UNIVERSITY OF SOUTH FLORIDA

COLLEGE OF NURSING
Student: Amanda Poplin

PATIENT ASSESSMENT TOOL .

Agency: TGH

1 PATIENT INFORMATION
Patient Initials: B.S.

Age:

Gender:

Marital Status:

Female

Assignment Date: 3/11/15

26

Admission Date:
Single

3/10/15

Primary Medical Diagnosis with ICD-10 code:

Primary Language: English

Acute Abdominal Pain

Level of Education:

Other Medical Diagnoses: (new on this admission)

Some college - AA

Occupation (if retired, what from?):

Unemployed

Pancreatitis

Number/ages children/siblings:
Two children; 4 years old, 6 months old
Served/Veteran: No

Code Status: Full Code

Living Arrangements:
Home with two children

Advanced Directives: No
If no, do they want to fill them out? No
Surgery Date:
Procedure:

Culture/ Ethnicity /Nationality: African American

3/11/15

Religion: Christian

Type of Insurance: None

Laparoscopic Cholecystectomy

1 CHIEF COMPLAINT:
I was having a lot of pain in my stomach.

3 HISTORY OF PRESENT ILLNESS: (Be sure to OLDCART the symptoms in addition to the hospital course)
B.S. is a 26 year old female who is being admitted for abdominal pain initially presumed to be secondary to pancreatitis,
however symptoms are more consistent with cholecystitis. Patient reports a past medical history of cholecystitis, stating
she had abdominal pain that was epigastric and radiating to her back three years ago, and was diagnosed with gallstones
at that time. She was offered surgical intervention but declined. Patient states pain has resolved on its own, however the
past three months since she gave birth she has had intermittent episodes of abdominal pain described as sharp and pressure
like in epigastric region radiating to the back and left. States that for the past three days, the pain has become more
frequent and severe. Denies aggravating factors, fever, chills, or nausea.

University of South Florida College of Nursing Revision August 2013

 2 PAST MEDICAL HISTORY/PAST SURGICAL HISTORY Include hospitalizations for any medical
illness or operation

Father
Mother
Brother
Sister

Tumor

Stroke

Stomach Ulcers

Seizures

Mental
Problems
Health

Kidney Problems

Hypertension

(angina,
MI, DVT
etc.)
Heart
Trouble

Gout

Glaucoma

Diabetes

Cancer

Bleeds Easily

Cause
of
Death
(if
applicable
)

Asthma

Cesarean section

Arthritis

8/28/14

Anemia

Cesarean section

Environmental
Allergies

10/10/2010

2
FAMILY
MEDICAL
HISTORY

Operation or Illness

Alcoholism

Preeclampsia

Age (in years)

Date
Unknown

N/
A
52
N/
A
32

relationship
relationship
relationship

Comments: Include date of onset

1 IMMUNIZATION HISTORY
(May state U for unknown, except for Tetanus, Flu, and Pna)
Routine childhood vaccinations
Routine adult vaccinations for military or federal service
Adult Diphtheria (Date)
Adult Tetanus (Date)
Influenza (flu) (Date)
Pneumococcal (pneumonia) (Date)
Have you had any other vaccines given for international travel or
occupational purposes? Please List

YES

University of South Florida College of Nursing Revision August 2013

NO

 1 ALLERGIES
OR ADVERSE
REACTIONS

NAME of
Causative Agent

Type of Reaction (describe explicitly)

No known allergies

Medications

Other (food, tape,

latex, dye, etc.)

5 PATHOPHYSIOLOGY: (include APA reference and in text citations) (Mechanics of disease, risk factors, how to
diagnose, how to treat, prognosis, and include any genetic factors impacting the diagnosis, prognosis or
treatment)
The patients admitting diagnosis of abdominal pain has been attributed to cholecystitis, which is an inflammation of
The wall of the gallbladder. Patient has a PMH of gallstones (cholelithiasis), which is commonly linked with cholecystitis.
Gall stones are most often caused by cholesterol, which is thought to be linked to the high-fat diets that many Americans
Consume on a daily basis (Sommers, 2013). Risk factors include genetic factors as well as environmental factors; it is
More commonly found in women, older adults, women who have borne multiple children, obesity, Native American, and
Hispanic. Diagnosis is confirmed by multiple tests including leukocytosi and an ultrasound scan. Cholecystitis is treated
By analgesics, anxiety reduction, comfort and pain management, and laprascopic cholecystectomies.

