1

Running head: CLINICAL CARE PLAN

Clinical Care Plan

Course Number:
Course Name:

Medical/ Surgical Nursing Clinical

Student Name:

Mayra Pagan

Instructor Name:
Date:

STC 201625

NUR224

Smith & Ulseth

05/27/2016

Running head: CLINICAL CARE PLAN

Pathophysiology of medical diagnosis: Gastroenteritis

Gastroenteritis is a general term referring to inflammation or infection of the gastrointestinal tract, primarily the stomach and
intestines. It can be caused by infection with bacteria, viruses, or other parasites, or less commonly reactions to new foods or
medications. It often involves stomach pain (sometimes to the point of crippling), diarrhea and/or nausea/vomiting, with noninflammatory infection of the upper small bowel, or inflammatory infections of the colon. It usually is of acute onset, normally
lasting fewer than 10 days and self-limiting. Sometimes it is referred to simply as 'gastro'. It is often called the stomach flu or gastric
flu even though it is not related to influenza. If inflammation is limited to the stomach, the term gastritis is used, and if the small
bowel alone is affected it is enteritis. As such, this has a relationship on the concept fluids and electrolyte. Because dehydration the
most common complication of gastroenteritis if not treated or no immediate intervention done it could lead to shock and eventually
can lead to death.

Gastroenteritis is an uncomfortable and inconvenient ailment, but it is rarely life-threatening in the United States and other
developed nations. However, an estimated 220,000 children younger than age five are hospitalized with gastroenteritis symptoms in
the United States annually. Of these children, 300 die as a result of severe diarrhea and dehydration. In developing nations, diarrheal
illnesses are a major source of mortality. In 1990, approximately three million deaths occurred worldwide as a result of diarrheal
illness. (Muttagin, 2011)

STC 201625

Running head: CLINICAL CARE PLAN

If untreated

STC 201625

Running head: CLINICAL CARE PLAN

Etiology of Medical Diagnosis: Gastroenteritis

In general, gastrointestinal inflammatory condition is caused by infection with the invasion of the mucosa, producing or producing
enterotoxins and cytotoxins. This mechanism results in an increase or decrease fluid secretion of fluid and causes dehydration and
loss of nutrients and electrolytes.
Gastroenteritis is an inflammation of the stomach, small intestine and large intestine with a variety of pathologic conditions of the
gastrointestinal tract with the manifestation of diarrhea, with or without vomiting, and abdominal discomfort. Infection is a major
cause of acute diarrhea, either by bacteria, parasites or viruses. Other causes that can cause acute diarrhea are toxins and drugs,
enteral nutrition followed by prolonged fasting, chemotherapy, fecal impaction (overflow diarrhea), or a variety of other
conditions. (Inayah, 2004)
Gastroenteritis is an inflammation of the stomach, small intestine and large intestine with a variety of pathologic conditions of the
gastrointestinal tract with the manifestation of diarrhea, with or without vomiting, and abdominal discomfort.
Inayah, Iin.SKp. , 2004. Nursing the Client with Disorders Digestive System.Jakarta: Salemba Medika

Expected Findings:
STC 201625

Running head: CLINICAL CARE PLAN

Physical Assessment
Mrs. M is a 46- year old female who started developing nausea, vomiting, diarrhea, RUQ abdominal pain and general
malaise two days ago. She is alert and oriented x 3, verbalization was hesitant and unsure. Patient in poly drugs, medication
list attached. Facial grimacing noted. PERRLA to light, eye sclera white. Skin mostly warm and dry. No noted decubitus
ulcers in coccyx, hips or heels. Grips, flexion and extension strong bilaterally. S1 and S2 auscultated and clearly heard. Pulse
rate 63. Radial pulse 3+, right dorsalis pedis 2+. Capillary Refill < 3 sec. 30 ML of hazy amber urine voided today at 0835.
No pain, urgency, frequency or tenderness when voiding reported. Abdomen soft, flat and symmetric without distention, no
lesion, scars or visible peristalsis. Aorta midline without bruit or visible pulsation, umbilicus inverted without herniation;
bowel sounds present in all four quadrants. Liver, kidney and spleen non- palpable; tenderness noted upon palpation of
RUQ. Patient reports no appetite, nausea/ vomiting and liquid yellow in color diarrhea. Pain noted at 7 on a 0-10 number
scale, pain radiating to right upper back. c/o Abdominal pain of 7/10 on a pain scale, Nausea/vomiting x yesterday. Patient
states Every time I try to eat anything it just come right back up. Patient encouraged to maintain fluid and oral restrictions
as ordered by HCP. VS, T 99.6, RR 28, HR 108, BP 174/94, O2 Sat. 98%.
Laboratory Data (x-rays, Blood work, CT scan)
Test (lab)
Hematology
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
STC 201625

