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Clinical Week 1 Care Plans, Vaginal and Pelvic Masses, Whipple Procedure…
Clinical Week 1 Care Plans
Vaginal and Pelvic Masses
Abdominal Distension
Laparoscopic Procedure
Laparoscopic removal of tissue
LR for fluid volume replacement
Ambulation
SCDs
Absence of gas and stooling post-operatively
Simethicone for gas
Acetaminophen for pain relief
US for visualization of ovarian cysts
MRI for visualization of pelvic/vaginal masses
5 laparoscopic sites, well-approximated, no redness, s/s of Infection
5 Pregnancies, at least one C-section
Previous hysterectomy
History of cervical cancer
Whipple Procedure 9/20/22
Rule Out Fistula s/p Whipple Procedure
Acetaminophen, Ibuprofen
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Low RBC, H&H
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Blood Transfusion If Hemoglobin drops too low; Indicates fistula or bleeding Internally
CT/X-Ray for visualization of tissues surrounding bile duct and small Intestine
Surgery to correct fistula, If applicable
Pain Management
Repeat UA, WBC for signs of Infection
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Visualization of JP Drain Insertion site to look for S/S of Infection
Removal of JP Drain when producing <30mL/24 hours, or per provider Instructions
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Daily JP drain serum checks and levels for pancreatic/liver enzymes and byproducts
Docusate Sodium
Protonix
Pancrealipase
Rule Out C. Difficile Infection s/p antibiotics
C. Difficile stool sample
Erythromycin
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Hypothyroidism
Low Calcium
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Muscle Weakness
New left sided weakness
Rule Out Stroke
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Calcium and Vit D Supplement
Levothyroxine (Synthroid)
Previously Independent; lives alone and performs ADL appropriately
OT Consult
Hypertension
Amlodepine
400cc output JP drain overnight
Lasix
Serosanguinous chest tube drain fluid, 70cc 0700-1300
Pleural Effusion
CXR with opacities, left mediastinal shift
Pigtail Chest Tube Insertion w/ water seal drain
SCD w/ bedrest to prevent clots
At home Pleurx for drainage moving forward
Emergent Thoracenteses
Aspirin
Cultures of Pleural Effusion Sample
Antibiotics, If needed
Low RBC, H&H
Blood Transfusion If Hgb drops below 8
Acute Pain s/p Pleural Effusion
Morphine
Acetaminophen
PET Scan
Hx Lung Cancer
Mets to the brain
Synthroid
Opacities R lung
Hx of DMT1
Insulin Pump
Right sided chest pain
EKG
7L of fluid removed In ED
Increased confusion
Acute Delirium
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MRI: no acute stroke
Neurology Consult
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CT: no acute changes
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Psychology Consult
Anti-anxiety medications
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Overnight Observation
Anti-psychotic medications
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Normal CBC, CMP
hallucinations
disorganized speech; Inappropriate words
No Increased frequency, Incontinence, burning, discomfort with urination
Rule Out UTI
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UA: no signs of Infection, UTI
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Repeat UA - confirm absence of UTI
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ABX If appropriate, following repeat UA
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Normal WBC Count
Agitation, Restlessness
Relevant Findings: Increased Confusion
Agitation
Restlessness
Disorganized Speech, Inappropriate Words
Muscle Weakness
History of UTIs
Afebrile
New Medication Prescription
Priority Problem:
Acute Delirium Episode
Priority Actions:
Repeat Labs and UA for UTI Data
Expected Outcome: If the delirium episode was due to an Infection, we would expect to see an Increase In WBC In the CBC and an changes to the WBC differential that could help us to determine what type of Infection Is occuring. In the UA, we could expect to see an Increase of WBC, as well as bacteria present that would allow us to culture and determine what Infection we have going on.
Actual Outcome: the patient's CBC showed no elevated WBC, and the UA showed no bacteria present. This helped us rule out UTI associated delirium.
Priority Actions:
Medication Reconciliation
Expected Outcome: We would want to check and make sure that her home medication regimen Is actively treating her symptoms and are not contributing towards any cognitive decline or delirium.
Actual Outcome: When looking through her medications, the only two recent medications were the Haldol and Seroquel. These medications were started and first taken 9/11, right before the symptoms began and the patient came to the ED. By stopping these while In patient, we saw a decline In the delirium and a return to a baseline level of functioning.
Priority Actions:
Psychiatry Consult
Expected Outcome: We would expect the psychiatric team to do a full and complete work up of our patient to determine If there are any new or developing psychosocial conditions, like anxiety, dementia or schizophrenia causing the new confusion and hallucinations.
Actual Outcome: the psychiatry team determined that the patient's delirium was due to a reaction to Haldol and Seroquel given to help the patient sleep on her first night In patient. Psychiatry recommended melatonin and Trazodone for sleep, as opposed to the other medications that caused the reverse effect.
Priority Actions:
Neurologic Consult
Expected Outcome: We would expect, and want, our patient's neurological evaluation to be unremarkable for any signs of stroke or acute TIA.
