperative
prepping of her bowel that would clean her out.
Urinary elimination pattern
Did the patient get up to the bathroom? Use a bedpan? Bedside commode?
o She is currently using a Foley catheter but to have a bowel movement she would
get up with the aid of the CNA or nurse and use the toilet.
Did the patient have a Foley catheter? Patent? Any signs of infection?
o Yes she had a Foley catheter put in and there were no signs of irritation or
infection.
Did the patient have at least 30 ml of urine out per hour?
o Yes
Perspiration: excessive?
No
If the patient is on I & O, why?
Due to the surgery she is prone to holding a lot of her fluids and becoming edematous. By
keeping track of her intake and output we can determine how to better treat her based off

NURSING PROCESS PAPER

16

of the data acquired. To maintain normal fluid balance, body water intake and output
should be approximately equal.

**List all nursing diagnoses related to elimination for this patient:

Bowel incontinence, diarrhea, readiness for enhanced urinary elimination.

Activity/Exercise
1. Activity order for this patient:
Physical therapy visited twice a day and would get her out of bed and walk about 50 feet
each time. They said this extra movement will not only help her recover mentally but also
will help get the bowels up and running again.
2. How many times will you plan to get this patient out of bed while you are caring
for him/her?
Twice for physical therapy and maybe one more time if she ever needed to use the
restroom.
3. What will be the best time to get the patient up?
When she is awake and after she has had time for pain medications to kick in (30min post
administration of pain meds.)
4. Type of bath you plan for this patient:
Bed bath
5. When do you plan to do mouth care?
While giving bed bath she would brush her teeth. (She was able to do it herself when I
gave her the tools to do so.)
6. What is the plan for checking vital signs?
We made it a habit to check her vitals each time we took her glucose levels every two
hours.
7. Labs: Explain possible reason(s) for and the significance of lab values in regard
to activity/exercise:
Which activities of daily living was the patient unable to perform? How did you
help?
o She was unable to use the restroom on her own, dress, wash herself, stand and
walk. What I did to help was just support her as she did walked, helped her out

NURSING PROCESS PAPER

17

and into bed, helped her on and off the toilet, dressed her, and bathed her with
cleaning wipes.

What activity level did you implement? Why?

o Her required activity level was lots of bed rest due to her fatigue and pain level
when on her feet.
What was the patients level of activity tolerance? How did the patient tolerate the
activity which you did with him/her?
o Her level of activity intolerance was very high. She was able to walk a little bit
but was very cautious and worried the whole time about falling. Not to mention
she was very fatigued and in pain.
How much help does the patient need to move in bed? Get in a chair? Ambulate?
o She didnt require any assistance in the bed to move around but anything outside
of the bed she would have to have a walker and the assistance of one of the staff.
Does the patient need to use assistive devices for mobility? If so, which ones?
o The patient did need assistive devices to help her mobility and the assistive device
of choice for her was a walker.
Was the patient at risk for falls? If so, what did you do about it?
o Yes The nurse on staff made sure her room was near the main desk area so they
could keep a better eye on her, we kept 3 out of the 4 bed rails up, and with any
ambulation there was someone on the staff helping her while she used her walker.
What kind of bath/mouth care did you implement?
o We used bed bath wipes for her bed bath and we provided her a toothbrush and
toothpaste so she could brush her own teeth while we provided the bed bath.
Were the patients vital signs within normal limits (WNL)? If not, what did you do
about it?
o The patients vital signs were within normal limits except for her blood pressure
which ran a little high. We spoke to her doctor about it and he said to just keep an
eye on her.
**List all nursing diagnoses related to activity/exercise for this patient:
Activity intolerance: fatigue, impaired bed mobility, impaired home maintenance,
impaired physical mobility, impaired transfer ability, impaired walking, readiness for
enhanced self care, risk for activity intolerance, self care deficit: bathing and toileting.

Sleep/Rest
Which planned interventions may interfere with this patients sleep/rest?

NURSING PROCESS PAPER

18

How well did the patient sleep the night before you cared for him/her?
o She said she was woken up by the IV monitor going off twice and once more by
the nurse coming in to get vitals. She did mention that she has trouble sleeping
anyway. So, being woken up 3 times in one night wasnt pleasant considering how
difficult it is for her to go back to sleep.
How well is the patient resting during the day?
o She seeded to rest fairly well during the day. Every time I went into the room she
was waking up. We also were giving her more pain medications during the day,
which played a part in making her drowsy.
Did the patient have any signs of not having enough sleep/rest?
o Other that the subjective information she gave us about her lack of sleep she
didnt show any other signs of not having enough sleep/rest.
What can be done to help the patient to rest better?
o Something that I think would have helped her a lot is just the nurse being more
conscious of the IV monitors in her room and preventing them from sounding
their alarm through the night. Unfortunately vital signs are a must in the middle of
the night.
**List all nursing diagnoses related to sleep/rest for this patient:
Disturbed sleep pattern, sleep deprivation, readiness for enhanced sleep.
Cognitive/Perceptual
Describe the patients level of consciousness (LOC):
o Alert and oriented times 4
Vision and hearing statusany aids?
o Contacts
Other sensory difficulties:
o None
Is the patient at risk for falls? If so, what did you do about it?
o Yes - The nurse on staff made sure her room was near the main desk area so they
could keep a better eye on her, we kept 3 out of the 4 bed rails up, and with any
ambulation there was someone on the staff helping her while she used her walker.
Communication statusreading, writing, comprehension, language spoken, method
of communication:

NURSING PROCESS PAPER

19

o Her primary language is English and she can read and write.

Is there anything that will affect this patients ability to learn?

o None
Are there any cultural considerations to consider in regard to care of this patient?
o None

Was the patient experiencing pain? How much? What did you do about it? Did you
reassess pain after your interventions? Were the interventions successful?
o Yes the patient was in both chronic pain from her joints and acute pain in her
abdomen due to the surgery.
Interventions:
Tell the client to report pain location, intensity and quality when
experiencing pain. Assess and document the intensity of the pain
with each new report of pain and at regular intervals.
Ask the client to describe past and current experiences with pain
and the effectiveness of the methods used to manage the pain,
including experiences with side effects, typical coping responses
and the way the client expresses pain.
Provide pain medication before pain gets past a 5/10.
We did reassess after the intervention were executed and they were
successful in reducing her pain and discomfort.
**List all nursing diagnoses related to cognition/perception for this patient:
Risk for acute infection, acute pain, impaired comfort, readiness for enhanced comfort,
risk for acute confusion.
Self-perception/Role Relationships
How does the patient feel about his/her ability to function at home?
o She said it will be hard to function while at home for the first little while let alone
get back to where she was prior to the surgery, but she mentioned that she had a
great support system at home to help her.
Will this illness affect the patients ability to function at home?
o Yes

NURSING PROCESS PAPER

20

If so, what will be affected and what needs to be done about it?
She will not be able to do the many cleaning chores around the
house and the hobbies she does on a regular basis.

Who depends on this patient at home?

o Husband, children and grandchildren
Who is available to help this patient at home?
o Husband
Who is in charge of discharge planning for this patient?
o The nurse I was assigned to for my shift was in charge of his discharge planning
and teaching.
Will the patient need teaching in regard to needed changes in lifestyle (including
diet, exercise, medications, etc)? If so, what and why? Who will do the teaching?
o Yes Due to now having a stomach the size of a lemon she will need a whole new
diet regime. We had her speak with a dietitian about what she will be eating from
here on out and what she wont be. When she follows this new diet she will be
able to get her knee surgeries and finally be without pain.
**List all nursing diagnoses related to self perception/role relationships for this
patient:
Interrupted family process, Risk for caregiver role strain
Sexuality/Reproduction
Even though we didnt have to assess this area of the functional health patterns I
went ahead and did so anyway. I felt I got to a place by the end of my shift that it
wouldnt be too imposing if I asked. She was more than willing to talk to me about it and
ended up having a positive outlook on the matter by the end of our conversation.
Does this illness have the potential to affect the patients sexuality?
o Yes Due to her obesity she said she hasnt been interment with her husband in a
long time.
Did the patient express any concerns about the impact of this illness on his/her
sexuality? If so, what should be done to address the concerns?
o She said it would possibly effect her intimacy in a positive way later on when she
looses weight.
**List all nursing diagnoses related to sexuality/reproduction for this patient:
Ineffective sexuality pattern, sexual dysfunction.

NURSING PROCESS PAPER

21

Coping/Stress Management/Values/Belief Patterns

Being in the hospital is rough. How is the patient coping?
o Actually at this point, when I brought up being at the hospital and away from
home, she started to cry and mentioned how much she missed her husband and
being at home. I then left her and came back a little later. By this point her
husband was there visiting and she said, Being away from home to me is the
hardest part of my visit here at the hospital.
If the patient is not coping well, what did you do about it?
o Just talking to her helped her to calm down but it got to the point where she just
needed a moment to herself and I left her alone to collect her feelings. Also
having her husband there was a big help to her.
Are the patients spiritual needs being taken care of? How do you know?
o Yes We spoke of both of us being LDS and how she feels that by reading her
scriptures and praying she is able to not only satisfy her need for spirituality but
also it helps her a lot to get through everything especially when she is alone.

**List all nursing diagnoses related to this functional health pattern for this patient:
Hopelessness, powerlessness, readiness for enhanced hope, readiness for enhanced
power, situational low self-esteem
III. General head to toe assessment:
General Survey:

Dress clean and appropriate for situation and weather. Hair neat, nails
manicured, breath fresh, no body odor. Upright in the bed (HOB 45 degrees), posture
erect, gait not assessed upon arrival due to being bed ridden, body build is severely obese.
Mood and affect appropriate for situation. Sitting quietly, rates anxiety as 3 on a scale of
0 to 10. Oriented to person, place, time, and speech clear.

Height/Weight:

She is 160 cm tall and weighs 132 Kg.

Vital signs:
TIM
E
7:00
AM

B
P
1
2

99

OX
YG
EN
2
LT

TE

97.

NURSING PROCESS PAPER

22

2
/
6
0

1
3
9
/
6
5

7:30
AM

12:0
0
AM

1
1
7
/
6
1

10

98

3:00
PM

1
1
8
/
7
0

94

Na
sal
can
nul
a
2
LT
Na
sal
can
nul
a
2
LT
Na
sal
can
nul
a
2
LT
Na
sal
can
nul
a

97

97

98.

Blood sugar: We checked her blood sugar every 2 hours due to doctors order. These
readings started at 6:30 am until I left at 5:30 pm
132, 149, 119, 135, 121, 153
(As you can see for the most part she was hyperglycemic. Eat time we were told to just
keep an eye on her instead of provide insulin by the doctor.)

Skin, Hair and Nails:

Skin color Caucasian, pink undertone, even pigment, no odor. Warm, moist, smooth, no
areas of thickness or thinness. Turgor elastic. No superficial vasculature. Skin was
sensitive areas with staples were the trocars and surgical instruments were inserted for her
laparoscopic gastric bypass surgery and incision site along the midline of her abdomen
(25 cm long), Hair clean, no nits. Dark brown, uniform, wavy, soft with even distribution.
No alopecia or scalp lesions. Nails Fingernails and toenails clean, trimmed. Nail beds
pink, white crescents at bases, capillary refill immediate. Surface slightly convex. Nail
texture smooth, strong, regular, firm attachment at base. Cuticles smooth and flat. Around
2:00 pm 9/11/2013 I was asked to remove every other staple of the midline incision site
and all the staples from each area that the instruments were inserted.

NURSING PROCESS PAPER

23

Due to her difficulty ambulating and other aspects she had a score of 17 on the Braden
Scale. With a score of 15 to 18 means was high risk and needed to be turned frequently,
maximized remobilization, protected heels, and managed moisture, nutrition, and
friction/shear.
Wound care: Dry to dry dressing over incision (staple) area.
IV site: They put her on a saline lock by the end of my shift and the site showed no
redness or inflammation and was open and clear.
HEENT:
Head: Normocephalic, all facial structures symmetric. Movements symmetric and
smooth. Temporal Artery smooth, no bruit. TMJ full ROM, no pain.
Neck: Color consistent with face, symmetric. Full ROM. Pulsation of carotids visible,
jugulars not visualized. Trachea midline, distance to sternocleidomastoids equal, C-Rings
palpable, mobile. Thyroid visible on swallow, nonpalpable, no bruits. Lymph nodes
nonpalpable.
Eyes: Distant Vision 20/20 with contacts. EOM intact, no nystagmus. Corneal Light
Reflex symmetric. PERRLA. Eyebrows, lashes black, symmetric, corneas clear. Eyeball
firm, no swelling or tenderness, conjunctiva pink, sclera no lesions. Fundus disc oval,
creamy pink, distinct margins.
Ears: symmetric, no lesions. Tragus nontender, mastoid smooth and nontender. Canal
patent, no drainage, small amount cerumen in canal, no scars,
Nose and Sinuses: Nose straight, septum midline, nares equal, patent, no drainage,
mucosa pink. Sinuses nontender.
Mouth and Throat: Lips smooth, symmetric, no lesions. Teeth 28 intact, clean, smooth
edges. Oral mucosa pink, intact. Tongue mobile, dark pink. Gums intact, no swelling.
Salivary ducts visible, productive, no swelling or pain. Palates smooth, continuous, uvula
midline, rises with aah.
Respiratory:
Respirations 16, regular and deep, with no use of accessory muscles. Skin color
consistent. Chest 2:1 Transverse to AP diameter. Symmetric thoracic expansion. Clear
vesicular sounds on auscultation. No adventitious breath sounds throughout.
Cardiovascular:
Apical pulse 95, Chest color consistent, no edema, no visible pulsations, heaves, thrills.
Carotid pulsations not visible, jugular veins not visible. Heart Sounds: Apical point
S1=S2, No extra sounds auscultated. Carotid pulse Apical pulse.

NURSING PROCESS PAPER

24

Peripheral Vascular Extremities:

Color consistent, warm. Edema 2+ in legs bilaterally and no edema in arms, superficial
vessels, or varicosities. Sensation intact for pain and temperature. Pulses: All strong and
regular.

Abdomen:
Shape and contour very round (due to obesity), symmetric, smooth, no lesions, bulges,
pulsations, or visible peristalsis. Skin color consistent. Bowel sounds present all
quadrants. No bruits, venous hums, or friction rubs. Abdomen soft, smooth, no palpation
performed due to surgery on abdomen otherwise there would be extreme tenderness upon
palpation.
GI / GU:
Patient was on strict intake and outtake and had a Foley catheter placed. Urine is a clear,
light yellow color and there is no odor.

