NURSING CARE PLAN- Spring 2019 (Two Nursing diagnoses)

Student: _____________________________ Date: _________________ Unit: _______________

(Total= 6 points)
Patient Initials _______________________ Bed No. ______
Medical history:
Case No. ________________ Admission Date ____________
Nursing Diagnosis Scientific Rationale for Nursing Diagnosis Expected Outcome Nursing Intervention Scientific Rationale for Criteria for Evaluation of
(3pts) (10pts) (3pts) (14pts) Nursing Intervention (14pts) Expected outcome with
Diet: Surgical history: justification (3pts)
Acute pain Bariatric Surgery is done to patients At the end of the Assessment: Assessment:
Activity:
related to tissue who have a BMI over 40 or have a shift: 1. Vital signs every 1. an alteration in
trauma and reflex BMI over 35 with severe health  Patient will be 4 hrs. vital signs
muscle spasms effects
Intravenous Therapy
such as atherosclerosis, able (temperature,
to Medications specially blood
secondary to gallbladder disease, heart disease, describe blood pressure, pressure may
surgery hypertension, osteoarthritis, sleep satisfactory heart rate, SPO2). lead to dizziness,
(laparoscopic apnea, type 2 diabetes mellitus and pain control at nausea and pain.
gastric bypass) many others. My patient did a level less Temperature
Allergies
evidenced by Laparoscopic Gastric Bypass which than 5 on the should be
patient’s report is one of the bariatric surgeries due pain scale (0- maintained
of pain 11/10 on to a BMI 48.55kg/m and after this
Treatments 10). within normal
the pain scale, surgery the patient will lose 25-35%  the patient range of 36.5 and
abdominal of his weight within the first 18-24 will be able to 37.5 degrees.
spams, inability months. On the other hand, diabetes, know the Increase in heart
to ambulate due hypertension and sleep apneas will suitable rate and
to the pain, and be resolved and dyslipidemia will be healthy diet to respiratory rate
pain when using improved. The Roux-en-Y gastric prevent any are also
the incentive bypass is a commonly done surgery injuries in the indicators of pain
spirometer. that reduces stomach size and stomach and
bypasses some of the small intestine. hence pain 2. Assess pain
It can be done as an open or  Patient characteristics: 2. Assessment of
laparoscopic surgery and it is a displays Quality (e.g., pain experience
combined restrictive (restricting the improvement burning, sharp, is the first step in
patient’s ability to eat) and shooting)- planning pain
malabsorptive (interfering with in mood, Severity (scale of management
ingested nutrients absorption) coping. 0 or no pain to 10 strategies. The
procedure. First, a small stomach  Patient or most severe most reliable
pouch the size of a thumb is created. displays pain)-Location source of
This small pouch causes a quick improved (anatomical information
satisfactory feeling of fullness well-being description)- about the pain is
during a meal, which is the key to such as Onset (gradual or the patient.
the success of this procedure. Next, baseline sudden)-Duration Descriptive
the small intestine is divided, and the levels for (how long; scales such as a
pouch is connected to the lower part pulse, BP, intermittent or visual analogue
of the cut small intestine to allow respirations, continuous)- can be utilized to
food to bypass the lower stomach, and relaxed Precipitating or distinguish the
duodenum, and part of the jejunum. muscle tone relieving factors degree of pain.
Digestive juice flow is maintained, or body
and food enters the jejunum within posture.
10 minutes of eating. There is little 3. Assess for signs
malabsorption of food. Surgical and symptoms
procedure: a horizontal row of relating to pain.
staples across the fundus of the 3. The patient’s
stomach creates a pouch with a skin may be pale
capacity of 20 – 30 ml. the jejunum and cool to
is divided distal to the ligament of touch.
Treitz, and the distal end is Restlessness and
anastomosed to the new pouch. The 4. Assess the inability to
proximal segment is anastomosed to patent’s concentrate are
the jejunum. This surgery, as any anticipation for also some
other surgery causes acute pain to pain relief. manifestations.
the patient and discomfort that was 4. Some patients
evidenced by the patient’s report of may be satisfied
pain and it can also cause when pain is no
hemodynamic changes. My patient longer massive;
reported abdominal cramps and pain others will
of 11/10 when asked to evaluate his demand complete
pain on a scale from 0 till 10 with 0 elimination of
no pain and 10 max pain. He also pain. This
reported inability to ambulate and influences the
use the incentive spirometer due to perceptions of
the pain. the effectiveness
of the treatment
of the treatment
modality and
their eagerness to
engage in further
treatments.
5. Weigh the
amount of pain
medication the 5. If requests for
References: patient is using to medication are
Nursing Care of Patients with Upper his or her reports quite frequent,
Gastrointestinal Disorders of pain. the patient’s
LAZETTE V. NOWICKI pages: dosage may need
720-725 to be increased to
promote pain
Brunner and Suddarth’s textbook of Interventions: relief.
medical-surgical nursing, unit 10,
chapter 47, p. 1272-1278. 1. Foresee the need Interventions:
for pain relief.
1. Preventing the
pain is one thing
that a patient
experiencing it
can consider.
Early
intervention may
decrease the total
amount of
2. Get rid of analgesic
additional required.
stressors or 2. Patients may
sources of experience an
discomfort exaggeration in
whenever pain or a
possible. decreased ability
to tolerate
 painful stimuli if
environmental,
intrapersonal, or
intrapsychic
factors are
3. Provide rest further stressing
periods to them.
promote 3. One’s
relief, sleep, and experiences of
relaxation. pain may become
exaggerated
because of
exhaustion. Pain
may result
in fatigue, which
may result in
exaggerated pain.
A peaceful and
quiet
4. Administer environment may
Opioid facilitate rest.
analgesics: 4. Opioids may be
morphine. administered
orally,
intravenously,
systemically by
PCA systems, or
epidurally (either
by bolus or
continuous
infusion).
Intramuscular
injections are not
reliably
absorbed.
Opioids are
indicated for
 severe pain,
especially in the
hospice or home
setting.

