NURSING CARE PLAN
Patient: ___RC____________
Medical Diagnosis: ___GI bleed, hematemesis, ETOH, depression _________
Co-Morbidities: __ pancreatitis, DM, alcohol abuse, prostate enlargement, active anal fistula, covid 2/21, HTN, PE on Xarelto
Nursing Supporting Assessment
Diagnosis Data
SUBJECTIVE:
 “My stomach hurts so
bad, 10/10” (then
pointed at the
PAIN r/t mid/right upper
pancreatitis, quadrant of the
hepatitis, GI abdomen)
bleed and  “Can I have Morphine
anal fistula please?”
 “It’s hurting again,
when is the next time I
can get Morphine?”
 “My fistula in the
bottom is painful.”
 “The pain keeps me
from sleeping”
OBJECTIVE:
 Constant pain 10/10
 Upon palpation,
tender abdomen in all
quadrants
 Normoactive bowel
sounds in L upper and
both lower quadrants,
hypoactive in R upper
quadrant
 NPO for bowel rest
and abd pain
 BP148/88 P127 RR22
 Moaning, constantly
Nursing Interventions Expected Patient Evaluation
Outcome
Monitor:
 VS (BP, HR, RR)
 Assess prior experience with pain,  Pt will have a Goal is met, pt
effectiveness of prior interventions, responses decrease in pain said “I still feel
to analgesic meds including SE level to a the pain, but
 Assess comfort-functional goal tolerable pain it’s just a little
 Comprehensive pain assessment PQRST, level of 7-8/10 by now”
characteristics of pain before and after the end of the
administering opioid analgesics shift
 Monitor effectiveness of pain medications
 Assess CNS status, sedation level, and  Pt can relax/sleep Goal met, pt able
respiratory status at regular intervals, and 1-2 in bed without to relax in bed,
hours after administering opioid analgesics being awakened slept
 Assess for bowel elimination, appetite, ability by pain during intermittently
to rest and sleep my shift without
 Labs: Lipase, LFT, H/H, WBC discomfort
from pain
Manage:  Pt’s BP, HR and Goal not met, VS
RR are at his are still higher
Non-pharmacological interventions: baseline levels at than baseline,
 Distraction (TV, music), imagery, reduce the end of my BP 161/99,
noise/light, relaxation, meditation, heat/cold shift P145, RR22.
applications Considering pt
 Maintain bedrest with BRP is also going
 Promote position of comfort on one side with through ETOH
withdrawal
knees flexed, sitting up and leaning forward
with anxiety
 Keep NPO to rest the bowel
and tremors,
 Cognitive-behavioral strategies, lifestyle pain
Ativan IVP 1mg
management
was given with
 Perform nursing care when pt is comfortable
CIWA neuro
 asking for pain meds (at the peak time of analgesics) checks q1hr
 Diaphoresis after
 Last BM 3 days ago, Pharmacological interventions: administering
constipation possibly  Morphine IVP 2mg/ml q4hr PRN for moderate-
due to pain meds severe pain
 CT-AP without  Request orders to implement pain
contrast shows management interventions to achieve a
pancreatitis, no bowel satisfactory level of comfort
obstruction, hepatic  Protonix continuous drip at 10ml/hr and
steatosis, Sandostatin continuous drip at 12.5ml/hr for
esophagitis/reflux GI bleed
 Last time he vomiting  Topical Lidocaine TID applied on anal fistula
blood was on 5/8  Obtain a prescription for stool
 Dry heaving, indicating softener/peristaltic stimulant to prevent
nausea opioid-induced constipation
 Hep panel: (+) HBV
 Abnormal LFT: AST 58 Teach:
(H), albumin 3.5 (L),  Explain the pain management approach
bilirubin 0.3 (H) including pharm and non-pharm interventions
 Normal lipase (151)  Report effectiveness of pain medications
 On Morphine IVP  Education and report if experiencing any
2mg/ml q4hr PRN for SE/addiction
moderate to severe  Education about use of call light, get help when
pain needed
 Topical Lidocaine TID  Teach pt about alcohol cessation
applied on anal fistula
 Protonix drip at
10ml/hr infusing at
72hr duration
 Sandostatin 12.5ml/hr
continuous infusion
Nursing Supporting Assessment Nursing Interventions Expected Patient Evaluation
Diagnosis Data Outcome

SUBJECTIVE: Monitor:
 “I can’t see clearly, it’s  Neuro check q4hr routine, and q1hr after  Pt’s cognitive  Goal met, pt
blurry” administering Ativan, utilizing CIWA neuro status will return A&Ox4 at the
 “I’m sweating” assessment tool with awareness of pt’s baseline to baseline by the end of the
Neurologic  “Can I have 2 doses of mental status end of the shift shift
 r/t ETOH Ativan?”  Monitor LOC, orientation to time, place, person,
withdrawal  “I can’t control my and purpose
shaking”  Monitor overall appearance, manner, attitude  Pt will be absent  Goal met: no
 Monitor behavioral characteristics, level of of seizure during seizure
OBJECTIVE: psychomotor behavior, attention span, mood, the shift occurs during
 A&Ox3-4, confused at and affect the shift
times  Monitor speech, language
 Altered mental status  Sedate pt carefully, monitor SE of sedatives  Goal met:
 Anxiety, tremors  Monitor VS, CT Head result, EEG, labs: alcohol  Pt will remain even though
 Clear speech, but levels, CK, CBC calm with low pt still feels
pattern is abnormal levels of anxiety anxious and
d/t tremors Manage: and less periods has tremors
 Unsteady, weak gait of tremors during periodically,
 Ataxia Non-pharmacological interventions: the shift it happened
 Weak hand grips,  Reorient if pt becomes confused, or after seizure less
foot pushes  Promote regulation of bowel and bladder frequently
 Diaphoresis function and was
 Hyperactive delirium  Give clear, slow, short instructions with simple controlled
 PERRLA terms to promote understanding after
 No numbness,  Repeat information and instruction as necessary administering
tingling  Lower light/noise to reduce triggers Ativan.
 No facial drooping,  Seizure precautions: pad side rails, bed in lowest
 CT head shows no position, locked
hemorrhage, no  Suction setup at bedside
acute infarction  Bed alarm on
 Seizure precautions  Frequent rounding
 Neuro check q4hr
 Ativan 1mg IVP q4hr Pharmacological interventions:
PRN for anxiety,  Ativan 1mg IVP q4hr PRN for anxiety, tremors
tremors  Treat underlying causes of delirium, AMS such as
dehydration with LF @100ml/hr, Banana bag
500ml over 6hrs.

Teach:
 Education pt and family about S/S of altered
mental status, seizures warning signs and report
when it happens
 Educate pt and family about SE of sedatives
 Teach pt about alcohol cessation