Result
24.2
5.11
12.1
46.0
90.0
28.9
32.1

Test (lab)
General Chem
Sodium
Potassium
Chloride
CO2
Glucose
BUN
Creatinine

Result
115
3.2
103
24
119
24
0.558

Running head: CLINICAL CARE PLAN

RDW
PLT
MPV
Urinalysis
Color
Appearance
Sp Grav
Ph
Protein
Glucose
Ketone
Bilirubin
Blood
Urobilinogen
Leuk est.
Nitrate
Bacteria
HCG

12.7
309
8.2
Amber
Hazy
1.035
6.0
2+
Neg
3+
Neg
Neg
1.0
Neg
Neg
Trace +
Neg (-)

Calcium
Protein
Albumin
Globulin
Alb/ Glob
Phosphorus
Bili, Total
Alk Phos
ALT
AST
GGT
Lipase
Mag

9.4
8.4
2.9
4.1
1.0
2.9
0.7
128
73
41
545
66
2.0

X-ray report
CT abdomen & Pelvis
Ultrasound Abdomen

CXR Neg (-)

Neg (-) Normal
Neg (-) Normal

Assessment

Nursing
Diagnosis

Plan (Goals)

Interventions

Rationales

Evaluation (of
Goals)

#1)
Subjective:
Patient states Every
time I tried to eat or
drink anything it just
come right up

#1) Deficient Fluid

Volume
(dehydration/
hypovolemia)

ND #1:
After 2hrs of
continuous
nursing care and
proper health
teachings the

#1)
Maintain
accurate intake and
output, calculate
24-hour fluid
balance and weigh

#1)
It serves as a
baseline for doing such
interventions.
(Doenges, p145)

ND #1:
1) Goal
successfully met.
After 2hrs of
continuous
nursing care and

STC 201625

r/t:

Running head: CLINICAL CARE PLAN

Patient also states she nausea, vomiting,

has been feeling
and diarrhea
lightheaded, tired and
weak.
As evidenced by:
Cultural:
Patient married for
25 years, 3 daughters
and a 1-yr-old
grandson.

-decreased urine
output -30 mL/hr
-increased urine
concentration
(viscosity)
-weakness
Communication:
-Mild fever 99.6
English/ patient able -decreased skin
to read and write
turgor
-dry mucous
Religion: Catholic
membranes
Values & Beliefs: Pt
-increased pulse
pray before and after rate RR 28
each meal - requested -Urine specific
no interruptions.
gravity: 1.035
-Serum sodium
Ethnicity: Caucasian -115.5 mEq/L
/American
-Serum potassium
3.2 mEq/L
Socioeconomic
status and social
class: low- income,
patient has two jobs;
primary provider for
STC 201625

patient will
manifest:

daily.

-Decrease risk for

complications of
Fluid volume
deficit

Promote a wellventilated
environment
conducive for
eating

After 4 hours
of thorough
Provide
nursing
intervention, the
frequent oral and
client will be able
skin care
to:
-reduce
vomiting
by
promoting
an
environment
conducive for
doing ADLs
-improve skin
turgor of the
patient
from
poor to fair.
After 1 day of
nursing
intervention, the
patient will able
to maintain body
fluid levels,
completely

Change position
frequently

To avoid the
occurrence of
vomiting. (Nelms,
297)

To prevent injury
from dryness.
(Doenges, 145)
To promote proper
circulation of blood,
thus, preventing rom
fluid deficit.
(Carpentino, p122)

To decrease the
occurrence of
vomiting. (Doenges,
145)
Administer
medication
(Ondansetron 4mg
prn IV), as ordered.

