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Date Submitted:11/18/16_________________
Age/Sex 72
Medical Diagnosis
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:
(Lewis,2011)
III.
IV.
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)
V.
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
VIII.
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.
Assessment Data
Nursing Diagnosis
Nursing Actions
Rationale
Evaluation
According to NANDA
Subjective:
HX: Crohns disease
Expected Outcome:
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
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
According to NANDA
Expected Outcome: