Med-Surg Case Study #1 - CSC SNA Web Resources

POINTS POSSIBLE	POINTS EARNED	GRADE: _X_ Satisfactory (>74.9%) GRADE: ___ Unsatisfactory (<74.9%) 74.9% = 149.8 POINTS
20	20	PART A: Data Base 1. Assessment Data (Med-Surg Assessment Form) NOT INCLUDED a. Subjective b. Objective
10	8	2. Developmental Level
10	10	3. Lab & Diagnostic Studies (results, nursing implications, reference)
110	8	4. Medical Treatments (include rationale, evaluation, reference)
10	10	5. Medication Worksheets
10	10	6. Data Analysis
70	66	TOTAL PART A
12/12	12/12	Care Plan (2 required) 1. Assessment: a. subjective data b. Objective data (includes applicable meds, labs, diagnostic studies, and treatment)
6/6	6/6	2. Nursing diagnosis: a. Relivant/Valid b. Correct format (2 - part)
6/6	6/6	3. Goal (1 per diagnois) a. Client centered b. Realistic Attainable c. Addresses nursing diagnosis d. Time for achievement
6/6	6/6	4. Outcome Criteria (minimum of 2 per goal): a. Measureable b. Clearly specific
15/15	15/15	5. Interventions: a. Appropriate number to meet goal (5-6) b. Specific (What, when, how often, how long, where) c. Creative d. Individualized e. Rationale (supports interventions; reference) f. Relevant to goal/outcome criteria
5/5	5/5	6. Evaluation: a. Relevant to started intervention or expected outcome b. Objective/subjective data
100	100	TOTAL PART B
2	2	PART C: Pathophysiology 1. Etiology
3	3	2. Description
2	2	3. Signs/Symptoms
4	2	4. Medical Treatments
7	7	5. Nursing Implications
2	2	6. Quality of References (Need at least 2)
20	18	TOTAL PART C
5	5	PART D: Format 1. Legible; appropriate terminology and abbreviations; correct spelling
5	5	2. References a. Cited in text b. Reference Sheet
10	10	TOTAL PART D
70	66	TOTAL PART A
100	100	TOTAL PART B
20	18	TOTAL PART C
200	194	TOTAL POINTS (Good work!)

Generativity vs. Stagnation: Age 21-45 (DeLaune, 76) (Intimacy vs. Isolation: DeLaune's text has errors on the age groups for the later developmental levels. Use a different reference.)
Individual: 36 yo female that is working toward Generativity. (Intimacy)

Task: to establish a family and become productive.
Implications: Provide emotional support. Recognize individual accomplistments and provide appropriate praise. (DeLaune, 76)
Individual: TB is married and has a 5mo son. Before the birth of her son, she enjoyed a teaching career. She has decided to stay home, raise her son, and support her husbands career.

Task: Adults who have acheived generativity feel good about their lives and are comfortable with themselves.
Implications: Provide emotional support. (DeLaune, 76)
Individual: TB is relaxed, open, and confident. She said that she doesn't have any major stressors in her life.

Task: They become more active in altruistic acts.
Implications: Encourage to become involved in community activities. (DeLaune, 76)
Individual: TB's husband works in the school system and she enjoys attending school activities with her husband. They are both very active in the community.

Task: They usually experience changing family rolos.
Implications: Instruct about the need to care for self while caring for others. (DeLaune, 76)
Individual: TB's son was born 5 months ago. She loves staying home with him and supporting her husband's career. She maintains a very close relationship with her parents. We discussed her limitations during ercovery adn she said that her mother was going to help her while her husband was at work.