To gradually correct
the deficient in fluid
(hypertonic) (Doenges,

proper health
teachings the
patient
manifested:
-Decreased risk
for complications
of Fluid volume
deficit
2) Goal met.
After 4 hours of
thorough nursing
intervention, the
client was able to
reduce vomiting
by promoting an
environment
conducive for
doing ADLs and
improved skin
turgor of the
patient from poor
to fair.
3) Goal met.
After 1 day of
thorough nursing
intervention, the
patient was able
to maintain body
fluid levels,
completely

Running head: CLINICAL CARE PLAN

her 3 daughters,
grandson and disable
husband. Patient
sates that is difficult
for her to maintain a
healthy diet, she said
food is too expensive
so they eat whatever
she can afford,
mostly junk food,
and frozen dinners

Objective:
VS:
Temp-99.6
Pulse-104
BP-174/95
RR-28
O2 Sat-97% -Room
Air
-Decreased urine
output 30 mL/hr
-Concentrated urine
-Decreased venous
filling
-Thirst
-Increased pulse rate
STC 201625

eliminated the
occurrence of
vomiting and
increased serum
sodium level of
115.5 meq/L to a
normal level
(135-145)
After 2 days of
continuous
nursing care and
proper health
teachings the
client will
maintain fluid
volume at
functional level
as evidenced by:

144)
Administer
fluids and
electrolytes
(Potassium
chloride 10 mEq, =
100 mL, IVPB,
q1hr: 2 dose) ,as
ordered.

Assess or
instruct patient to
monitor weight
daily and
consistently, with
same scale, and
preferably at the
same time of day.

-Normalized
Bowel Movement Evaluate fluid
Moist mucous
status in relation to
membrane and
dietary intake.
good skin turgor
Patients
urinary output
will maintain at

This facilitates
accurate measurement
and follows trends.
(Gulanick, p78)

Determine if patient
has been on a fluid
restriction. Most fluid
enters the body through
drinking, water in
foods, and water
formed by oxidation of
foods. (Doenges, p144)

eliminated the
occurrence of
vomiting and
increased serum
Na+ level from
115.5 meq/L to
128.7meq/L.

Running head: CLINICAL CARE PLAN

104 bpm
-Decreased skin
turgor
-Dry mucous
membranes
-Weakness
-Changes in mental
status (confusion)
Labs:
-Urine specific
gravity: 1.035
-Serum sodium
-115.5mEq/L
-Serum potassium
3.2 mEq/L
Medications:
-NaCl 0.9% 1,000mL
IV, Rate 125mL/hr,
Infuse over 8 hr
-Potassium chloride
10 mEq, = 100 mL,
IVPB, q1hr: 2 dose
-Lactated Ringer 200
mL, IV
-Ondansetron
(Zofran) 4mg IV,
STC 201625

least 30 mL/hr.
Patient will be
able to tolerated
clear liquids
without vomiting
within 24 hours.
Patient will
have equal intake
and output within
24 hours.
Patients
electrolyte levels
will remain
within normal
range throughout
hospital stay.
Patient will
report feeling less
lethargic within
48 hours

Monitor and
document vital
signs.

Assess skin
turgor and mucous
membranes for
signs of
dehydration

Sinus tachycardia
may occur with
hypovolemia to
maintain an effective
cardiac output. Usually
the pulse is weak, and
may be irregular if
electrolyte imbalance
also occurs.
Hypotension is evident
in hypovolemia.
( Doenges 145)
The skin in elderly
patients loses its
elasticity; therefore,
skin turgor should be
assessed over the
sternum or on the inner
thighs. Longitudinal
furrows may be noted
along the tongue.
(Carpentino, p68)

10

Running head: CLINICAL CARE PLAN

q4hr, prn
nausea/vomiting

Concentrated urine
denotes fluid deficit.
(Doenges, p145)

Diet:
NPO
[Patient is allergic to
Gluten]

Assess color and

amount of urine.
Report urine output
less than 30 ml/hr
for 2 consecutive
hours

Monitor serum
electrolytes and
urine osmolality
and report
abnormal values.