5 MEDICATIONS: [Include both prescription and OTC; home (reconciliation), routine, and PRN medication. Give trade and
generic name.]
Name
Concentration (mg/ml)
Dosage Amount (mg)
Novolog (insulin aspart)
2-10 units
2-10 units
Route
Frequency
Subcutaneous
3 times daily with food and at bedtime
Pharmaceutical class
Home
Hospital
or
Both
Anti-diabetics
Indication
Control of hyperlgycemia
Side effects/Nursing considerations
hypoglycemia, swelling, erythema, anaphylaxis; Proper technique and proper serum glucose testing
Name
Concentration
Dosage Amount
ciprofloxacin
400 mg
400 mg
Route
Frequency
IV
Every twelve hours
Pharmaceutical class
Home
Hospital
or
Both
fluoroquinolones
Indication
Treatment of bone and joint infections
Side effects/Nursing considerations
Elevated ICP, hepatotoxicity, seizures, anaphylaxis; maintain fluid intake (500-2000mL per day). dont take antacids 4 hours before or 2 hours after.
Name
dextrose 50%
Route
IV

Concentration
50 mL

Dosage Amount
50 mL
Frequency
PRN

University of South Florida College of Nursing Revision August 2013

Pharmaceutical class
Home
Hospital
or
Both
Carbohydrates
Indication
Hypoglycemia
Side effects/Nursing considerations
Inappropriate insulin secretion, fluid overload, hyperglycemia; Explain correct method for serum glucose testing
Name
Concentration
docusate sodium (Colace)
100 mg
Route
Oral
Pharmaceutical class
Home
Stool softener
Indication
Prevention of constipation
Side effects/Nursing considerations
mild cramps, diarrhea; Avoid straining and use only for short term therapy

Dosage Amount
100 mg
Frequency
Twice daily
Hospital

or

Both

Name
Concentration
morphine
2 mg
Route
Frequency
IV
Every four hours PRN
Pharmaceutical class
Home
Hospital
or
Both
Opioid agonist
Indication
Moderate to severe pain
Side effects/Nursing considerations
Confusion, sedation, hypotension, constipation; Avoid driving and activities requiring alertness.

Dosage Amount
2 mg

Name
ondanestron (Zofran)
Route
IV
Pharmaceutical class
Antiemetic
Indication
Nausea, vomiting
Side effects/Nursing considerations
Headache, constipation, diarrhea / Take as directed

Dosage Amount
4 mg/2 mL

Concentration
4 mg/ 2 mL
Frequency
Every six hours PRN
Home

Name
Concentration
tramadol (Ultram)
50 mg
Route
Oral
Pharmaceutical class
Home
analgesic
Indication
moderate to severe pain
Side effects/Nursing considerations
Seizures, dizziness, headache, nausea / Avoid driving and change positions slowly
Name

