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HOWARD COMMUNITY COLLEGE

NURSING EDUCATION PROGRAM


NURSING CARE PLAN
Student Name: Shaleah McQueen
Patient Initials: MM

Date Submitted:11/18/16_________________
Age/Sex 72

Medical Diagnosis

Small bowel obstruction

Complete using your nursing textbooks (cite references used). Underline the etiologies and clinical
manifestations that relate to your client.

I.

Pathophysiology:

II.

Intestinal obstruction occurs when intestinal contents cannot pass the GI tract.
The obstruction may occur in the small intestine or colon and can be partial or
complex, simple or strangulated. (Lewis, 2011)

Etiology:

Mechanical: a detectable occlusion of the intestinal lumen.


Most intestinal obstructions occur in the small intestine
Surgical adhesion is the most common cause of small bowel obstructions and
can occur within days of surgery or several years later.
Hernia
Strictures from Crohns disease
Intussusception following bariatric abdominal surgery
Colon obstruction: cancer
Diverticular disease

(Lewis,2011)

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III.

Clinical Manifestations (Signs & Symptoms):


Coliky, cramplike, intermittent pain
Rapid onset
Vomiting
Nausea
Abdominal distention
Bowel movement (feces for a short time)
(Lewis,2011)

IV.

Treatment and Nursing Management:

Surgery is performed if the bowel is strangulated, most bowel obstructions resolve with
constructive treatment
Place the patient on NPO adhesions
Inserting a NG tube for decompression
Providing IV fluid therapy (NS or LR) *fluid losses from the GI are isotonic
Adding potassium to IV after verifying renal function
Administering analgesic for pain control
DETAILED patient history and physical examination
Maintain a strict I and O record (including emesis and tube drainage)
Vital signs regularly and notify the doctor if changes in VS and bowel sounds
(Lewis,2011)

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V.

Diagnostic Studies/Lab Analysis

Test
HCT

Date
11/16

BUN

11/16

Creatinine

11/16

Hemoglobin

11/16

WBC

11/16

Serum
electrolytes

11/16

V.

Clients Result
35.4%

Normal Result
36-44%

Reason
May indicate bleeding from
neoplasm or strangulation with
necrosis; hemoconcentration
7-20mg/dL
To assess the
degree of
dehydration
0.7-1.4
To assess the
degree of
hydration
12-15 g/dL
May indicate
bleeding from
neoplasm or
strangulation with
necrosis:
hemoconcentration
5,500-10,000
May indicate
strangulation or
perforation
To assess the
degree of
dehydration:
metabolic acidosis
can develop from
vomiting

Discharge Planning and Client Teaching


Normal fluid and electrolyte status
Minimal to no discomfort
Relief of the obstruction and return to normal bowel function
Diet: Consult a dietician provide adequate nutrition w/o exacerbating symptoms
Promote walking to increase bowel movements to resolve blockage

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VIII.

Growth & Development


According to Erikson: Stage: _Late Adulthood___
________________________

Crisis:

Tasks:

A.

Describe your patients ability to achieve their growth and developmental tasks.
How is this ability affected by the underlying disease process and/or the current
admission?

B.

List nursing actions to assist your client in meeting their growth and
developmental needs.
Encourage patients to talk about self-care strategies. An explanation of all procedures and
treatment helps to build trust and decrease apprehension
(Lewis, 2011)

IX.

List in priority order all relevant nursing diagnoses for your patient. Include
NANDA diagnosis, etiology and supporting data.

Deficient fluid volume r/t vomiting


Acute pain r/t abdominal distention
Deficient fluid volume r/t NG suction

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Assessment Data

Nursing Diagnosis

Nursing Actions

Rationale

Evaluation

Identify all data that support the


priority nursing diagnosis.

According to NANDA

List in order of priority. Label


aspect of care.

State the rationale for each


nursing action. Cite reference
and page number.

Evaluate the patient response to


each nursing action providing
objective & subjective data.
Revise nursing actions as
necessary.