Document
baseline mental
status and record
during each
nursing shift.
(Confusion)

STC 201625

Elevated
hemoglobin and
elevated blood urea
nitrogen (BUN)
suggest fluid deficit.
Urine-specific gravity
is likewise increased.
(Doenges, P145)
Dehydration can
alter mental status.
(Carpentino, p145)

This prevents
complications
associated with
therapy. (Carpentino,
p145)

11

Running head: CLINICAL CARE PLAN

During
treatment, monitor
closely for signs of
circulatory
overload
(headache, flushed
skin, tachycardia,
shortness of breath,
increased BP,
tachypnea, cough).
Encourage
patient to drink
prescribed fluid
amounts, if oral
fluids are tolerated,
provide oral fluids
patient prefers.
Place at bedside
within easy reach.
Provide fresh water
and a straw. Be
creative in
selecting fluid
sources (e.g.,
flavored gelatin,
frozen juice bars,
sports drink).

STC 201625

Oral fluid
replacement is
indicated for mild fluid
deficit. Elderly patients
have a decreased sense
of thirst and may need
ongoing reminders to
drink. (Carpentino,
p145)

These decrease
venous return and
optimize breathing.
(Carpentino, p145)

12

Running head: CLINICAL CARE PLAN

Maintain IV
flow rate, should
signs of fluid
overload occur,
stop infusion and
sit patient up or
dangle
Teach
interventions to
prevent future
episodes of
inadequate intake

Assessment

ND #2:
Subjective:
Patient states: I feel
pain in my upper
STC 201625

Nursing Diagnosis

#3) Acute Pain

r/t
abdominal pain.

Patients need to
understand the
importance of drinking
extra fluid during bouts
of diarrhea, fever, and
other conditions
causing fluid deficits.
(Carpentino, p145)

Plan (Goals)

Interventions

ND #2: Given
the prescribed
nursing care,
the patient will

#2)
Assess patients pain
including: location,

Rationales

#2)
Pain assessment is
fundamental in

Evaluation
(of Goals)
ND #2:
1. Goal met
patient
verbally

13

Running head: CLINICAL CARE PLAN

stomach when I
drink, eat or have a
bowel movement
Cultural:
Patient married for 25
years, 3 daughters
and a 1-yr-old
grandson.
Communication:
English/ patient able
to read and write
Religion: Catholic
Values & Beliefs: Pt
pray before and after
each meal - requested
no interruptions,
Ethnicity:
Caucasian /American
Socioeconomic
status and social
class: low- income,
patient have two jobs;
primary provider for
his 3 daughters, 1year-old grandson
and disable husband.
Objective:
STC 201625

As Evidence by:
Patient taking
pain meds q4
hours.
(Hydromorphone
IV 1mg/ Morphine
IV 4mg)
Pain has been
high as 7 on pain
scale.
Patient states
pain unbearable at
times.
verbal reports of
pain
grimacing
moaning
guarding of
abdomen when
assessed.
P: eating
/drinking/ bowel
movements
Q: aching/
burning
R: middle
epigastric region
S: 7/10

have
relieved/contro
lled pain
As evidence
by/
1.Patient
verbally states
relieved pain
within one
hour. Patient
stated his scan
acceptable
pain level is
3/10.
2. Nonverbal
indicators of
pain including
grimacing and
moaning will
be
absent/dimini
shed within 30
minutes
3. Patient will
be able to his
basic ADLs

onset/duration,
frequency, quality, and
intensity using a pain
scale of 0-10 every two
hours.

Provide patient with

information to help
increase pain tolerance
(reason for pain, how
long it last)

Perform comfort
measures to promote
relaxation, such as
massage, bathing and
relaxation techniques.

Assess patient verbal

and nonverbal cues.

assisting the diagnosis

of the cause of the pain
and it should not be
assumed that this is
self-evident. Cardiff
University. (2010).
Pain Community
Centre. Retrieved May
06, 2016.