Hospital

or

Both

Dosage Amount
50 mg
Frequency
Every six hours PRN
Hospital

or

Both

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name
Route

Concentration

Dosage Amount
Frequency

University of South Florida College of Nursing Revision August 2013

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations
Name

Concentration

Dosage Amount

Route

Frequency

Pharmaceutical class

Home

Hospital

or

Both

Indication
Side effects/Nursing considerations

University of South Florida College of Nursing Revision August 2013

 5 NUTRITION: Include type of diet, 24 HR average home diet, and your nutritional analysis with recommendations.
Diet ordered in hospital?
NPO
Analysis of home diet (Compare to My Plate and
Diet pt follows at home?
Regular
Consider co-morbidities and cultural considerations):
24 HR average home diet:
Breakfast:
Patients home diet does not contain enough vegetables
Bacon, white toast, scrambled eggs, water
to maintain adequate health. Patient consumes little
Lunch:
Meat and consumes a high fat and high sugar diet,
Turkey sandwich with mayonnaise and tomatoes
Which are most likely contributing to her gastric
Dinner:
Issues. Patient would benefit from eliminating Pringles,
Pasta with alfredo sauce
Bacon, alfredo sauce and mayonnaise and replacing
Snacks:
With fruits, baked or grilled chicken, wheat toast, and
Pringles, banana, yogurt
whole wheat pasta with vegetables on the side in order
Liquids (include alcohol):
To maintain a healthy diet.
Water, coffee, fruit juice
Use this link for the nutritional analysis by comparing the patients
24 HR average home diet to the recommended portions, and use
My Plate as reference.

1 COPING ASSESSMENT/SUPPORT SYSTEM: (these are prompts designed to help guide your discussion)
Who helps you when you are ill?
My mom.
How do you generally cope with stress? or What do you do when you are upset?
Typically I just like to take a nap.

Recent difficulties (Feelings of depression, anxiety, being overwhelmed, relationships, friends, social life)
I have been feeling more anxious because of my hospital admission and not being able to take care of my kids.

+2 DOMESTIC VIOLENCE ASSESSMENT

Consider beginning with: Unfortunately many, children, as well as adult women and men have been or currently are
unsafe in their relationships in their homes. I am going to ask some questions that help me to make sure that you are
safe.
Have you ever felt unsafe in a close relationship? _______________No________________________________________
Have you ever been talked down to?___No____________ Have you ever been hit punched or slapped?
_____No_________
Have you been emotionally or physically harmed in other ways by a person in a close relationship with you?
_______________No___________________________ If yes, have you sought help for this? ______________________
Are you currently in a safe relationship?

N/A

University of South Florida College of Nursing Revision August 2013

 4 DEVELOPMENTAL CONSIDERATIONS:
Eriksons stage of psychosocial development:
Inferiority

Identity vs.

Role Confusion/Diffusion

Trust vs. Mistrust

Autonomy vs. Doubt & Shame
Initiative vs. Guilt
Industry vs.
Intimacy vs. Isolation
Generativity vs. Self absorption/Stagnation
Ego Integrity vs. Despair

Check one box and give the textbook definition (with citation and reference) of both parts of Ericksons developmental stage for your
patients age group: Isolation is the readiness to isolate and, if necessary, to destroy those forces and people whose essence
seems dangerous to our own.
Describe the stage your patient is in and give the characteristics that the patient exhibits that led you to your determination:
My patient appears to be in the stage of isolation because she is not currently in an intimate relationship, and has no
Relationship at all with the father of her children. The patient is also currently isolated from her children, the only people she
Has relationships with, as she is in and out of the hospital with her illness.

Describe what impact of disease/condition or hospitalization has had on your patients developmental stage of life:
Patient is unable to spend time with or take care of her young children due to being hospitalized, leading to feelings of
loneliness.

+3 CULTURAL ASSESSMENT:
What do you think is the cause of your illness?
Problems with my gallbladder theres an infection in it.

What does your illness mean to you?

I dont really know.

+3 SEXUALITY ASSESSMENT: (the following prompts may help to guide your discussion)
Consider beginning with: I am asking about your sexual history in order to obtain information that will screen for
possible sexual health problems, these are usually related to either infection, changes with aging and/or quality of life.
All of these questions are confidential and protected in your medical record
Have you ever been sexually active?________________________Yes____________________________________
Do you prefer women, men or both genders? _____________________Men___________________________________
Are you aware of ever having a sexually transmitted infection? _______________________________________________
Have you or a partner ever had an abnormal pap smear?______________________Yes____________________________
Have you or your partner received the Gardasil (HPV) vaccination? __________No_____________________________
Are you currently sexually active? _________No_______________When sexually active, what measures do you take to
prevent acquiring a sexually transmitted disease or an unintended pregnancy? Condoms and birth control
.
How long have you been with your current partner?_________________________N/A___________________________
Have any medical or surgical conditions changed your ability to have sexual activity? _________No_______________
Do you have any concerns about sexual health or how to prevent sexually transmitted disease or unintended pregnancy?
No