Reproductive:
No exam necessary at this time.
Musculoskeletal:
All joints and bones symmetrical, full ROM. No edema, visible deformities, Some
crepitus, crackling, clicking, and pain in right and left knees. Muscles in arms legs and
neck are symmetric, firm, nontender and strong bilaterally. Spinal alignment normal
curvatures, vertebral processes aligned. Scapulae, iliac crests and gluteal folds level and
symmetric, leg length equal. Gait is staggered but is able to walk about 50 feet but then
needs to sit down due to fatigue and pain in her abdomen.
Fall Risk: 50 - All items in medium prevention plus provide commode at bedside (if
appropriate), Foley catheter was placed. Place patient in room near nurses station
(especially first 24-48 hours of admission) consider patient safety alarm, consider bedside
mat. Keep call light, bedside table, and personal items within reach. Keep three of the
four bedrails up at all times and tell her to notify staff when she needs to get out of bed.
Neurological:
Memory intact. Abstract reasoning can state differences and similarities in several
categories. Facial expression congruent with topic. Maintains eye contact throughout
interaction. Follows directions. Cranial Nerves intact. Walks heel to toe with the help of
another person and a walker. Finger to nose with smooth movements with eyes open and
closed. Able to feel light touch on feet and hands.
IV. Developmental level of this patient

L.P. is deffinately in the Generative vs. stagnation period, which is to feel

the need to create or nurture things that will outlast them, often by having children, or
creating a positive change that benefits other people. Success leads to feelings of

NURSING PROCESS PAPER

25

usefulness and accomplishment, while failure results in shallow involvement in the

world. (Wilkinson 2011).

The whole time I was there talking with her she would constantly talk
about her kids and grand kids and how they are always at her home. She spoke of loving
to have them all over and making dinner for everyone. She is a natural caregiver and
loves her family.

V. Look at all of the nursing diagnoses from the above assessment. Prioritize the
first 5 nursing diagnoses according to which are most threatening to the life and
integrity of the patient and/or family. Include a paragraph stating your rationale for
prioritization.

Out of all the nursing diagnoses that I have identified I have been able to
narrow down the five that I feel are most pertinent to start with. Even though there are
many that could be considered important I feel that these five are both important but
more importantly, urgent. The prevention of infection is probably the up most important
of the five. Not only does she have a huge healing incision in her abdomen but also 5
other small incisions around the area for the instruments used during the surgery. She is
also a diabetic, which always makes the healing process more difficult.
Acute pain is a no brainer as well but not quite as urgent as infection control. Pain
in most cases wont kill you but could effect your healing time. I truly feel that a happy
patient is a faster recovering patient and nothing says angry hopeless patient more than a
patient in severe pain. So, getting the pain of the surgery and the chronic osteoarthritic
pain under control is a must.
Next thing on the list for faster healing is getting up and moving. She is going to
have some activity intolerance, but getting her moving a little at a time will not only help
the bowels start their peristaltic action but also boost moral. But, like I said before in
order to accomplish more movement we need to subdue the pain so it is more bearable.
I couldnt leave out her obesity considering that is probably the main reason for
most if not all of her preventable medical conditions. Yes, she had the laparoscopic
gastric bypass surgery to help her loose the weight but there are plenty of stories of
people stretching out their new stomach to the same size it was before. In other words,
she needs to get what got her to this point in check. This is probably her eating habits and
lack of exercise. Genetics might play a role in this as well but anything in the right
direction will be an improvement. Small chance she could gain more weight at this point.
Lastly I thought of the silent killer, or her lack of knowledge there of, was
important to include. While it might not be as urgent it is still hugely important to inform
her of the importance of her blood pressure management. It has its nickname for good
reason. Considering the weight loss she will most likely will have and the diet that will
help her get there you would think that her blood pressure issues would improve. That
aside, she still needs to know why it is so important to her bodys well being to bring
down her BP and keep it there. Obviously keeping her on her Lisinopril is important, but
helping her eat a diet close to the DASH diet and exercising in some way would also be
just as important.

NURSING PROCESS PAPER

VI. Care Plan: make a plan of care for each of the 5 prioritized above nursing

Diagnoses

Subjectiv
Nursin
Short
Nursing
Document

e&
g
& long
Intervention
ed
Objective
Diagn
term
s:
rationale
data
osis
measur
Independent
for your
pertinent
R/T &
able &
,
interventi
to
AEB
realisti
Collaborativ
ons
nursing
or
c
e or
diagnosis
AMB
patient
Dependent
if
goals

applic
&
able.
outcom
es

1- Patient
L.,R. is
Risk
Short:
1- Observe

may be
for
for
signs
of

Patient
55 years
admitted
Infecti
infection

will
with
of age.
on
and
demon
infection,
She has
inflammatio
which could

strate
Diabetes
have
n,
e.g.,
techniq
r/t:
precipitated
Mellitus
fever,
ues,
High
the
flushed
lifestyl
II. She is
glucos
ketoacidotic
appearance,
e
state, or
e
in the
wound
may
change
levels,
hospital
develop a
drainage,
s to
decrea
nosocomial
right now
purulent
prevent
sed
infection.
for a
sputum,
develo
leukoc
(LeMone
cloudy
pment
2013)
laparosco
yte
urine.

of
functi
pic
2- Reduces

infecti
on,
bypass
risk of
on
by
2- Promote
alterati
crosssurgery
the end
ons in
good
contaminati
and a
of my
circula
handwashin
on.