To educate the
patient and to
encourage compliance
in trying alternate pain
measurements.
(Lippincott, Williams
& Wilkins, pg. 140)
To reduce muscle
tension or spasm,
redistribute pressure
on body parts and help
patient focus on non
-pain related subjects.
(Lippincott, Williams
& Wilkins, pg. 140)
Discrepancy

reported
decreased pain
as being
much better.
2. Goal met,
nonverbal
indicators of
pain were
absent upon
observation.
3.Goal met,
patient did not
guard
abdominal
area upon
assessment
and position
changes.
4. Goal met,
Patient
revealed a
decrease
discomfort;
expressed pain
at tolerable
levels,

14

Running head: CLINICAL CARE PLAN

VS
Temp-99.6
Pulse-104
BP-174/95
RR-28
O2 Sat-97% -Room
Air
Pain Level- 7/10
P: eating /drinking/
bowel movements
Q: aching/ burning
R: middle epigastric
region
S: 7/10
T: starts when she
eats or drink also
when patient have a
bowel movement; it
stops when patient is
laying down in fetal
position or is given
the prescribed pain
medications ordered.
Labs:
Not applicable
Medications:
-Tramadol (Ultram)
50mg PO Q6hrs
STC 201625

T: starts when she

eats or drink also
when patient have a
bowel movement;
it stops when
patient is laying
down in fetal
position or is given
the prescribed pain
medications
ordered.
Autonomic
responses:
-Diaphoresis
-change in BP
- HR
-Change in
respiratory rate
-pallor
- nausea/ vomiting

and activities
upon
discharge
from hospital.

Ask patient about the

pain. Determine pain
characteristics (aching,
stabbing or burning).
Have the patient rate
intensity on a 0-10 scale.

between verbal and

indicating
nonverbal cues may
relaxed
provide clues to degree
of pain, need for
effectiveness of
interventions.
(Doenges, pg147)

The use of the rating

scale and
characteristics aids
patient in assessing
level of pain and
provides a tool for
evaluating
effectiveness of
analgesics, enhancing
patient control of pain.
Evaluate effectiveness (Doenges, pg147)
of pain control.
Pain management is
Encourage sufficient
medication to manage
best left to patient
pain; change medication discretion. (Doenges,
or time span as
pg147)
appropriate.

Monitor patients vital

signs for signs of pain

15

Running head: CLINICAL CARE PLAN

-Hydromorphone
(Dilaudid) 1 mg/ml
IV Q4hrs prn
-Morphine 4mg/ml
IV Q4hr prn (Hold if
RR < 14)
-Oxycodoneacetaminophen 5/325
Q4hr PO prn
-Docusate Sodium
(Colace) 100mg PO
2x Daily

including: increased
heart rate, blood
pressure, and respiratory
rate every two hours.

Observe patient for

nonverbal indicators of
pain including: facial
grimacing, moaning,
guarding, and crying
during assessment of
pain and vital signs.

Encourage
verbalization of feelings
about pain.

Administer prescribed
Morphine 4mg/ml IV
STC 201625

Acute pain activates

the sympathetic branch
of the ANS causing
responses as increasing
blood pressure,
tachycardia and
fluctuating respiratory
rates. (Lippincott,
Williams & Wilkins,
pg. 362)
Pain is a subjective,
multifaceted
experience that varies
considerably between
individuals.
Cardiff University.
(2010). Pain
Community Centre.
Retrieved May 06,
2016.
Fears, concerns can
increase muscle
tension and lower
threshold of pain
perception. (Doenges,
pg148)

16

Running head: CLINICAL CARE PLAN

Q4hr or
Hydromorphone
(Dialudid) 1mg/mL
Q4hr as ordered by
physician, monitor the
patients response to
pain medication and
reassess in 30 minutes
after administration.

Provide and teach

caregivers nonpharmacologic comfort
measures including
repositioning and
massage when patient
reports pain prior to
discharge.

Assess the
appropriates of the
STC 201625

Analgesics are
helpful in relieving
pain and in aiding the
recovery process by
promoting greater
ventilator excursion.
(Swearingen, pg. 423)

Non-pharmacologic
therapy focuses on
treatment modalities
that modify physical or
cognitive aspects of
the painful condition.
Non-pharmacologic
measures support
analgesia therapy in
reducing pain.
Cardiff University.
(2010). Pain
Community Centre.
Retrieved May 06,
2016.
Maintaining a

17

Running head: CLINICAL CARE PLAN

patient as a PCA
candidate.

Teach the patient and

family members the use
of nonpharmacological
techniques.

Assess to what degree

cultural, environmental,
intrapersonal, and
intrapsychic factors may
contribute to pain or
pain relief.

STC 201625

constant drug level

avoids cyclic periods
of pain, aids in muscle
healing, and improves
respiratory function
and emotional comfort
and coping. (Doenges,
p148)
The use of
noninvasive pain relief
methods can increase
the release of
endorphins and
enhance the
therapeutic effect of
pain relief
medications.
(Carpentino-Moyet,
p130)

This may modify

patients expression of
his experience. HCP
should not stereotype
any patient response
but to evaluate the
unique response of

18

Running head: CLINICAL CARE PLAN

each patient.
(Gulanick, p145)

Instruct the patient to

evaluate and report the
effectiveness of
measures used.

Give stool
softeners/laxatives as
prescribed by MD
--Docusate Sodium
(Colace) 100mg PO 2x
Daily

Assessment

ND #3:
Subjective:
Mrs. M is taking
multiple
polypharmacy
STC 201625

Nursing Diagnosis

ND) 3
Knowledge
Deficient,
r/t
lack of

Plan (Goals)

#3)
Patient will
consult Case
Management
for treatment

Interventions

ND#3
Monitor liver
enzymes and observe
the patient for
abdominal distention,

Pain reliefs
strategies can be
modified to promote
more satisfactory
comfort levels.
(Gulanick, p148)
Stool softeners and
laxatives promote
passage of waste.
(Gulanick, p148)

Rationales

ND#3
Opioids may
intensify or mask the
pain of gallbladder
disease. Pain

Evaluation
(of Goals)
Goal met,
Patient started
the use of nonpharmacologic
al methods for

19

Running head: CLINICAL CARE PLAN

medications. Patient
states: I lost my job
1 year ago because of
this issue and my
mirage in on the line
if I dont give-up
on the use of pain
meds
Cultural:
Patient married for 25
years, 3 daughters
and a 1-yr-old
grandson.
Communication:
English/ patient able
to read and write
Religion: Catholic
Values & Beliefs: Pt
pray before and after
each meal - requested
no interruptions,
Ethnicity:
Caucasian /American
Socioeconomic
status and social
class: low- income,
patient have two jobs;
primary provider for
STC 201625

understanding of
medications
actions and side
effects
As evidence by:
-misinterpretation
of information,
including dosage
and time of dosages
-Emotional state
affecting learning
(anxiety and
depression)
-Lack of recall on
time of medication
administration,
risking an overdose
-Verbalization of
inaccurate
understanding of
the drugs action
side effects and
adverse effects.
- Patient states: I
lost my job 1 year
ago because of this
issue and my
mirage in on the
line if I dont

for opioids
dependence by
the end of the
shift.
Patient will
report the use
of nonpharmalogical
methods for
the treatment
of pain and
will decrease
the use of pain
medications.
Patient will
demonstrate an
understanding
of the drugs
action
accurately
describing
drug side
effects and
precautions
upon D/C

tenderness and rigidity.

medications can cause

anorexia, nausea and
vomiting, and may
trigger biliary tract
spasms. Morphine
raises serum amylase
levels. (Brophy, p97)

Opioids are schedule

2 controlled substances.
Instruct the patient to
take necessary steps to
safeguard drug supply
and to avoid sharing
medications with others.

Opioids produce
both physical and
psychological
dependence. (Brophy,
p97)

Monitor vital signs

regularly, particularly
respirations. Withhold
medication for any
difficulty in breathing or
respirations below 12
breaths per minute.

Opioids interact
with receptors in the
brain; respiratory
depression and cardiac
arrest may occur.
(Brophy, p97)

Monitor for signs of

acute drug withdrawal
such as extreme anxiety,
ventricular tachycardia,

Withdrawal
symptoms are
precipitated by
rebound stimulation of

the treatment
of pain
Goal mat,
Patient
attended pain
management
clinic within 2
days of D/C
from the
hospital.
Goal not
met, patient is
not
demonstrating
an
understanding
of the drugs
action by
accurately
describing
side effects
and
precautions.

