‫بسم هللا الرحمن الرحيم‬

Royal Medical Services College for Allied Health Professions

Adult health Nursing /clinical
Nursing Care Plan (50 Mark)

Student name ‫ نانسي حسن احمد‬Instructor ‫النقيب ياسمين الججاج‬

Hospital ‫الحسين الطبيه مدينة‬ Ward‫جراحة رجال‬

Demographic data: (2 Marks)

Patient`s Name ‫سليم شكيب يوسف بلبل‬ patient No 9681030350

Main diagnosis: acute pancreatitis Admission date :9/10/2021

Age: …………53 years old…….……... Marital status : married…………………………………

Gender……male……………….. Allergies(food,medication,other)………
free………..

Assessment: (2 Marks)

Surgical history …………catheter……………………………………

Medical history …HTN/ IHD (ischemic heart disease)

……………………………………………………..

……………………………………………………………………………………….

History of present illness: (2 Marks)

Description of problem: (When started, location, character, severity, duration, frequency, aggravating or
relieving factors, client’s perception of what the symptom means)

…abdominal pain ,like stabbing a knife a week ago ,and sever pain(9)recurs daily .when taking Panadol
the pain subsides and increases in intensity when walking
……………………………………………………………………………………………………………
…………………………………………………………………………………………………………

Family history (chronic illness, hereditary disorder) ( 2 Marks )

…………
free……………………………………………………………………………………………………………
…………………………………………………………………………………………………………………
……………………………………………………………………………………………………………

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Social history ( smoking , substance and alcohol ) ( 2 Marks ) ………don’t…
smoking………………………………………………….........................................................................…..
………………………………………………………………………………………………………

Blood transfusion where, when and why ,if reaction developed (2 mark)

……not
givien……………………………………………………………………………………………………………
……………………………………………………………………………………………

Elimination pattern

Urine elimination ( 2 Marks )

Amount ………2000 L/day………………………………………

Frequency ……three times…………………………………………

Color and odor ………straw not odor…………………………………..

Any problems ………no…………………………………….

Stool elimination ( 2 Marks )

Amount ……………470g/week………………………………………

Frequency ……………daily……………………………………

Color and odor ………………yellow smelly………………………………

Any problems ………………………diarrhea………………………

Nutritional pattern: (2 Marks)

Diet…NPO…………………………………………………………………………..

Number of meals ………………………………………………………………………………….

Snacks……………………………………………………………………………………………………..

Others ………………………………………………………………………………………………….

Intravenous fluid (2mark)

Intravenous fluid TYPE AMOUNT Drop factor
IV. FLUID

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 G 1/2s hypotonic 3000×20/24×60=41
ggt/ml
3ooo ml

Vital signs: (6 Marks)

Readings Nursing intervention

Vital signs
(normal , abnormal)

Blood pressure
120/80
(write the measurement body site)

80
Heart Rate
(write the measurement body site)

Temperature
36.5
(write the measurement body site)

Respiratory Rate 18

Oxygen saturation 94%

Comfortable positioning
Pain severity (0-10) 9(sever)
Avoid stressful situation

Diagnostic and lab results ( 10mark)

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 Laboratory test Results Normal Range

Complete blood count (CBC )

20.87 4-11
White blood cells (WBC)
RBC 4.52 4.4-6
Packed cell volume (PCV/HCT) HB 12.9 13.5-18
HCT 37.4 40-51
364 140-450
Platelet

Kidney Function Test

18 6-20
Blood Urea Nitrogen (BUN)
0.64 0.5-1.2
Creatinine
137 135-153
Sodium
4.32 3.5-5.5
Potassium
194 70-110
Glucose
7.8 8.4-10.5
Calcium

Other tests he was

Radiologic test ( chest x-ray, CT, MRI,….) complaining of
SoB and dry
Septic work up
cough HRCT
Urine and stool analysis / culture was done in
8/12 - mainly
in the lower
lobes Lung
segments seen
in Abdominal
CT done in
9/12 -

Medication (6 Marks)
Medication name Dosage Frequency Route Side effects Nursing considerations

1g 3 iv Intestinal Monitor allergic

disorders(abdom
reaction and sign
inal pain,
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 fortum diarrhea ,nausea hemopathy and
headache ,ane injection site for pain
fortum
mia ,itch and irritation

flagyl Dizziness ,nau It is taken before or

sea, headache, after eating according
500mg 3 1v
loos of to the concentration
appetite ,dry
mouth

Magnesium It should be taken on

deficiency in an empty stomach
omeprazole 20 mg 1 oral
the blood,
abdominal
pain, vomiting

Write three nursing diagnosis with nursing intervention (8 marks)

Assessment Nursing diagnosis Nursing planning and Nursing Nursing evaluation
expected outcome interventions
Subjective : as Diagnosis acute After 4 hours of Maintain bed rest After 4 hours of
verbalized by the
pain. May be nursing during acute nursing
patient(I am having
related to interventions the attack and interventions the
sever abdominal pain )
Objective: abdominal
obstruction of patient will report provide quiet patient was able
guarding behavior pancreatic , pain is relieved restful to report pain is
inability to biliary ducts, follow prescribed environment relieved ,follow
concentrate. chemical therapeutic regimen -promote position prescribed
irritability
contamination of and demonstrate use comfort therapeutic
peritoneal of methods that --maintain regimen and
demonstrate use
surfaces by provide relief meticulous skin
of methods that
pancreatic care provide relief
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 Subjective: Lack Imbalanced Patient will Evaluate total Patient will
of Nutrition: Less demonstrate daily food intake demonstrate
nutrition(anorexia) Than Body progressive weight behaviors,
Requirements gain toward goal. -Promote lifestyle changes
Patient will display adequate/timely to regain and/or
normalization of fluid intake. maintain
laboratory values appropriate
and be free of signs weight
of malnutrition.

Objective: Ineffective Changes position in Maintain semi- Changes position

Shortness of breathing pattern bed frequently • Fowler's position. in bed frequently
breathing related to Coughs and takes -Instruct and • Coughs and
splinting from deep breaths at least encourage patient takes deep
severe pain, every hour to take deep breaths at least
pulmonary Demonstrates breaths and to every hour
infiltrates, normal body cough every Demonstrates
pleural effusion, temperature 2hours normal body
atelectasis. temperature

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