26

Evaluati
on of
goals:

Short
term:
Patient
was able
to tell
me
everythi
ng she
could
rememb
er about
cleanlin
ess of
herself
and the
wound
and
why.
She was

NURSING PROCESS PAPER

cholecyst
ectomy.
She has a
medical
history of
:
ArnoldChiari
Malform
ation
Arthritis
of hands
and feet
Chronic
knee pain
(Osteoart
hritis)
Depressi
on
Diabetes
mellitus
Hyperte
nsion
Migrain
e
headache
s
Severe
Obesity

tion,
and
surgic
al
openin
gs in
her
abdom
en.

27
shift.
9/11/20
13

Long:
Will
have
success
fully
healed
wound
s
withou
t an
infecti
on in 2
months
time.

g by staff
and patient.

3- Keep
wound area
clean and
change
dressings
when soiled
4Encourage
adequate
dietary and
fluid intake
(approximat
ely3000
mL/day if
not
contraindica
ted by
cardiac or
renal
dysfunction)
, including 8
oz of
cranberry
juice per
day as
appropriate.

(LeMone
2013)

She
speaks
English
as her
dominant
language.

3- By not
allowing
drainage to
sit and
cleaning the
area you are
creating an
uninhabitabl
e area for
bacteria to
grow and
live.
(LeMone
2013)
4Decreases
susceptibilit
y to
infection.
Increased
urinary flow
prevents
stasis and
aids in
maintaining
urine
pH/acidity,
reducing
bacteria
growth and
flushing
organisms
out of
system.
Note: Use
of cranberry
juice can
help prevent
bacteria
from
adhering to
the bladder
wall,
reducing the
risk of
recurrent
UTI.
(LeMone
2013)

able to
successf
ully
mention
all the
importa
nt
aspects
of
infectio
n
control
9/11/201
3.

Long
term:
Unable
to assess
at this
time.

NURSING PROCESS PAPER

28

Subjectiv
e&
Objective
data
pertinent
to nursing
diagnosis

L.,R. is
55 years
of age.
She has
Diabetes
Mellitus
II. She is
in the
hospital
right now
for a
laparosco
pic gastric
bypass
and a
cholecyst
ectomy.
She has a
medical
history
of :
ArnoldChiari
Malforma
tion

Nursing
Diagnosi
s R/T &
AEB or
AMB if
applicabl
e.

Acute
Pain
r/t:
cholecys
tectomy
and
laparosc
opic
gastric
bypass
surgery
AEB:
- Patient
selfreport of
pain
level of
a 6/10
while on
narcotic
opioid
medicati
ons.
Grimaci
ng upon

Short &
long term
measurabl
e&
realistic
patient
goals &
outcomes

Short:

Usepain
rating
scaleto
identify
current
levelof
pain
intensity,
and
determin
e
comfort/f
unction
andgoal
bythe
endof
myshift.
9/11/201
3

Long:
Patient

will
function
on

Nursing
Interven
tions:

Documen
ted
rationale
for your
interventi
ons

Evaluat
ion of
goals:

1- Tell
the client
to report
pain
location,
intensity
and
quality
when
experienc
ing pain.
Assess
and
document
the
intensity
of the
pain with
each new
report of
pain and
at regular
intervals.

1- Systematic
ongoing
assessment
and
documentatio
n provide the
direction for
pain treatment
plans ;
adjustments
are based on
the clients
response.
(Lemone,
2013)

Short
term:
Patient
was
able to
tell me
her
pain
level
and
also
relay to
me
what
she
normall
y does
to
subdue
the
chronic
pain
and I
was
able to
assist
her in
doing
so and

2- Ask
the client
to
describe
past and
current
experienc
es with
pain and
the
effectiven

2- A number
of concerns
(barriers) may
affect patients'
willingness to
report pain
and use
analgesics

(LeMone
2013)
3- Opioids
may cause
respiratory
depression
because they
reduce the
responsivenes
s of carbon
dioxide
chemorecepto
rs located in
the respiratory
centers of the
brain. Because
even more
opioid is
required to

NURSING PROCESS PAPER

Arthritis
of hands
and feet
Chronic
knee pain
(Osteoart
hritis)
Depressi
on
Diabetes
mellitus
Hyperten
sion
Migraine
headaches
Severe
Obesity

acceptabl
eability
levelwith
minimal
interferen
cefrom
painand
medicatio
nside
effectsin
two
months.

moveme
nt or
touching
of
surgical
are

29

Multiple
incisions
on
abdomen

She
speaks
English as
her
dominant
language.

produce
respiratory
depression
than is
required to
produce
sedation,
patients with
clinically
significant
respiratory
depression are
usually also
sedated.
Respiratory
depression can
be prevented
by assessing
sedation and
decreasing the
opioid dose
when the
patient is
arousable but
has difficulty
staying awake

ess of the
methods
used to
manage
the pain,
including
experienc
es with
side
effects,
typical
coping
responses
and the
way the
client
expresses
pain.
3- When
opioids
are
administe
red,
assess
pain
intensity,
sedation,
and
respirator
y status at
regular
intervals.

4- Assess
client and
family
knowledg
e of side
effects
and
safety
precautio
ns
associate
d with
pain
medicatio
ns

Subjectiv
e&
Objectiv
e data

Nursing
Diagnosi
s R/T &
AEB or

Short &
long
term
goals &

Nursing
Intervent
ions:

(LeMone
2013)

it did
the
trick.
(Movin
g the
joint
around,
Tylenol
and a
pillow
under
her
knees)
9/11/20
13.

4- The
cognitive
effects of
opioids
usually
subside within
a week of
initial dosing
or dose
increases
(McCaffery,
Pasero, 1999).
The use of
long-term
opioid
treatment does
not appear to
affect
neuropsycholo
gical
performance.
Pain itself
may
deteriorate
performance
of
neuropsycholo
gical tests
more than oral
opioid
treatment
(Sjogren et al,
2000).

Docume
nted
rationale
for your

Long
term:
Unable
to
assess
at this
time.

Evalua
on of
goals:

NURSING PROCESS PAPER

pertinent
to
nursing
diagnosis

L.,R. is 55
years of
age. She
has
Diabetes
Mellitus
II. She is
in the
hospital
right now
for a
laparoscop
ic bypass
surgery
and a
cholecyste
ctomy.
She has a
medical
history of :
ArnoldChiari
Malformat
ion
Arthritis
of hands
and feet
Chronic
knee pain
(Osteoarth
ritis)
Depressio
n
Diabetes

AMB if
applicabl
e.

Activity
intolerance
r/t:
cholecystec
tomy and
laparoscopi
c gastric
bypass
surgery
AEB:
- Verbal
report of
fatigue
- Her
telling me
that she has
a 6/10 of
abdominal
acute pain
while on
medication
Grimacing
upon
moving in
bed and
limited
movement
while
performing
PT. 50 feet
of walking
with aid
from
walker and
physical
therapist
and has to
stop and
rest for
hours after.

30
outcome
s

intervent
ions

Sh
ort:
She
wil
l
de
mo
nstr
ate
the
pro
per
use
of
ada
pti
ve
equ
ip
me
nt
to
inc
rea
se
mo
bili
ty
by
the
end
of
my
shif
t.

9/1
1/2
013

Lo
ng:
In
thr
ee
we
eks

1- I will
contact a
dietitian
and ask
he/she to
come and
help me
explain the
appropriate
foods to eat
for
promotion
of healing
and higher
quality of
life.
2- Educate
patient on
the
importance
of her at
home
Physical
Therapy
sessions
and to put
in practice
what she
has been
taught post
PT in her
daily
activities.
3- pain
medications
that have a
longer
lasting
effect to

1- By having a
professional there to
explain what to eat
and not to eat will
help the patient to
possibly take the
information more
seriously and to
heart. Also my the
nurse being there
and reassuring the
dietitian on the
information will
only help the nail be
driven deeper.
Provide a diet high
in protein and
kilocalories. A highprotein, highkilocalorie diet
provides the
necessary nutrients
to meet metabolic
and tissue healing
needs. (LeMone
2013)
2- By engaging ones
self in Physical
Therapy post surgery
one will not only
promote healing due
to increased blood
flow but also boost
moral by be ing able
to see and have other
notice the progre ss
that person is making.
(John Hopkins
Medicine 2012)
3- By providing the
pain medication we
will be attacking the
problem at it's roots
by subduing the pain
and allowing the
patient to feel more
comfort able. This
will also help the
patient to see that her
healing process is
something that she
can over come due to
the lack of unbearable
pain. Also by

Sh
t
te
:
W
w
e
ab
to
ge
he
to
w
k
th
ha
sh
w
in
no
on
he
he
to
ge
ou
of
be
an
m
e
ar
nd
bu
al
to
as
st
w
sh
w
us
g
he
as
tiv
de
ce
In

NURSING PROCESS PAPER

mellitus
Hyperten
sion
Migraine
headaches
Severe
Obesity

She
speaks
English as
her
dominant
language.