University of South Florida College of Nursing Revision August 2013

1 SPIRITUALITY ASSESSMENT: (including but not limited to the following questions)

What importance does religion or spirituality have in your life?
Faith is really important to get through tough times._______________________________________________________
______________________________________________________________________________________________________
Do your religious beliefs influence your current condition?
No, not really.________________________________________________________________________________________
______________________________________________________________________________________________________

+3 SMOKING, CHEMICAL USE, OCCUPATIONAL/ENVIRONMENTAL EXPOSURES:

1. Does the patient currently, or has he/she ever smoked or used chewing tobacco?
If so, what?
How much?(specify daily amount)
Cigarettes
1 pack a day
Pack Years:

Yes
No
For how many years? 10 years
(age 16

thru

26

If applicable, when did the

patient quit? N/A

1 pack per day for 10 years

Does anyone in the patients household smoke tobacco? If

so, what, and how much? No

Has the patient ever tried to quit?

2. Does the patient drink alcohol or has he/she ever drank alcohol?
Yes
No
What?
How much? (give specific volume)
Tequila
3 shots, once every few days.

No

For how many years? 8

(age 16

thru

24

If applicable, when did the patient quit?

October 2013
3. Has the patient ever used street drugs such as marijuana, cocaine, heroin, or other? Yes
No
If so, what?
How much?
For how many years?
(age

Is the patient currently using these drugs?

Yes No
N/A

thru

If not, when did he/she quit?

4. Have you ever, or are you currently exposed to any occupational or environmental Hazards/Risks

No

University of South Florida College of Nursing Revision August 2013

 10 REVIEW OF SYSTEMS
General Constitution
Recent weight loss or gain

Integumentary
Changes in appearance of skin
Problems with nails
Dandruff
Psoriasis
Hives or rashes
Skin infections
Use of sunscreen
SPF:
Bathing routine:
Other:

HEENT
Difficulty seeing
Cataracts or Glaucoma
Difficulty hearing
Ear infections
Sinus pain or infections
Nose bleeds
Post-nasal drip
Oral/pharyngeal infection
Dental problems
Routine brushing of teeth
Routine dentist visits
Vision screening
Other:

Gastrointestinal

Immunologic

Nausea, vomiting, or diarrhea

Constipation
Irritable Bowel
GERD
Cholecystitis
Indigestion
Gastritis / Ulcers
Hemorrhoids
Blood in the stool
Yellow jaundice
Hepatitis
Pancreatitis
Colitis
Diverticulitis
Appendicitis
Abdominal Abscess
Last colonoscopy?
Other:

Chills with severe shaking

Night sweats
Fever
HIV or AIDS
Lupus
Rheumatoid Arthritis
Sarcoidosis
Tumor
Life threatening allergic reaction
Enlarged lymph nodes
Other:

Genitourinary

Anemia
Bleeds easily
Bruises easily
Cancer
Blood Transfusions
Blood type if known:
Other:

nocturia
dysuria
hematuria
polyuria
kidney stones
Normal frequency of urination: 5
Bladder or kidney infections

x/day

Hematologic/Oncologic

Metabolic/Endocrine
2

x/day
x/year

Diabetes
Type:
Hypothyroid /Hyperthyroid
Intolerance to hot or cold
Osteoporosis
Other:

Pulmonary
Difficulty Breathing
Cough - dry or productive
Asthma
Bronchitis
Emphysema
Pneumonia
Tuberculosis
Environmental allergies
last CXR?
Other:

Cardiovascular
Hypertension
Hyperlipidemia
Chest pain / Angina
Myocardial Infarction
CAD/PVD
CHF
Murmur
Thrombus
Rheumatic Fever
Myocarditis
Arrhythmias
Last EKG screening, when?
Other: 3/10/15