I. Description: Surgical removal of the gallbladder for acute and chronic cholecytitis. The gallbladder is removed through a small opening just above the umbulicus. There are usually three other holes made for the special instruments used to assist in the removal of the gallbladder. The organs are viewed on a television monitor through a camera attached to the laparoscope. Following the procedure, bile ducts will eventually dilate to accomadate the volume of bile once held by the gallbladder. (Nettina, 540)

II. Etiology: Cholecystectomy is one of the most frequent surgical procedures performed. There are more than 600,000 performed each year in the United States. (Nettina, 540) Ninety percent of patients with cholecistitis have gall stones. Most of the 15 million Americans with gallstones have no pain and are unaware of the problem. (Smeltzer, 1006)

III. Signs/Symptoms: There are two types of symptoms, those related to the disease and those related to obstruction of the bile passage by a gallstone. Symptoms may be acute or chronic and pain may be vague in the RUQ or abdomen. The distress usually occurs after a meal high in fried or fatty foods. Pain and billiary colic occur if the gallbladder becomes inflamed, distended and eventually infected. Excruciating pain that radiates to the back or right shoulder. The pain is usually associated with nausea and vomiting. The patient moves restlessly unable to find a comfortable position. Jaundice occurs with a small percentage of patients. Bile in the urine gives it a dark color and the feces will look clay colored. The absorption of fat-soluble vitamins is disrupted. (Smeltzer, 1007)

IV. Medical Treatments: Patients must be NPO from midnight the night before the surgery and void before the surgery. IV fluids should be started before the surgery to improve hydration if the patient has been vomiting. Antibiotics are ordered for acute cholecystitis. (Nettina, 541)

V. Nursing Implications:
__A. Relieving Pain: (Nettina, 541)
____1. Assess pain level, location, and characteristics
____2. Give pain medication as ordered.
____3. Encourage splinting of incision when moving.
____4. Encourage ambulation as soon as prescribed to prevent flatus and abdominal distention and promote bowel motility.
____5. Instruct patient that activity can usually be resumed within 10 days after the procedure.
__B.Preventing Infection: (Nettina, 541)
____1. Assess wound drainage and dressings.
____2. Assess T-tube and drainage.
____3. Report RUQ pain, abdominal distention, fever, chills, jaundice.
____4. Give antibiotics as ordered.
____5. Encourage use of incentive spirometer, coughing, and deep breathing.

DRUG ORDER: VISTARIL 25mg/1mL IM q3h PRN with Demerol NORMAL DOSE: PO/IM PO 25-100mg tid-qid IS ORDER SAFE? Yes REASON FOR GIVING: Nausea, vomiting & sedation, pruritis.. Depresses subcortical levels of CNS. Sedative-hypnotic PRE-ADMINISTRATION ASSESSMENT: B/P, liver, mental status IMPLICATIONS FOR ADMINISTRATION: Z-track in large muscle to decrease pain. Assist with ambulation. Raise side rails. POST-ADMINISTRATION EVALUATION: Absence of nausea and sedation. TEACHING: orthostatic hypotension, report confusion; avoid hazardous activities & alcohol. REFERENCE: Skidmore-Roth, 534-535	DRUG ORDER: Demerol 50mg IMq3h PRN with Vistiril NORMAL DOSE: PO/SC/IM 50-150mg q3-4h prn IS ORDER SAFE? Yes. REASON FOR GIVING: Post-operative pain PRE-ADMINISTRATION ASSESSMENT: Assess pain (0-10 scale, location, onset, quality). I&O: watch for urinary retention. Respirations: <12/min reported to physician. Allergic reaction: rash, uticaria. Precautions with addictive personalities. IMPLICATIONS FOR ADMINISTRATION:With antiemetic for nausea, vomiting. Increased interactions with other CNS depressants. POST-ADMINISTRATION EVALUATION: Decrease in pain. Side effects include: drowsiness, dizziness, confusion, euphoria, palpations, brady/tachy-chardia, tinnitus, blurred vision, nausea, vomiting, constipation, urinary retention, rash, pruritus. REFERENCE: Skidmore-Roth, 632-634
DRUG ORDER: Reglan 10mg IV q6h PRN Cholinergic NORMAL DOSE: 10-15mg qid, 30min ac. IS ORDER SAFE? Yes REASON FOR GIVING: Prevention of nausea & vomiting. PRE-ADMINISTRATION ASSESSMENT: Mental status for depression, anxiety, irritability. GI complaints: nausea, vomiting, anorexia, constipation, EPS and tardive dyskinesia. IMPLICATIONS FOR ADMINISTRATION: 1//2-1h before meals for better absorption. Gum, hard candy, rinse mouth frequently for dry oral cavity. POST-ADMINISTRATION EVALUATION: Absence of nausea, vomiting, anorexia, fullness. Side effects include: fatigue, restlessness, headache, sleeplessness, dry mouth, constipation, nausea, hypotension, superventricular tachycardia, urticaria, rash. REFERENCE: Skidmore-Roth, 672-673	DRUG ORDER: D5W2% NaCl @ 75cc/h NORMAL DOSE: IV depends on individual requirements IS ORDER SAFE? Yes REASON FOR GIVING: increases caloric intake and increases fluids PRE-ADMINISTRATION ASSESSMENT: electrolytes, assess injection site IMPLICATIONS FOR ADMINISTRATION:- POST-ADMINISTRATION EVALUATION: no weight loss, adequate hydration TEACHING: reason for dextrose/fluid REFERENCE: Skidmore-Roth, 345
DRUG ORDER: PERCOCET 1 PO q4h PRN Narcotic Analgesic NORMAL DOSE: PO 5mg q4-6h or 10mg tid or qid prn IS ORDER SAFE? Need more information from pharmacy REASON FOR GIVING: Moderate to severe pain. Inhibits ascending pain pathway in CNS, increases pain threshold, alters pain perception. PRE-ADMINISTRATION ASSESSMENT: I&O, CNS changes, Allergic reaction, Respiratory disfunction, Need for pain meds. IMPLICATIONS FOR ADMINISTRATION: with antiemetic if N&V, when pain begins to return POST-ADMINISTRATION EVALUATION: decrease in pain TEACHING: Physical dependence risk, withdrawal may occur, report allergic reaactions REFERENCE: Skidmore-Roth, 764-765	DRUG ORDER: NORMAL DOSE: IS ORDER SAFE? REASON FOR GIVING: PRE-ADMINISTRATION ASSESSMENT: IMPLICATIONS FOR ADMINISTRATION: POST-ADMINISTRATION EVALUATION: TEACHING: REFERENCE:

DATE	TEST	NORMAL VALUES	OBTAINED VALUE	IMPLICATIONS FOR NURSING CARE WITH REFERENCE*
3/10/99	ALKALINE PHOSPHATE	42-98 IU/L	86	1. TB had N&V before surgery and her electrolytes were disturbed. 2. IV fluids as ordered, urge to drink extra fluids adn eat regular diet. 3. Corbett, 117
3/10/99	ANION GAP	6-16	3 L	1. Warning of bone or liver abnormality. Had cholecystitis. 2. Cholecystectomy was performed. 3. Corbett, 291
3/10/99	LYMPHOCYTES	23.0-61.0 %	22.0 L	1. Lymphocytes decrease when neutrophils increase to fight infection (cholecystitis). 2. Good handwashing, allow ample rest, ensure good nutrition, avoid exposure to illness. 3. Corbett, 56

DATE	TREATMENT	RATIONALE WITH REFERENCE	EVALUATION OF CLIENT'S REFERENCE
3/11/99	Regular diet	Client has no dietary restrictions related to her health.	Objective: ate 100% of breakfast
3/11/99	Routine vital signs q4h	Routine vital signs are accessed for changes that may indicate adverse effects of meds, illness, infection, hemorrhage, and patient progress.	Objective: Client's vital signs were T-98.4, P-64, R-18, B/P 100/70.
3/11/99	Bed rails up X 2	Side rails are raised to prevent the patient from falling or rolling out of bed. She was given Percocet for pain and may experience drowsiness or dizziness.	Objective: -no falls
3/11/99	Assess IV site (removed) and 4 abdominal incisions for redness, swelling and drainage.	-nfection would cause redness and swelling. Hemorrhage is a risk after surgery. (Reference?)	Objective: no redness, swelling or drainage. Steri-strips dry and intact with scant dried blood.

Diagnostic Divisions	Nursing Problems	Diagnoses	Maslow's Priorities
Activity/Rest	GB pain for 3 wks Very tender abdomen		1 1
Ego Integrity	New baby 5 mo ago		3
Elimination	Tender abdomen High Alkaline Phos		1 1
Food/Fluid	N&V before surgery Anion Gap Low		1 1
Hygiene	Assist mobility, pain med Assist dressing, pain		2 4(?)
Neurosensory	R & L vision loss, glasses Drowsy, pain med C/O dizziness, pain med C/O lightheaded, pain med		2 2 2 2
Pain/Comfort	Pain abd & R shoulder Pain 6/10, 2/10 p meds lap Constant pain Throbbing pain in abd Radiates R shoulder Pain since surgery Percocet 5mg Grimace c positioning	Pain r/t tissue trauma secondary to cholecystectomy.	1 1 1 1 1 1 1, 2 1
Respiration	Resp allergic rxn to milk " dog & cat hair Recurrent pneumonia		2 2 2
Safety	Low lymphcytes Resp allergic rxn to milk . " dog & cat hair R knee cartilage removed Arthritis R knee Lower back pain til 1/99 Moles changed, pregnancy Glasses IV was in L hand 4 abd incisions (<1" ea) Strength 7/10 Slow gait, guards abd	Risk for infection r/t interruption in tissue integrity.	2 2 2 2 2 2 2 2 2 2 2 2
Social Interaction	-
Teaching/Learning	Learning Mother & father HTN Father kidney stones 1 Percocet qh4 prn pain Cholecystectomy Pain since 12/98 Wants pain relief R knee surgery '(78) Tonsilectomy ('67) 2-3d assist with food prep No driving, pain meds Caution walking, pain med Self care assist to < pain		2 2 1,2 2 1 2 2 2 2 2 2 1

*1-PHYSIOLOGICAL; 2-SAFETY/SECURITY; 3-LOVE/BELONGING; 4-SELF-ESTEEM; 5-SELF-ACTUALIZATION

NURSING DIAGNOSIS: Pain r/t tissue trauma secondary to laparoscopic cholecystectomy.

Assessment Data: constant, throbbing, abdominal pain, constant, radiating, right shoulder pain, rates pain 6/10 before pain medication, grimaces with positioning, pain is 2/10 after Percocet 5mg PO

Goal: Patient is free from or able to cope with pain during hospital stay AEB:

NURSING INTERVENTIONS

RATIONALE FOR CHOSEN INTERVENTIONS WITH REFERENCE

EVALUATION

The nurse will:

1. Assess pain on 0-10 scale, quality, location, onset, duration.

2. Administer pain medication as ordered and evaluate patient's response.

3. Teach patient to splint abdomen when coughing or moving.

4. Anticipate need for pain relief.

5. Respond immediately to complaint of pain. Check on patient frequently. Show concern and caring toward the patients pain and the anxiety that it causes.

6. Educate on how to use medication for pain management.

1. Frequently assess clients pain level, location, duration, & quality. Especially when her medication should be starting to wear off and/or another dose may be given. The most effective way to deal with pain is to prevent it. Early intervention may decrease the total amount of analgesia required. (DeLaune, 848)

2. Above (DeLaune, 848)

3. Minimizes pressure against incisions and decreases movement or abdomen. (Nettina, 84)

4. Above, (DeLaune, 848)

5. Decreases anxiety during pain and client may have a distorted perception of time. Aids in development of a trusting relationship. (DeLaune, 844-845)

6. It is important to request pain medication before the pain becomes severe and more difficult to control. (DeLaune, 848)

1. Before pain medication she C/O a constant, throbbing pain in abdomen (6/10) and a constant radiating pain in her right scholder (6/10). After Percocet 5mg, she rated the pain 2/10.

2. Before pain medication she C/O a constant, throbbing pain in abdomen (6/10) and a constant radiating pain in her right shoulder (6/10). After Percocet 5mg, she rated the pain 2/10.

3. Client demonstrating splinting with the pillow when coughing and changing position. She also held her abdomen when walking to the restroom. She stated that it reduced the pain.

4. Client's pain level was assessed three times during 2.5 hours she was in my care. Patient was asked to evaluate her pain on a 1-10 scale. She rated it a 6 and asked for medication at 0730. Percocet 5mg was given at 0745. At 0855 she rated the pain 2/10.

5. Asked client her pain level and she requested pain medication. I immediately contacted her nurse and my instructor so that it could be given. Percocet 5mg was given at 0745 when pain was 6/10. At 0855, pain was 2/10.

6. Explained to the client that it is important to request pain medication before the pain becomes too severe and more difficult to control. She was informed that her pain medication could be taken every 4 hours. Patient verbalized understanding of using medication for pain management and at discharge she and how often she can be given her pain medication.

NURSING DIAGNOSIS: Risk for infection r/t interruption in tissue integrity secondary to laparoscopic cholecystectomy.

Assessment Data: low lymphocytes, IV was in left hand, 4 abdominal incisions. (All objective data.)

NURSING INTERVENTIONS

RATIONALE FOR CHOSEN INTERVENTIONS WITH REFERENCE

EVALUATION

The nurse will:

1. Assess vital signs q4h and prn.

2. Encourage intake of protein- and calorie-rich foods.

3. Encourage coughing and deep breathing.

4. Wash hands before and after patient contact.

5. Assess incisions and IV site for sidbs of infection or henorrhage: purulent drainage, redness and swelling from incision sites.

1. An elevated temperature may indicate infection.(Ellis, 126-144)

2. To maintain optimal nutritional status and provide the body with nutrients necessary to heal and protect itself from infection. (Corbett, 56)

3. Reduces stasis of secretions in the lungs and bronchial tree. When stasis occurs, pathogens can cause upper respiratory infections, including pneumonia. (Ellis, 123)

4. Friction and running water effectively remove microorganisms from hands. Washing between procedures and patients reduces the risk of transmitting pathogens from one area or person to another. Use of disposable gloves does not reduce the need for handwashing. (Ellis, 20)

5. Assess incisions and IV site for purulent drainage, redness and swelling from incision sites. (Ellis, 69)

1. Client's vital signs were taken at 0700 and upon discharge at 0915. Patient's vital signs were T 98.4, P 64, R 18, B/P 100/70 at 0700 and T 98.4, P 72, R, 20 and B/P 102/74 upon discharge at 0915.

2. The head of the bed was elevated so the client was in a sitting position for her breakfast. The importance of proper nutrition were discussed. The client ate 100% of her breakfast. She verbalized understanding the importance of protein and high nutrient foods in the healing process and in infection prevention.

3. Client was shown how to use a pillow to splint her abdomen when coughing and explained the rationale for TCDB. The patient demonstrated using the pillow to splint her abdomen and TCDB. She also verbalized understand the rationale for doing it.

4. Nursing student washed hands before and after all patient contact.

5. The IV site and incisions were assessed at 0700 and upon discharge at 0915. Clients IV site was free from redness swelling and drainage. The abdominal incision's steri-strips were dry and intact with scant amounts of dried blood.

Nettina, S. (1991). The Lippencott Manual for Nursing Practice. Philadelphia, Pennsylvania: Lippencott-Raven Publishers.

Skidmore-Roth, L. (1999). Mosby's 1999 Nursing Drug Reference. St. Louis, Missouri: Mosby-Yearbook, Inc.

Smeltzer, S.C. & Bare, B.G. (1996). Brunner and Suddarth's Textbook of Medical-Surgical Nursing. Philadelphia, Pennsylvania: Lippencott-Raven Publishers.

OUTCOME CRITERIA	EVALUATION
1. Changing position without complaints of pain.	MET: Patient rated her pain 2/10 after taking Percocet 5,g. Patient stated that splinting her abdomen "makes it hurt less."
2. Sleeps without interruption of pain.	MET: Client stated that she was able to sleep for six hours last night.

OUTCOME CRITERIA	EVALUATION
1. Vital signs within normal ranges.	MET: Patient's vital signs were T 98.4, P 64, R 18, B/P 100/70 at 0700 and T 98.4, P 72, R, 20 and B/P 102/74 upon discharge at 0915.
2. Absense of purulent drainage, redness and swelling from incision sites.	MET: Clients IV site was free from redness swelling and drainage. The abdominal incision's steri-strips were dry and intact with scant amounts of dried blood.