31
tim
e
she
wil
lbe
abl
eto
wal
k
200
feet
whi
le
usi
ng
the
assi
sta
nce
ofa
wal
ker
and
rep
orti
ng
a3
on
the
pai
n
sca
le
whi
le
usi
ng
me
dic
atio
ns.

use during
the day so
that she can
participate
more
willingly in
her PT and
ADLs

do
g
w
w
e
ab
to
he
he
un
er
nd
ho
to
us
th
e
de
ce
in
m
e
er
no
ic
m
ne
an
in
do
g
w
w
he
pr
en
fu
he
in
y
th
m
ht
oc
r
w
he

continuously
providing pain
medication you are
able to prevent severe
pain from setting in.
Established,
persistent, severe pain
is more difficult to
treat than pain that is
at its onset. (LeMone
2013)

9/
/2
3.

Lo
g
te

NURSING PROCESS PAPER

32

Subjectiv
e&
Objective
data

L.,R. is
55 years
of age.
She has
Diabetes
Mellitus
II. She is
in the
hospital
right now
for a
laparosco
pic
bypass
surgery
and a
cholecyst
ectomy.

Nursin
g
Diagno
sis R/T
& AEB

Severe
Obesity

Short:

r/t:
Excessi
ve
intake
in
relation
to
metabo
lic need
AEB:
- BMI
level of
51
- body
fat
percent
age

Short &
long term
goals &
outcomes

Shewill
verbalize
backto
usthe
importan
ceof
practicin
gbetter
eating
patterns,
better
food
quantity/
quality,
and
utilizatio
nofan
exercise

Nursing
Interven
tions:

Rational

Evaluat
ion of
goals:

1Establis
h
weight
reductio
n
program
in
accorda
nce with
her new
Gastric
Bypass
with
Physical
Therapi
st and
Dietitia
n

1- Current
research
(Sacks et al.,
2009) shows
no
significant
difference in
the efficacy
of selected
diet plans.
Offering a
selection of
appropriate
diet plans
empowers
the patient to
choose a
plan that
best matches
food
preferences
and lifestyle
and
therefore
produces
better

Short
term:
Me and
the
Physica
l
Therapi
st
talked
with
her for
about
an hour
during
her PT
about
the
importa
nce of
these
things
and she

2Discuss

:
U
bl
to
as
ss
th
tim
.

NURSING PROCESS PAPER

She has a
medical
history
of :
ArnoldChiari
Malforma
tion
Arthritis
of hands
and feet
Chronic
knee pain
(Osteoart
hritis)
Depressi
on
Diabetes
mellitus
Hyperten
sion
Migraine
headaches
Severe
Obesity

She
speaks
English as
her
dominant
language.

greater
than
22%
Triceps
skin
fold
>25
mm

33

program
provided
byher
Physical
Therapist
andhow
bythe
endof
myshift
today.
9/11/201
3

her
motivati
on for
weight
loss (for
own
satisfact
ion of
selfesteem,
or to
gain
approva
l for
knee
surgery
she is
due for
but can't
because
the
doctor
says she
is too
obese)

Long:
Demonstr

ating
appropria
te
changes
in
lifestyle
and
behaviors
,
including
eating
patterns,
food
quantity/
quality,
and
utilizatio
nofan
exercise
program
provided
byher
Physical
Therapist
in3
weeks

3Recom
mend
her to
weigh
herself
only
once per
week at
the
same
time and
day of
the
week,
clothes,
and
graph it
on a
chart.

results.
(LeMone
2013)

2- Even
though her
road to
enough
weight being
lost for her
knee surgery
might be far
off small
goals to get
her there
will make t
he
experience
more
bearable.
Small goals
provide
more
opportunitie
s for
success.
Positive
feedback
and
encouragem
ent provide a
comfortable
environment
in which to
develop selfesteem.
(LeMone
2013)
3Continuing
assessment
not only is
import ant to
evaluate the
safety of
weight loss
strategies,
but also to
reinforce
positive
benefits of
weight loss.
(LeMone
2013)

clearly
verbali
zed
back to
us how
she
underst
ood
what
we
were
saying
and
how
much
this
will
influen
ce her
life for
the
better.
9/11/20
13.
Long
term:
Unable
to
assess
at this
time.

NURSING PROCESS PAPER

34

time.

Subjectiv
e&
Objective
data
pertinent
to
nursing
diagnosis

L.,R. is
55 years
of age.
She has
Diabetes
Mellitus
II. She is
in the
hospital
right now
for a
laparosco
pic
bypass
surgery
and a
cholecyst
ectomy.
She has a
medical
history of
:
Arnold-

Nursing
Diagnos
is R/T
& AEB
or AMB
if
applicab
le.

Knowle
dge
Deficit
(hyperte
nsion)
r/t: Lack
of
informat
ion
needed
about
hyperte
nsion
manage
ment
AEB:
- Lack
of BP
control
- Her
concern
about
how she
already
has cut

Short &
long
term
measura
ble &
realistic
patient
goals &
outcome
s

Short:

Use
pain
rating
scaleto
identify
current
levelof
pain
intensit
y,and
determi
ne
comfort
/functio
ngoal
bythe
endof
my
shift.
9/11/20
13

Long:

Measure
body fat
when
possible
.

Nursing
Intervent
ions:

Documente
d rationale
for your
intervention
s

Evalua
tion of
goals:

1- Assess
patient
understa
nding of
direct
relations
hip
between
hyperten
sion and
obesity.