Education: Education:

1. Discuss with the 1. To distract the

patient and family patient from the
non-invasive pain pain and thus
relief measures decrease it.
such as watching
tv, listening to
music (non-
pharmacological
therapy)
2. Educate the
patient to report 2. To prevent pain
pain directly and prevent
complications
and fasten the
healing process.
3. teaching the
patient how to 3. patient’s
use the incentive knowledge about
spirometer and the spirometer
CPAP. and CPAP is
important to
prevent dyspnea.

Nursing Diagnosis Scientific Rationale for Nursing Expected Outcome Nursing Intervention Scientific Rationale for Criteria for
(3pts) Diagnosis (3pts) (14pts) Nursing Intervention (14pts) Evaluation of
 (10pts) Expected outcome
with justification
(3pts)
Imbalanced Bariatric Surgery is done to At the end of my shift, Assessment: Assessment:
nutrition: less patients who have a BMI 1. electrolytes will be 1. Assess risk or 1. Obesity is an added risk
than body over 40 or have a BMI over within the normal presence of with high blood pressure
requirements 35 with severe health effects range. (Chem 9). conditions because of the
related to such as atherosclerosis, 2. Patient demonstrates associated with disproportion between
protein and gallbladder disease, heart behaviors, lifestyle obesity fixed aortic capacity
vitamin disease, hypertension, changes to recover and increased cardiac
requirements osteoarthritis, sleep apnea, and/or keep output associated with
for wound type 2 diabetes mellitus and appropriate weight. increased body mass.
healing and many others. My patient did 3. Patient takes adequate 2. Motivation for weight
decreased Laparoscopic Gastric amount of calories or 2. Determine reduction is internal. The
intake Bypass which is one of the nutrients. patient’s desire individual must want to
secondary to bariatric surgeries due to a 4. Patient shows no signs to lose weight. lose weight, or the
surgery BMI 48.55kg/m and after of malnutrition. program most likely will
(laparoscopic this surgery the patient will 5. Demonstrate change in not succeed.
gastric bypass) lose 25-35% of his weight eating patterns (4 3. This assessment is vital
evidenced by within the first 18-24 different stages of that it needs to be
patient NPO, months. On the other hand, food) to attain 3. Note real and accurate. It will be used
calcium and diabetes, hypertension and desirable body weight exact weight as basis for caloric and
phosphate sleep apneas will be with optimal nutrient requirements.
deficiencies, resolved and dyslipidemia maintenance of health. 4. to obtain baseline data
and anemia that will be improved. The 6. Display heart rate, BP, and electrolyte
could be due to Roux-en-Y gastric bypass is and laboratory results imbalance manifests
malnutrition a commonly done surgery within normal limits 4. Assess vital through vital signs
(iron that reduces stomach size (WNL) for client; signs, including elevation.
deficiency). and bypasses some of the absence of muscle BP and HR and 5. to monitor for progress
small intestine. It can be weakness; and assess other of therapy and degree of
done as an open or neurological hemodynamics. imbalance to plan care
laparoscopic surgery and it irritability. 5. monitor labs accordingly.
is a combined restrictive (electrolytes, 6. to check for cardiac
(restricting the patient’s chem 9). functions associated with
ability to eat) and electrolyte balance.
malabsorptive (interfering
with ingested nutrients 6. auscultate heart 7. These assessment
absorption) procedure. First, sounds and findings are usually
a small stomach pouch the palpate linked with the surgery.
size of a thumb is created. peripheral
This small pouch causes a pulses. 8. Laboratory tests play a
quick satisfactory feeling of 7. Assess for significant part in
fullness during a meal, abdominal determining the patient’s
which is the key to the discomfort, pain, nutritional status. An
success of this procedure. and cramping. abnormal value in a
Next, the small intestine is 8. Review single diagnostic study
divided, and the pouch is laboratory values may have many possible
connected to the lower part that indicate causes.
of the cut small intestine to well-being or - These counts are
allow food to bypass the deterioration: frequently dropped in
lower stomach, duodenum, RBC and WBC malnutrition,
and part of the jejunum. counts revealing anemia, and