Actual Outcome: the MRI and CT of the heads both came back negative for any acute findings/causes of the delirium. The scans both showed no signs of a stroke or TIA.
Potential Complication: Fall Risk
Action to Overcome: Call provider and notify of fall; anticipate orders for possible x-rays and CT scans to ensure no fractures or Internal bleeding. Potentially pause or stop enoxaparin to again reduce risk of bleeds.
Action to Overcome: Fill out appropriate paper work and documentation In chart, fall packets and PSN to ensure adequate reporting completed.
Action to Prevent: Fill out Fall Risk scores and Implement Interventions recommended for her level of need: I.e. bed alarms, chair alarms, bedside sitters, non-slip socks
Action to Prevent: Stop medications causing delirium (Haldol, Seroquel)
Significant History of UTIs
New medications: Seroquel and Haldol
Orange/serosanguinous JP drain fluid color
0700-1430 260mL output JP drain
Dry, Intact dressing surrounding JP drain
JP Drain Fluid Amylase < 3units/L
JP Drain Fluid Triglycerides 155mg/dL
Relevant Findings:
Orange/Serosanguinous Fluid
400cc output from JP drain in 12 hours
260cc output from JP drain 0700-1430
JP Drain Fluid Triglycerides 155mg/dL
No signs external infection
No WBC elevation
Low RBC, H&H
Dry, intact dressing surrounding JP drain
2 post-JP drain wound dressing changes in 5 hour time
Priority Problem:
Risk for Delayed Wound Healing
Priority Actions: Imaging, either a CT or Xray should be done to visualize the healing tissue Inside the JP drain and determine If a fistula Is visualized/likely to have formed
Expected Outcome: we would expect to be able to visualize an abnormal opening somewhere surrounding the new connection made between the pancreas, liver, stomach and small Intestine If a fistula was formed
Actual Outcome: no Imaging of the area was done during this hospitalization due to reduced output overnight
Priority Actions:
ambulation as much as possible and as soon as possible
Expected Outcome: we would expect that Increased ambulation and decreasing the time spent In bed will help Improve circulation, Improve overall well being, and Improve the healing of the wound, while also preventing any bedsores from developing or becoming a complication
Actual Outcome: our patient has been up and walking laps for the past few days, and her wound has been healing great! No external signs of Infection are present, and the wounds are well-connected, closed, and draining as appropriate
Priority Actions: antibiotics post operatively to prevent infections at the surgical site or the wound from the removed JP drain
Expected Outcome: we would expect our patient to not develop any Infections post-operatively and would want their surgical site to remain free of Infection/complications, and heal properly and timely
Actual Outcome: Our patient, while showing no signs of Infection, Is now having liquid stools and Is now being tested for clostridium difficile, to ensure that the antibiotics did not wipe out her gastrointestinal flora to the point where the opportunistic bacteria could Invade and Infect our patient.
Priority Actions: removal of JP drain when the patient's output Is less than 30mL In 24 hour or upon provider's discretion/orders
Expected Outcome: we would want to remove the drain as soon as possible, typically when the output Is decreased significantly and the provider team is happy with the amount and quality/consistency of the fluid draining
Actual Outcome: the provider team did discharge the JP drain overnight on 9/27 and placed sterile 4x4 gauze and an abdominal pad over the opening to catch any remaining drainage.
Potential Complication: Risk for Dehydration
Action to Overcome: maintain hospitalization to monitor strict I&Os, and utilize PO and IV rehydration
Action to Overcome: antibiotics would be needed to treat Clostridium difficile Infection If found, and without removing the source of Infection, could continue and further complicate and continue the dehydration
Action to Prevent: ensure that JP drain continues to heal properly to cease fluid leakage through surgical site.
Action to Prevent: ensure that patient does not have C. difficile Infection, and promote adequate hydration and cessation of diarrhea/liquid stools
Liquid Stools
2 Dressing changes post drain removal within 5 hours
Relevant Findings:
SOB
Right Sided Chest pain
7L fluid removed In ED
Hx Lung Cancer w/ Mets to Brain
Opacities In CXR
Left mediastinal shift In CXR
Hx pleural effusion x1 year
Priority Problem:
Imbalanced fluid retention s/p Pleural Effusion
Priority Actions: Serial CXR daily to monitor pleural effusion status
Expected Outcome: We would expect that, with the Insertion of the chest tube, we would see a decrease In the left mediastinal shift back towards baseline, and see more clear and less opaque lungs on a CXR.
Actual Outcome: the CXR from 10/25 showed worsening opacities compared to 10/24, the opposite of what we expected would happen
Priority Actions: culture and evaluation of pleural effusion fluid to determine If any bacteria/pathogen present, and any presence of cancer cells within pleural fluid Itself.
Expected Outcome: we would expect bacteria or pathogens In the fluid If any Infection Is present within the lungs. We would possibly expect cells In the pleural fluid If the cancer cells In the lungs are numerous enough that they are sloughing off Into the fluid.