1- Obesity is an
added risk with
high blood
pressure
because of the
disproportion
between fixed
aortic capacity
and increased
cardiac output
associated with
increased body
mass. Reduction
in weight may
obviate the need
for drug therapy
or decrease the
amount of
medication
needed for
control of BP.
Faulty eating
habits contribute
to
atherosclerosis
and obesity,
which
predispose to
hypertension
and subsequent
complications,
e.g., stroke,
kidney disease,
heart failure.
(LeMone 2013)

Short
term:
Patient
was
able to
tell me
her
pain
level
and
also
relay
to me
what
she
norma
lly
does
to
subdu
e the
chroni
c pain
and I
was
able to
assist

2Discuss
necessity
for
decrease
d caloric
intake
and
limited
intake of
fats, salt,
and
sugar as
indicated
.

NURSING PROCESS PAPER

Chiari
Malform
ation
Arthritis
of hands
and feet
Chronic
knee pain
(Osteoart
hritis)
Depressi
on
Diabetes
mellitus
Hyperte
nsion
Migrain
e
headache
s
Severe
Obesity

She
speaks
English
as her
dominant
language.

out
sodium,
exercisi
ng, and
loosing
25 lbs.
and her
blood
pressure
hasnt
changed
.
- Her
saying
I didnt
know
about a
lot of
things
pertaini
ng to
hyperte
nsion
prevente
rs like
eating
more
potassiu
m,
calcium,
magnesi
um etc.
I only
knew
about
not
eating
sodium.

35

Patient
will
function
on
accepta
ble
ability
level
with
minimal
interfer
ence
from
pain
and
medicat
ionside
effects
two
months.

3Encoura
ge
patient to
maintain
a diary
of food
intake,
includin
g when
and
where
eating
takes
place
and the
circumst
ances
and
feelings
around
which
the food
was
eaten.

2- Excessive
salt intake
expands the
intravascular
fluid volume
and may
damage
kidneys, which
can further
aggravate hyp
ertension. Not
e: One study
showed that
sodium
reduction
reduced the
need for
medication by
31%. Weight
loss lowered
the need for
medication by
36% and the
combination of
the two by
53%. (LeMone
2013)
3- Provides a
database for
both the
adequacy of
nutrients eaten
and the
emotional
conditions of
eating. Helps
focus attention
on factors that
patient has
control over/can
change.
(LeMone 2013)

VII. Include a paragraph summarizing your care of this patient.

her in
doing
so and
it did
the
trick.
(Movi
ng the
joint
around
,
Tyleno
l and a
pillow
under
her
knees)
9/11/2
013.

Long
term:
Unabl
e to
assess
at this
time.

NURSING PROCESS PAPER

36

Taking care of L.P. was very pleasant considering how great of a person she was.
It was also very educational due to the many different aspect of her health to consider
before providing a solution. Being able to help her through only one day of her stay at the
hospital left me wanting to continue to take care of her the next day or to just find out
how things turned out for her. Ironically enough while I was in my endoscopy rotation
Mrs. L.P. showed up to get a check up on how well her surgery had taken. Being able to
see and talk with her again was a great experience. She was in great shape and had
already lost weight due to her surgery and new diet. She was very help with it and was
thanking me way more than she needed to for my assistance. They even invited me for
dinner after their appointment. I didnt end up going to dinner with them of-course but
the feeling they left me with, through their appreciation of my time with them, made my
day and really helped me see how this career is right for me.

NURSING PROCESS PAPER

37

Citations

Arnold Chiari Malformation: Symptoms, Types, and Treatment. (n.d.). WebMD.

Retrieved November 17, 2013, from http://www.webmd.com/brain/chiari-malformationsymptoms-types-treatment
Barr, R., Myslinski, M., & Scarborough, P. (2008). Understanding type 2 diabetes:
pathophysiology and resulting complications. PT: Magazine Of Physical Therapy, 16(2),
34-34-40, 42, 44 passim.
Deglin, J. H., & Vallerand, A. H. (2009). Davis's drug guide for nurses (11th ed.).
Philadelphia, Penn.: F.A. Davis.

LeMone, P. (2013). Medical-surgical nursing: critical thinking in patient care. (5th ed.,
Pearson new international ed.). Upper Saddle River, N.J.: Pearson.

Redinger, R. (2007, November 1). The Pathophysiology of Obesity and Its Clinical
Manifestations. NCBI. Retrieved November 17, 2013, from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104148/
Staff, M. (2012, February 10). Definition. Mayo Clinic. Retrieved November 18, 2013,
from http://www.mayoclinic.com/health/depression/DS00175/DSECTION=causes
Taber's cyclopedic medical dictionary (Ed. 21 ed.). (2005). Philadelphia: F.A. Davis.
Wilkinson, J. M., & Treas, L. A. (2011). Fundamentals of nursing (2nd ed.). Philadelphia:
F.A. Davis Co..