Digestive juice flow is reduced resistance to
maintained, and food enters Serum infection.
the jejunum within 10 electrolyte - Potassium is typically
minutes of eating. There is values elevated, and sodium is
little malabsorption of food. typically lowered in
Surgical procedure: a Serum albumin malnutrition.
horizontal row of staples -This determines degree
across the fundus of the of protein reduction (2.5
stomach creates a pouch g/dl signifies severe
with a capacity of 20 – 30 diminution; 3.8 to 4.5
ml. the jejunum is divided g/dl is normal).
distal to the ligament of
Treitz, and the distal end is Interventions:
anastomosed to the new
pouch. The proximal 9. Improvement in
segment is anastomosed to nutritional status may
the jejunum. After the take a long time. Patient
surgery, the patient is NPO, may lose interest in the
so he is not ingesting whole process without
anything especially day 1 Interventions: short-term goals.
post operation for the
stomach to heal. Then he 9. Set appropriate 10. To strengthen and
will follow different stages short-term and improve the gastric
of diet during his recovery
period (liquid-semisolids
and pureed-soft-and then
regular small meals). In
addition, his surgery
reduces the amount of food
that can be eaten since the
new stomach capacity is
approximately between
20ml – 30ml which will
lead to intentional decrease
of weight (30%-40% of
initial weight).
References:
Nursing Care of Patients
with Upper Gastrointestinal
Disorders LAZETTE V.
NOWICKI pages: 720-725
Brunner and Suddarth’s
textbook of medical-
surgical nursing, unit 10,
chapter 47, p. 1272-1278.
motility and prevent
long-term goals. gastric weakness after
surgery and to prepare
for other stages of diet to
prevent malnutrition.
11. Water helps in the
10. Start with the elimination of
clear fluid diet. byproducts of fat
breakdown and helps
prevent ketosis.
12. To avoid dehydration
due to decreased oral
intake after the surgery.
13. Experts like a dietician
can determine nitrogen
11. Encourage water balance as a measure of
intake. the nutritional status of
the patient. A negative
nitrogen balance may
mean protein
12. IV hydration malnutrition. The
dietician can also
determine the patient’s
daily requirements of
13. Ascertain specific nutrients to
healthy body promote sufficient
weight for age nutritional intake. The
and height. Refer dietitian also specifies
to a dietitian for which food stage is
complete appropriate for the
nutrition patient based on his
assessment and healing process and
methods for duration post operation.
nutritional 14. To prevent aspiration,
support. and to decrease the
nausea and vomiting
 sensation due to the pain
and small capacity of the
stomach.
15. Give and take with the
patient will lead to
culturally harmonious
care.

14. Elevate the head

of bed when the Education:
patient drinks his 16. To follow the required
clear fluid diet. diet and exercises to
reduce wait and to
prevent injuries caused
15. Negotiate with by lifting and heavy
the patient exercises
regarding the
aspects of his or
her diet that will
need to be
modified.
Education:
16. need to practice
lifelong healthy 17. To prevent
eating and complications after the
exercising habits. surgery and to promote
Keep in mind healing process
after your
surgery do not
lift anything
heavy until your
doctor tells you
it is safe. This
may be up 2
weeks or more
17. Contact your
 doctor if your
recovery is not 18. To avoid feeling of
progressing as fullness, nausea,
expected or you vomiting, pain, and to
develop keep abdominal comfort
complications and reduce pressure on
such as: Signs of the stomach after
infection, surgery and eating large
including fever meals might stretch the
and chills, stomach and increase its
Worsening capacity again and he
abdominal pain, will gain wait again.
and Blood in the
stool
18. need to eat very
small amounts 19. To avoid malnutrition
and eat very and provide the body
slowly: You will with the nutrients needed
begin with 4-6 for proper health and to
meals per day. A avoid weight gain and
meal is 2 ounces irritation of the stomach.
of food. For the
first 4-6 weeks
after surgery, all
food must be
pureed. When
you move to
solid foods, they
must be chewed
well.
19. When making
food choices,
you will need to
consume enough
protein and
nutrient rich not
calories rich diet.
Avoid sweets
and fatty foods