Actual Outcome: no presence of metastasizing cells and/or Infection present In sample
Priority Actions: visualization of chest tube drainage site each shift
Expected Outcome: we would want to see the site of chest tube Insertion remaining free of signs/symptoms of Infection, Including redness, drainage, odor, pain, localized heat and spiked temperatures and/or WBC counts.
Actual Outcome: no S/S of Infection located, Indicating low likelihood of Infection In our patient currently.
Priority Actions: Placement of right sided pigtail chest tube
Expected Outcome: With the Insertion of the chest tube, we would expect to see drainage of the fluid In the lungs due to the pleural effusion
Actual Outcome: We have witnessed fluid drainage from the chest tube Into the Pleuravac drainage system, attached to no oxygen and on water seal.
Potential Complication: Risk for Infection
Action to Overcome: Antibacterial/antifungal/antiviral agents to treat the appropriate Infection, determined through culture samples
Action to Overcome: antipyretics and Increased analgesics to combat temperature/fever spikes and Increased malaise, fatigue and/or pain due to body attempting to fight off Infection.
Action to Prevent: monitor s/s of Infection surrounding port and chest tube Insertion site, Including fevers, localized temperature Increases, localized redness, pain around sites, chills, night sweats, malaise, etc.
Action to Prevent: keep dressings dry, Intact and free of drainage. Use clean, sterile gauze each dressing change to prevent any Introduction of bacteria/pathogens to Insertion site and thus Into the pleural space.
Routine Thoracenteses
Shortness of Breath
Hx of Hypothyroidism
Relevant Findings:
Hx of Cervical Cancer
Abdominal distension
5 laparoscopic sites, well-approximated, no redness or s/s of Infection
5 pregnancies, at least 1 C-section
Hx Hysterectomy
Absence of gas and stooling post-operatively
Priority Problem:
Constipation and Gas s/p surgery
Priority Actions: early ambulation
Expected Outcome: we would expect that early ambulation helps to get the GI tract moving again post-operatively and help with the abdominal pain, distension and lack of bowel movement/passing gas
Actual Outcome: the patient has ambulated a few times up and down the hall and to the restroom and states no relief from walking, and Increased pain to the abdomen
Priority Actions: weaning of opioid pain medications
Expected Outcome: we would want to help our patient understand that switching from opioid based pain medications, like her Oxycodone, can cause Increased constipation, and taking her acetaminophen extra strength Instead can help to treat pain and help prevent constipation
Actual Outcome: patient has declined her oxycodone while present today prior to discharge and Is utilizing her acetaminophen for pain relief, and understands the effects of opioid medications on constipation/bowel movements
Priority Actions: education on stooling practices
Expected Outcome: we would want our patient to be able to repeat back her understanding of not straining for stooling, to use Miralax and natural stool softeners, rather than OTC enema kits
Actual Outcome: the patient was able to affirm via the teach back method what signs and symptoms to watch out for and which OTC medications to take
Priority Actions: administration of stool softeners and laxatives
Expected Outcome: With the administration of a stool softener, laxative or both we would expect the patient to have an easier bowel movement without the need to strain
Actual Outcome: Our patient received her stool softener this morning before discharge so no actual outcome was Identified.
Potential Complication: Risk for Bowel Blockage
Action to Overcome: Have patient present back to ED for an enema administration with prior Imaging to determine no blockage present.
Action to Overcome: Possible use of digital decompaction or surgical removal of colon blockage if necessary and untreatable with enemas and other non-invasive procedures
Action to Prevent: teach the patient proper stooling techniques, Including possible positioning with knees up on a step stool, not to strain or bear down due to procedure, and not to sit too long on the toilet to prevent hemorrhoid formation.
Action to Prevent: encourage appropriate laxative use, with proper dosing and education to stop taking when able to produce a bowel movement to ensure no rebound constipation/laxative dependence occurs.
Nausea, vomiting
Leiomyosarcoma
Surgical lysis of retroperitoneal mass
Acute Pain
Timely medication administration for post-operative pain
Encouragement of early ambulation and ICS/respiratory vibrator use to ensure no clots or post-operative complications
Non-pharmaceutical analgesic Interventions Including heat pack, Ice pack, turns, movement, stool softeners to prevent constipation/straining, etc.
Education and monitoring of pain tolerance due to likely Increased threshold for analgesic medications due to previous substance abuse
Post-operative Constipation
Bisacodyl, Docusate, MiraLAX
Lidocaine Patch
Pantoprazole
Oxycotin
Left sided retroperitoneal mass
Malaise, fatigue, weakness
Tenderness to palpation of left abdomen, no distension or guarding
Hypertension
Amlodipine
Hx Substance Abuse
Assessment Findings
Active Medical Dx
Labs, Diagnostics, Procedures
Treatments
Medications
Assessment Findings
Active Medical Dx
Labs, Diagnostics, Procedures
Treatments
Medications
Assessment Findings
Active Medical Dx
Labs, Diagnostics, Procedures
Treatments
Medications
Assessment Findings
Active Medical Dx
Labs, Diagnostics, Procedures
Treatments
Medications
Assessment Cues
Disease/Patho Condition
Medical Treatments/Medications
Nursing Priority Problem
Nursing Priority Intervention