Patient Name


Room and Bed #



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)


__PICC NS@ 30cc/hr   __TPN @ 70cc/hr

__Focused assessment (All Diagnoses)

__Check doctor's orders and lab results (All


__Give Meds

__Do CBC, Diff, Lytes & Coags

My Coffee


__PICC NS @ 30cc/hr   __TPN @ 70cc/hr

__DB&C (2)

__Reposition (1 and 2)

__Give Meds

__Pain (1) 


__PICC NS @ 30cc/hr   __TPN @ 70cc/hr

__Assist with bath

__Chem strip (3)



__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


___ Rest      __PICC NS @ 30cc/hr   __TPN @ 70cc/hr

__Give Meds

__Dressing changes

My lunch


__PICC NS @ 70cc/hr   __TPN @ 30cc/hr

___Check O2 Sats (2)

__Flush Perc drain with 10mL NS

__Pain (1)

__Give Meds

__DB&C (2)




__PICC NS @ 70cc/hr   __TPN @ 300cc/hr

___Skin care and ROM exercises

__I&O (2 and 3)


__PICC NS @ 70cc/hr   __TPN @ 30cc/hr


___Reposition (1 and 2)

__Give Meds

__Chem Strip (3)

__Pain (1)


__PICC NS @ 70cc/hr   __TPN @ 30cc/hr

___Give Meds

__Assist with supper (provide Ensure) (3)


My Supper


__PICC NS @ 70cc/hr   __TPN @ 30cc/hr

__Give Meds

___BP ___HR (1)

__Pain (1)

__Patient Rounds, charting


 Report off to RN


Int: __


Pain__AE__Sat __BS__N/V__


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
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