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Intervention 2
Administer Hydromorphone 1 mg as per MD order
Intervention 1
Teach JK and family members the importance of frequent hand hygiene.
Intervention 3
Assess for any adverse effects to the medication.
Intervention 3
Monitor WBC/vital signs.
Intervention 1
Assess JK's pain characteristics by asking the patient for the location, onset, quality, severity, duration and any precipitating relieving factors.
Short Term Goal :
Long Term Goal :
Intervention 2
Administer Cefoxitin 1 gm as per MD order.
Short term goal 1:
Long term goal:
Intervention 4
Evaluate the effectiveness of the medication
Intervention 4
Monitor for signs and symptoms of an infection at surgical puncture wounds.
Nursing Dx 3
Risk for infection related to Robotic Gastrectomy Procedure AEB
Nursing Dx 1:
Acute pain related to surgical wounds AEB
Evaluation
After administration of hydromorphone, JK's pain was not relieved and she was still unable to ambulate. In the afternoon, a second dose was administered - as per MD order- JK was able to transition to her chair and eventually ambulate within the hallway with little to no pain. J.K.'s pain level diminished to 3/10 by end of shift.
Christine Chung
Jazmin Londono
Evaluation
JK's abdominal puncture sites remained C/D/I during shift and vital signs remained WNL.
Short term goal:
Long term goal:
Intervention 4
Assess treatment-related factors, such as side effects and interactions of medications.
Nursing Dx 4
Activity intolerance related to pain secondary to Robotic Gastrectomy AEB
Nursing Dx 2:
Risk for impaired skin integrity related to lack of mobility secondary to pain from surgical incisions AEB
Intervention 3
Assess emotional and psychological factors affecting the current situation.
Intervention 1
Change JK's position at least every two hours.
Short term goal
Long term goal
Intervention 1
Assess JK's ability to stand and move about and the degree of assistance necessary or use of equipment.
Intervention 3
Use pillows to keep bony prominences from direct contact with each other.
Intervention 4
Keep JK's skin clean and dry and lubricate with lotion as needed.
Intervention 2
Assess cardiopulmonary response to physical activity, including vital signs, before, during and after activity. Note accelerating fatigue.
Intervention 2
Encourage ambulation at least every four hours.
Evaluation
JK willingly ambulated to and from bathroom, and within the hallways - JK exhibited tolerance to activities. Vital signs remained WNL before, during and after activity.
Evaluation
JK's skin remained C/D/I and maintained adequate circulation AEB SpO2 of 100% on 2L/NC and capillary refill <3 seconds.
Works Cited
Gulanick, M., & Myers, J.L. (2014). Nursing Care Plans. Philadelphia, PA: Elsevier.
Hoffman, J.J. & Sullivan, N.J. (2017). Medical-Surgical Nursing. Philadelphia, PA: FA-Davis.
Tokunaga M, Kaito A, Sugita S, Watanabe M, Sunagawa H, Kinoshita T.(2017) Robotic gastrectomy for gastric cancer. Retrieved from http://tgh.amegroups.com/article/view/3772/4558
Ucentral. (2017). Davis’s Lab & Diagnostic Test [Mobile application software]. Retrieved from http://unboundmedicine.com
J.K. is a 63 yr old female , who came into the ED with complaints of abdominal pain and GI bleeding.
Admitting Dx:
Final Dx:
Diet:
Past Medical Hx:
Activity
JK had a gastrectomy performed as part of her diagnosis of having a mass towards the end of her stomach and beginning of the duodenum.
Radiology reports
Physical exam
Objective
Issue:
Teaching plan:
Issue:
Teaching plan:
add to the abdominal discomfort. Teach pt. to focus on high protein
foods (meat, fish, dairy) and to eat several, small meals per day
to avoid complications like dumping syndrome.
Issue:
Teaching plan: