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C.C, 38 y/o
G:1 P:0, CGA: 31(4), NKA - Coggle Diagram
C.C, 38 y/o
G:1 P:0, CGA: 31(4), NKA
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Respiratory: clear/unlabored breath sounds upon auscultation on all lung fields, breathing on RA.
Skin: Skin color consistent throughout, no lesions noted throughout skin. small incision in LRQ, dry and intact. color consistent with ethnicity/race.
Cardiovascular: normal heart sounds, radial pulse 88bpm, reg rate and rhythm, cap refill <2 seconds.
GI: abdomen distended, tender as expected 2 days post-op, bowel sounds present in all 4 quadrants. No bowel movements as of Saturday the 19th, around 8pm.
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Medications:
0.9% NaCl
Colase 1 capsule 100mg
Lovenox injection
Zosyn 3.375g
Miralax packet 17g
Hydrocodone-acetominophen 5-325mg - 2 tablets
Nursing diagnosis: Risk for infection r/t recent abdominal surgery
Goal: Patient remains free of infection, as evidenced by normal vital signs and absence of signs and symptoms of infection throughout shift.
Goal met As evidenced by no increase in VS or any lab work showing infection.
Interventions:
- Monitored patient for any signs of infection which include redness, swelling, increased pain, purulent discharge from incisions, or catheter in place.
- Monitored patients lab work that would indicate an infection (WBC - 8.8)
- Administered antibiotics prophylaxis
Nursing diagnosis:
Acute pain r/t abdominal surgery
Goal: Have patients pain at a comfortable level of 4/10 (per patient) throughout entire shift.
Goal partially met: Patients pain fluctuated throughout shift. For the most part, patients pain was controlled with analgesics and letting her rest.
Interventions:
- Ambulated with patient to help with normalization of organ function (stimulates peristalsis, helps with gas and reducing abdominal discomfort).
- Educated patient on some deep breathing techniques to help with relaxation and to get her mind off the pain, sat with patient and talked as well.
- Assessed patients pain frequently to make sure we kept her as comfortable as possible.
- Administered pain medication as directed.
- Repositioned patient in bed with extra pillows for comfort, provided wet wash cloth on forehead as well for comfort.
- Monitored for altered VS (high BP, HR, RR, dilation of pupils)
Nursing diagnosis:
Constipation r/t lack of activity
Goal: Have patient pas gas or stool by end of shift.
Goal not met: Patient was very uncomfortable and in pain, unable to pass gas.
Interventions:
- Ambulated with patient to help stimulate peristalsis, and to pass gas.
- Administered miralax and colace to help patient have a bowel movement.
- Repositioned patient in bed to help pass gas.
- Educated patient on eating green leafy vegetables once she was cleared from a clear liquid diet such as brussel sprouts, spinach, broccoli.
additional interventions:
- Educated patient on getting up to walk to help her pass gas and possibly get her to have a bowel movement. explained that some of the abdominal pain she was experiencing could be due to gas and the fact that she had not had a bowel movement since Saturday.
- Patient was in bed most of the day, put on SCD hose in order to help circulate some blood through her legs to prevent any DVT.
Labs:
- WBC 8.8
- HgBN: 8.5 (low)
- Hct: 25
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GU: last bowel movement 9/19 around 8pm. Voids frequently, light yellow urine, no distinct odor.