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 Data Nursing Interventions Expected Patient Evaluation

Diagnosis Outcome

SUBJECTIVE: Monitor:
 “My stomach hurts so  VS (BP, HR, RR)
bad” (then pointed at  Assess prior experience with pain,  Pt will have a Goal is met, pt
the mid/right upper effectiveness of prior interventions, decrease in pain said “I still
PAIN r/t quadrant of the responses to analgesic meds including SE level to a feel the pain
pancreatitis, abdomen)  Assess comfort-functional goal tolerated pain but it just a
hepatitis,  “Can I have Morphine  Comprehensive pain assessment PQRST level 7-8/10 by little now”
and GI bleed please?” characteristics of pain before and after the end of the
 “It’s hurting again, administering opioid analgesics shift
when is the next time I  Monitor effectiveness of pain medications.
can get Morphine?”  Assess CNS status, sedation level, and  Pt can relax/sleep Goal met, pt
 “My fistula in the respiratory status at regular intervals, and 1-2 in bed without relaxed in
bottom is painful.” hours after administering opioid analgesics being awaken bed, slept
 “The pain keeps me  Assess for bowel elimination, appetite, ability from pain during intermittently
from sleeping” to rest and sleep my shift without
discomfort
OBJECTIVE: Manage: from pain
 Constant pain 10/10  Pt’s BP, HR and Goal not met, VS
 CT-AP shows Non-pharmacological interventions: RR are remained is still higher
pancreatitis, no bowel  Perform nursing care when pt is comfortable at his baseline than
obstruction, hepatic (at the peak time of analgesics) levels at the end baseline, BP
steatosis,  Distraction (TV, music), imagery, reduce of my shift 161/99, P145,
esophagitis/reflux noise/light, relaxation, meditation, heat/cold RR22.
 Hep panel: (+) HBV applications Considering
 Abnormal LFT  Maintain bedrest with BRP pt is also
 Normal lipase (151)  Promote position of comfort on one side with going
 Upon palpation, tender knees flexed, sitting up and leaning forward through
abdomen in all  Keep NPO to rest the bowel ETOH
quadrant  Cognitive-behavioral strategies, lifestyle pain withdrawal
 Last vomiting blood management with anxiety
and tremors,
 was on 5/8
 Nausea
 No bloody stool, no
diarrhea
 Normoactive bowel
sounds in L upper and
both lower quadrants,
hypoactive in R upper
quadrant
 NPO
 BP148/88 P127 RR22
 Moaning, keep asking
for pain meds
 Diaphoresis
 Last BM ~3days ago
 On Morphine IVP
2mg/ml q4hr PRN for
moderate to severe
pain
 Topical Lidocaine TID
applied on anal fistula
 Protonix drip at
10ml/hr infusing at
72hr duration
 Sandostatin 12.5ml/hr
continuous infusion
Nursing Supporting Assessment Data
Diagnosis
SUBJECTIVE:
“I had a chest pain yesterday
but now it’s more about my
headache”
Neurologica “I have a cough and sore
l throat”
“I get tired when I go to the
bathroom”
“I can’t breath if I lay flat”
OBJECTIVE:
Ativan IVP
Pharmacological interventions: 1mg was
 Morphine IVP 2mg/ml q4hr PRN for given with
moderate-severe pain CIWA neuro
 Request orders to implement pain checks q1hr
management interventions to achieve a after
administering
satisfactory level of comfort
 Protonix continuous drip at 10ml/hr and
Sandostatin continuous drip at 12.5ml/hr for
GI bleed
 Topical Lidocaine TID applied on anal fistula
 Obtain a prescription for stool
softener/peristaltic stimulant to prevent
opioid-induced constipation
Teach:
 Explain the pain management approach
including pharm and non-pharm interventions
 Report effectiveness of pain medications
 Education and report if experiencing any
SE/addiction
 Education about use of call light, get help
when needed
Nursing Interventions Expected Patient Evaluation
Outcome
Monitor:
Mental status (A/Ox4), chest pain, dyspnea (SOB Patient maintains Patient is alert
upon exertion), headache, hypercapnia, hypoxia, pale adequate gas and awake, A/O
skin, restlessness, respiratory rate (RR20, unlabored exchange, O2 sat x4, maintains
breathing, chest expansion symmetrical), Nail beds >92%, remains alert bedrest with
(pink), mucous membranes (oral thrush with white with no further bathroom
patches on the tongue) deterioration in LOC, privileges, O2
Changes in VS (BP 123/85, HR 91, RR20, O2 sat 88% minimizes SOB, sat 92% on 2L
on RA  91% 2L NC) maintains effective NC considering
Heart sounds (S1, S2 regular rhythm, no murmur, no breathing pattern pt was talking
extra heart sounds) with relaxed, with family,
 A&Ox3-4, confused at Lung sounds (Crackles on both lower lobes) nonlabored unlabored
times Edema (no edema on any extremities) breathing at normal breathing with
 Tremors Radial pulses weak 1+ bilaterally, pedal pulses strong rate and depth with RR 19 and calm
 Diaphoresis 2+ Cap refill <3sec on all extremities absence of dyspnea, attitude, non-
 PERRLA Monitor for occurrence of cough with bloody sputum baseline HR (<100) dyspneic while
 Check for blood culture, urine culture, sputum C&S D-dimer decreases in bed, HR 91,
 Seizure precautions order, recommend ABGs order from MD towards negative D-dimer
Follow up with CT Angiogram, Doppler, and VQ scan value (<.5), and lower decreased from
status BNP. 1.66 to 1.00
H/H (12.6/39.9), PLT (196), PTT (therapeutic goal 55-
80) PTT 81 (higher than goal)  decrease from 900 to
800 ml/hr
Check for bleeding S&S (gums, black tarry stools,
hematuria, decrease H/H, BP)
Manage:

Non-pharmacological interventions: encourage

bedrest with bathroom privilege, position high fowler
in bed with HOB >45 degree, SCD/compression
stockings after Doppler confirms no DVT

Pharmacological interventions: oxygen therapy,

heparin drips/ASA to prevent blood clots

Teach:
SE of heparin such as increase bleeding time,
hematuria, fever, headache, rash, hyperlipidemia
Avoid OTC meds, NSAIDS
Use soft-bristle toothbrush to avoid bleeding gums
Repost any S&S of bleeding: gums, under skin, urine,
stools, unusual bruising even after d/c drug
Report any changes in mental status, SOB,
palpitation, chest pain.
Encourage activity as tolerated