Subjective:
HX: Crohns disease

Deficient fluid volume r/t


vomiting

Patient says My small


intestine was removed in
2001
Patient constantly asking
for ice chips.
Objective: B/P: 141/64
Temp:37.2(99)
Pulse: 80
RR:16

Expected Outcome:

Short Term Goal (STG):


The patients hct will
increase by the end of the
shift. The patient will
exercise by walking the
hallways 3-4 times every 2
hours.
Long Term Goal (LTG):
The patient will be able to
get off her NG tube and be
able to consume a adequate
meal to replace missing
nutrients from vomiting
and NPO status by
discharge.

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1. Nutritional
The nurse will
provide patient
teaching to
provide adequate
nutrition w/o
exacerbating
symptoms
The nurse will
administer iv fluid
therapy with
electrolyte and
glucose
replacement

1.To replace fluid and


electrolyte losses and
prevent malnutrition
(Lewis, 2011.pg.980)
2. Zofran block the
action of
serotonin(substance that
causes nausea and
vomiting(lewis,2011,pg.92
5)
3. Provide comfort
measures and promote a
restful environment
(Lewis, 2011,pg981)
To build trust and
decrease
2. Pharmacological
apprehension(lewis,2011,
The nurse will
pg.981)
administer an
4. This indicates
antiemetic to
relieve the patient inadequate vascular
of feeling nauseous volume and the potential
for kidney
3. Psychological
injury( Lewis,2011
The nurse will
pg.984)
provide support to
5.
the patient using
therapeutic
communication, to

Evaluate each expected


outcome:

Short Term Goal (STG):


Long Term Goal (LTG):

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build a rapport
and encourage
self-care
4. Physiological
The nurse will
assess and check
vital signs for the
patient regularly
and report to the
surgeon of
decreased
urine(<0.5mL/kg)
output, pain, etc.
5. Rehabilitation
The nurse will
promote the
patient to walk
every 4 hours to
increase bowel
movements

Assessment Data

Nursing Diagnosis

Nursing Actions

Rationale

Evaluation

Identify all data that support the


priority nursing diagnosis.

According to NANDA

List in order of priority. Label


aspect of care.

State the rationale for each


nursing action. Cite reference
and page number.

Evaluate the patient response to


each nursing action providing
objective & subjective data.
Revise nursing actions as
necessary.

Expected Outcome:

Short Term Goal (STG):


Long Term Goal (LTG):

Evaluate each expected


outcome:

Short Term Goal (STG):


Long Term Goal (LTG):

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MEDICATION PREPARATION SHEET


Allergies: Celebrex, Codeine, Tylenol w Codeine, Ibuprofen
Med as per MAR: Fluticasone (FLONASE) nasal spray * 1 spray each nostril
MD Order: 1 spray each nostril
Time(s) Due: 1000
Generic/Trade Name: FLONASE
Normal Dosage: 2 sprays in each nostril
Classification/Action: corticosteriods
Indication for Patient: allergic rhinitis
Major Side Effects: headache/ N/V
Parameters Checked: no parameters
Med as per MAR: piperacillin-tazobactam 3.375g in NACi 0.9% 100mL IV PB mini-bag
plus 25 mL/hr every 8 hours
MD Order: 3.375g in NACI 0.9% 100mL IV PB mini-bag plus 25 mL/hr every 8 hours
Time(s) Due: 900
Generic/Trade Name: Tazocin
Normal Dosage: 3.375g
Classification/Action: anti-infectives
Indication for Patient: risk for infection
Major Side Effects: seizure, diarrhea, pain
Parameters Checked: no parameters

Med as per MAR:


MD Order:
Time(s) Due:
Generic/Trade Name:
Normal Dosage:
Classification/Action:
Indication for Patient:
Major Side Effects:
Parameters Checked:
Med as per MAR:
MD Order:
Time(s) Due:
Generic/Trade Name:
Normal Dosage:
Classification/Action:
Indication for Patient:

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Major Side Effects:


Parameters Checked:

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