HEAD NURSING TEMPLATE

Student Nurse: Carnate, Bianca Mae H. Date: March 02, 2021 Head Nurse: Nicole Brombuela

Name of Patient: Mrs. M Gender: F Age: 88 y/o

Marital Status: N/A

Date of Admission: N/A Date of Discharge: N/A

Admitting Diagnosis: Acute pancreatitis

Final Diagnosis: N/A

MONITORING

TIME BP PR RR TEMP O2 SAT LOC

113/82 mmHg 84 20 cpm 37.6 N/A N/A
 NCP

ASSESMEN DIAGNOSIS SCIENTIFIC EXPLANATION PLANNING INTERVENTION RATIONALE EVALUATION

T
Subjective Acute pain Presence of Gallstones Goal: After 4 hrs. of independent: independent: Goal: After 4 hrs. of
cues: related to ↓↓↓ NI, the client will 1. Investigate 1. Pain is often NI, patient has
(+) inflammation Gallstones pass through the report relief of pain verbal diffuse, reported relief of
Grimacing , edema, common bile duct to enter the and discomfort and reports of severe, and pain and displayed a
(+) Facial distention of small intestine. display calm and pain, noting unrelenting relaxed and calm
mask of the pancreas, ↓↓↓ relaxed behavior. specific in acute or behavior.
Pain and location and hemorrhagic
(+) peritoneal Main pancreatic duct joins or lies Expected Outcome: intensity (0– pancreatitis. Expected Outcome:
Confusion irritation immediately next to the common After all the nursing 10 scale). Severe pain After all the nursing
bile duct interventions the Note factors is often the interventions the
Patient ↓↓↓ client will be able that major client was able to:
reports to: aggravate symptom in  Report or
Pain Rating stones that get stuck in the  Report or and relieve patients with verbalize less
Scale of common bile duct impinge on the verbalize less pain. chronic pain by giving
8/10 main pancreatic duct pain by giving 2. Acknowledg pancreatitis. lower pain
lower pain e the pain Isolated pain score from 8 to
Objective ↓↓↓ score from 8 to experience in the RUQ 5 with 10 being
cues: 5. and convey reflects the highest.
(+) obstruction of the normal flow of  Enumerate and acceptance involvement  Enumerate and
Distended pancreatic fluid re-demonstrate of client’s of the head re-demonstrate
Abdomen ↓↓↓ non- response to of the non-
(+) Anxiety pharmacologica pain. pancreas.
pharmacologica
leading to inflammation or injury 3. Observe Pain in the
l methods of l methods of
of the pancreas nonverbal left upper
pain relief pain relief.
cues and quadrant
>appear more >appeared more
Refs: pain (LUQ)
relax and calm. relax and calm.
https://www.scribd.com/documen behaviors. suggests
 t 4. Promote involvement
/344230045/NCP-Acute-Pain- position of of the
Pancreatitis comfort on pancreatic
one side tail.
with knees Localized
flexed, pain may
sitting up indicate
and leaning development
forward. of
5. Provide pseudocysts
alternative or abscesses.
comfort 2. Pain is a
measures subjective
like back experience
rub; and cannot
encourage be felt by
relaxation others.
techniques 3. Observations
like deep may not be
breathing congruent
exercises; with verbal
and quiet report.
diversional 4. Reduces
activities abdominal
e.g. listening pressure and
to music, tension,
socialization providing
with others. some
6. Keep measure of
environmen comfort and
t free of pain relief.
 food odors. Supine
position
Dependent: often
increases
1. Administer pain
analgesics in 5. Promotes
timely relaxation
manner and enables
(smaller, patient to
more refocus
frequent attention;
doses). may
2. Withhold enhance
food and coping.
fluid as 6. Sensory
indicated. stimulation
3. Prepare for can activate
surgical pancreatic
interventio enzymes,
n if increasing
indicated. pain.

Dependent:

1. Severe and
prolonged
pain can
aggravate
shock and is
more
 difficult to
relieve,
requiring
larger doses
of
medication,
which can
mask
underlying
problems
and
complication
s and may
contribute to
respiratory
depression.
2. Limits and
reduces
release of
pancreatic
enzymes and
resultant
pain.
3. Surgical
exploration
may be
required in
presence of
intractable
pain and
complication
 s involving
the biliary
tract, such as
pancreatic
abscess or
pseudocyst.

FDAR

Focus Data Action Response

Acute (Abdominal) Pain
Patients reports PRS of 8/10 Assessed verbal reports of pain Patient was able to report a PRS
through PRS of 5/10 and demonstrated
relaxed and calm behavior.
(+) Facial Grimace, Anxious, Provided alternative comfort
Appears Confused measures such as back rubs,
relaxation techniques, Deep
breathing exercises, etc.
Gave IV Morphine x 4’
prescribed by the client’s doctor.

Nurse’s Notes:

Received patient at emergency room.

