|
Patient Name |
Juanita |
|
Room and Bed # |
|
|
0800 |
Initial Round: __Pain__BS __BP __HR__R __O2Sat __Mood __Affect __LOC __Give Meds __Check forehead laceration __PICC NS @ 30cc/hr __TPN @ 70cc/hr __Ask LPN to assist pt with breakfast (provide Ensure) (3) |
|
0900 |
__PICC NS@ 30cc/hr __TPN @ 70cc/hr __Focused assessment (All Diagnoses) __Check doctor's orders and lab results (All Diagnoses) __Give Meds __Do CBC, Diff, Lytes & Coags My Coffee |
|
1000 |
__PICC NS @ 30cc/hr __TPN @ 70cc/hr __DB&C (2) __Reposition (1 and 2) __Give Meds __Pain (1) |
|
1100 |
__PICC NS @ 30cc/hr __TPN @ 70cc/hr __Assist with bath __Chem strip (3) __Charting |
|
1200 |
__PICC NS @ 30cc/hr __TPN @ 70cc/hr __DB&C (2) ___Reposition (1 and 2) __Give Meds __Assign care aid to assist with lunch (provide Ensure) __Up to chair (1 and 2) __Pain (1) __To radiology for CT of abdomen |
|
1300 |
___ Rest __PICC NS @ 30cc/hr __TPN @ 70cc/hr __Give Meds __Dressing changes My lunch |
|
1400 |
__Flush Perc drain with 10mL NS __Pain (1) __Give Meds __DB&C (2) __Reposition |
|
1500 |
__PICC NS @ 70cc/hr __TPN @ 300cc/hr ___Skin care and ROM exercises __I&O (2 and 3) |
|
1600 |
__PICC NS @ 70cc/hr __TPN @ 30cc/hr __DB&C(2) ___Reposition (1 and 2) __Give Meds __Chem Strip (3) __Pain (1) |
|
1700 |
My Supper |
|
1800 |
__PICC NS @ 70cc/hr __TPN @ 30cc/hr __Give Meds ___BP ___HR (1) __Pain (1) __Patient Rounds, charting |
|
1900 |
|
|
Report |
Int: __ HR__Rhythm__ Pain__AE__Sat __BS__N/V__ BM__Edema__ Dressings__Forehead laceration ___ Drainage __Perc drain __Issues: |
Nursing Diagnoses:
1. Pain related to disease process secondary to enzymatic tissue breakdown as evidenced by pancreatic inflammation and ascites.
- MRCP Jan 29 because of large pancreatic head pseudocyst
- ERCP Jan 28
- Abd ultrasound Jan 22 hypoechoic lesions in pancreas
- Abd/pelvic CT Mar 5
- C/O severe abdominal pain, fullness, and upper gastric burning evidenced by crying, immobility, grimacing, crying out for her mother(related to confusion)
- Lab values: urea (H), lipase (H), lymphocytes (L), neutrophils (H), CRP (H), bilirubin (H), glucose (H)
- Abdominal pain on palpation as evidenced by crying and grimacing
- Refusal to mobilize due to pain
- Leans forward when sitting (proning) to relieve pressure of the inflamed pancreas on celiac plexus nerves
- Nausea and vomiting related to pain
- Increased HR, RR, and BP
- Shallow breathing due to abdominal pain
- Severe abd distension
- PRN morphine
2. Impaired gas exchange related to fluid in pleural space as evidenced by thoracentesis and tube insert (Feb 26).
- PRN oxygen
- Shallow breathing and shortness of breath
- Chest x-ray Jan 23 moderate left lung effusion
- Hx of lung cancer and chemodectomas
- Congestive heart failure
- Pleural effusion related to inflammation of the pancreas
- Dyspnea
- Dullness of percussion with decreased breath sounds
- Inability to DB&C due to pain and confusion
3. Imbalanced nutrition: less than body requirements related to IV nutrition (TPN) as evidenced by decreased albumin levels.
- Lab values: Mg (L), RBC (L), Hct (L), K (L), glucose (H), albumin (L), urea (L), bilirubin (H)
- Risk for aspiration related to dysphagia
- Weight loss and decreased appetite
- Dehydration (poor skin turgor and dry mucous membranes)
- Insulin Dependent Diabetic
- Pulled out PICC line due to confusion
- Pulled out NG tube
- Diet: soft as tolerated with Ensure BID and PRN