20

Running head: CLINICAL CARE PLAN

his 3 daughters, 1year-old grandson

and disable husband.
Objective:
VS
Temp-99.6
Pulse-104
BP-174/95
RR-28
O2 Sat-97% -Room
Air
Pain Level- 7/10
Labs:
Liver Functions
-AST- 41
-Lipase 66
-ALT- 69
Medications:
-Tramadol (Ultram)
50mg PO Q6hrs
-Hydromorphone
(Dilaudid) 1 mg/ml
IV Q4hrs prn
-Morphine 4mg/ml
IV Q4hr prn (Hold if
RR < 14)
STC 201625

give-up on the
use of pain meds
-Patient
confirmation of the
excessive use of
pain medications,
tolerance &
dependence.
- Pt frequently
requesting pain
medication and
asking when the
next dose of
Dilaudid or
oxycodone can be
administered, pt.
appears agitated
prior to
administration of
pain medications.
Labs:
Liver Functions
-AST- 41
-Lipase 66
-ALT- 69
Medications:
-Tramadol (Ultram)

hypertension nausea and

vomiting, or muscle
cramping

the CNS. (Brophy,

p97)

Ensure patient safety.

Raise bed rails and place
call bell within patient's
reach and monitor
ambulation

Opioids can cause

changes in sensorium,
which may lead to
falls. (Brophy, p97)

Monitor frequency of
request and stated
effectiveness of narcotic
administered.

Opioids cause
tolerance and
dependence.

Monitor for side

effects such as
restlessness, dizziness,
anxiety, depression,
hallucinations.

Opiates bind mu and

kappa receptors in the
brain and spinal cord.
Stimulation of
chemoreceptors in the
GI tract may produce
nausea and vomiting.
(Brophy, p97)

Assessing and
managing pain to help
avoid accidental opioid
overdose.

The safe use of

opioids in hospital
settings relies on an
accurate pain

21

Running head: CLINICAL CARE PLAN

-Oxycodoneacetaminophen 5/325
Q4hr PO prn
-Cyclobenzaprine
(Flexeril) 10 mg PO
3x daily/ prn
-amphetaminedextroamphetamine
(Adderal XR 15mg
PO, extended release)
1xdaily
-Lorazepam (Ativan
1mg PO) 2xdaily, prn

50mg PO Q6hrs
-Hydromorphone
(Dilaudid) 1 mg/ml
IV Q4hrs prn
-Morphine 4mg/ml
IV Q4hr prn
-Oxycodoneacetaminophen
5/325 Q4hr PO prn
-cyclobenzaprine
(Flexeril) 10 mg
PO 3x daily/ prn
-amphetaminedextroamphetamine
(Adderal XR 15mg
PO, extended
release) 1xdaily
-Lorazepam
(Ativan 1mg PO)
2xdaily, prn

assessment and then

applying appropriate
pain management
techniques. (Brophy,
p97)
Keep resuscitative
equipment and narcoticagonist (naloxone)
medication at hand.
Withhold the drug if the
patient's respiratory rate
below 12.

Inform patient and

caregivers concerning
need for resuscitative
equipment and
rationale for frequent
monitoring of
respiratory rate.
(Brophy, p98)

Establish rapport
with patients

To increase
compliance and
cooperation. (Brophy,
p97)

Assess the patients

previous history of
analgesic use or abuse,
duration and possible
side effects to identify
potential opioid
tolerance or intolerance.
Use non-opioid
analgesics when

STC 201625

Identifying this
factor will reduce the
risk of an overdose and
respiratory depression.
(Brophy, p98)

Giving an opioid

22

Running head: CLINICAL CARE PLAN

possible

Assess the source,

quality, and severity of
the patients pain and
keep in mind that pain is
a subjective experience.
A patients report of
pain should be believed.

Monitor the patients

intake and output,
palpate the suprapubic
area of the abdomen for
bladder distention, ask
the patient about any
voiding problems, pain
in the bladder area, a
sensation of not
completely emptying the
bladder, or any unusual
odors in the urine.

STC 201625

along with a nonopioid may increase

analgesic effects and
allow a lower dose of
opioid to be given.
(Brophy, p97)
Pain is subjective.
(Carpentino, p 65)

Opioids may also

cause urinary
retention.(Doenges,
p62)