Patient’s physical assessment revealed a distended abdomen that is very tender on palpation and bowel sounds are present in all four
quadrants, but hypoactive.

Monitored vital signs.

Administered Pre-admission Drugs prescribed by Dr. (Pantoprazole Sodium & Levothyroxine Sodium IV)

Given Morphine IV 4 mg as per pain prescribed by physician.

Drug Study

Drug Action Indication Contraindication Nursing Responsibility

Generic Name: Inhibits proton pump Pantoprazole is a very PROTONIX is Reconstitute each vial
Pantoprazole Sodium activity by binding to widely used safe drug contraindicated in with normal saline
Brand Name: protonix hydrogen potassium and possesses anti- patients with known solution.
Route: IV adenosine inflammatory properties hypersensitivity to any Reconstituted solution
Dosage: 40 mg triphosphatase, located in vivo and even component of the may be stored for up to 2
Frequency: 1 at secretory surface of attenuates the course of formulation or any hrs. at room temp.
gastric parietal cells, to acute pancreatitis. substituted Treatment with IV
suppress gastric acid benzimidazole. pantoprazole should be
secretion. Hypersensitivity reactions stopped when PO form is
may include anaphylaxis, warranted.
anaphylactic shock, Don’t confuse Protonix
angioedema, with other drugs that
bronchospasm, acute sound alike.
tubulointerstitial Drug can be given
nephritis, and urticaria. without regard to meals.
Symptomatic response to
therapy doesn’t preclude
the presence of gastric
malignancy.
Generic Name: Stimulates metabolism of Levothyroxine is used to Contraindicated in Monitor BP and HR
Levothyroxine Sodium all body tissues by treat an underactive patients hypersensitive to closely. Use caution in
Brand Name: Eltroxin accelerating rate of thyroid (hypothyroidism). drug and in those with elderly patients.
Route: IV cellular oxidation. It replaces or provides acute MI uncomplicated Drug may be given IV/ IM
Dosage: n/A more thyroid hormone, by hypothyroidism, when PO ingestion is
Frequency: 1 which is normally untreated thyrotoxicosis, precluded for long
produced by the thyroid or uncorrected adrenal periods. However, dosage
gland. Low thyroid insufficiency. adjustment is needed.
hormone levels can occur
naturally or when the
thyroid gland is injured
by radiation/medications
or removed by surgery.
Having enough thyroid
hormone is important for
maintaining normal
mental and physical
activity. This medication
is also used to treat other
types of thyroid disorders
(such as certain types of
goiters, thyroid cancer).
Generic Name: A potassium sparing To treat the inflammation Contraindicated in Use cautiously in patients
Spironolactone diuretic that antagonizes or Edema of the patients hypersensitive to with fluid or electrolyte
Brand Name: Aldactone aldosterone in the distal pancreas. More-severe drug and in those with imbalances, impaired
Route: N/A tubules, increasing edema may be treated anuria, acute or renal function or hepatic
Dosage: N/A sodium and water with drugs that help your progressive renal disease. To enhance
Frequency: N/A excretion. body expel excess fluid in insufficiency or absorption, give drug
the form of urine hyperkalemia. with meals. Protect drug
(diuretics). from light. Monitor
electrolyte imbalances,
fluid intake and output,

Generic Name: Metoclopramide is
Metoclopramide principally a dopamine
Brand Name: Biclomet D2 antagonist but also (known as an antiemetic).
Route: IV acts as an agonist on
Dosage: N/A serotonin 5-HT4
Frequency: N/A receptors and causes
weak inhibition of 5-HT3
receptors.
Generic Name: Morphine Binds with opiate
Sulfate receptors in CNS, altering
Brand Name: Roxanol both perception and
Route: IV emotional response to
Dosage: 4 mg pain.
Frequency: q4
wt and BP. Monitor
elderly patients, who are
more susceptible to
excessive diuresis. Inform
lab that pt. is taking
spironolactone because it
may alter lab test results.
Metoclopramide is an Contraindicated in Use cautiously with
anti-sickness medicine patients hypersensitive to patients with depression,
the drug and in those Parkinson’s disease, or
It's used to help stop you with pheochromocytoma hypertension. Monitor
feeling or being sick or seizure disorders. Also bowel sounds. Safety and
(nausea or vomiting) for in those for whom effectiveness of drug
including: after stimulation of GI motility haven’t been established
radiotherapy or might be dangerous for therapy lasting longer
chemotherapy (hemorrhage, obstruction than 12 weeks.
(treatment for cancer) or perforation.)
Severe Pain Contraindicated in Use caution in elderly.
patients hypersensitive to Reassess patients level of
drug and in those with pain at least 15-30 mins
conditions that would after parenteral
preclude administration administration and 30
of opioids by IV route. mins after oral
Contraindicated in administration. Keep
patients with GI narcotic antagonist
obstruction. (Naloxone) and
resuscitation equipment
available.