Central Nervous System

WOMEN ONLY
Infection of the female genitalia
Monthly self breast exam
Frequency of pap/pelvic exam
Date of last gyn exam? 8/2014
menstrual cycle
regular
irregular
menarche
age? 12
menopause
age?
Date of last Mammogram &Result:
Date of DEXA Bone Density & Result:
MEN ONLY
Infection of male genitalia/prostate?
Frequency of prostate exam?
Date of last prostate exam?
BPH
Urinary Retention

CVA
Dizziness
Severe Headaches
Migraines
Seizures
Ticks or Tremors
Encephalitis
Meningitis
Other:

Mental Illness
Depression
Schizophrenia
Anxiety
Bipolar
Other:

Musculoskeletal
Injuries or Fractures
Weakness
Pain right hip joint
Gout
Osteomyelitis
Arthritis
Other:

Childhood Diseases
Measles
Mumps
Polio
Scarlet Fever
Chicken Pox
Other:

University of South Florida College of Nursing Revision August 2013

Is there any problem that is not mentioned that your patient sought medical attention for with anyone?
No

Any other questions or comments that your patient would like you to know?
No

University of South Florida College of Nursing Revision August 2013

10

10 PHYSICAL EXAMINATION:(Describe abnormal assessment below non checked boxes)

General Survey:
Temperature: (route taken?)
98.5 F, oral

Height: 54
Pulse: 54 bpm
Respirations: 18

Weight:175 BMI: 26.61

Blood
Pressure: 118/69

Pain: (include rating & location)

5 - abdomen

(include location) right arm

SpO2 100%
Is the patient on Room Air or O2: room air
Overall Appearance: [Dress/grooming/physical handicaps/eye contact]
clean, hair combed, dress appropriate for setting and temperature, maintains eye contact, no obvious handicaps
Overall Behavior: [e.g.: appropriate/restless/odd mannerisms/agitated/lethargic/other]
awake, calm, relaxed, interacts well with others, judgment intact
Speech: [e.g.: clear/mumbles /rapid /slurred/silent/other]
clear, crisp diction
Mood and Affect:
pleasant
cooperative
cheerful
apathetic
bizarre
agitated
anxious
tearful
Other:
Integumentary
Skin is warm, dry, and intact
Skin turgor elastic
No rashes, lesions, or deformities
Nails without clubbing
Capillary refill < 3 seconds
Hair evenly distributed, clean, without vermin

talkative
withdrawn

quiet
boisterous
aggressive
hostile

Peripheral IV site Type: 20 gauge

Location: median cubital
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what? Ciprofloxacin in dextrose 5% at 200 mL/hr
Peripheral IV site Type:
Location:
Date inserted:
no redness, edema, or discharge
Fluids infusing?
no
yes - what?
Central access device Type:
Location:
Date inserted:
Fluids infusing?
no
yes - what?

flat
loud

3/10/15

HEENT:
Facial features symmetric
No pain in sinus region
No pain, clicking of TMJ
Trachea midline
Thyroid not enlarged
No palpable lymph nodes
sclera white and conjunctiva clear; without discharge
Eyebrows, eyelids, orbital area, eyelashes, and lacrimal glands symmetric without edema or tenderness
PERRLA pupil size / mm
Peripheral vision intact
EOM intact through 6 cardinal fields without nystagmus
Ears symmetric without lesions or discharge
Whisper test heard: right ear- 6
inches & left ear- 6
inches
Nose without lesions or discharge
Lips, buccal mucosa, floor of mouth, & tongue pink & moist without lesions
Dentition: Teeth clean and intact
Comments:

University of South Florida College of Nursing Revision August 2013

11

Pulmonary/Thorax:

Respirations regular and unlabored

Transverse to AP ratio 2:1
Chest expansion symmetric
Lungs clear to auscultation in all fields without adventitious sounds
CL Clear
Percussion resonant throughout all lung fields, dull towards posterior bases
WH Wheezes
Sputum production: thick thin
Amount: scant small moderate large
CR - Crackles
Color: white pale yellow yellow dark yellow green gray light tan brown red
RH Rhonchi
D Diminished
S Stridor
Ab - Absent

Cardiovascular:
No lifts, heaves, or thrills PMI felt at:
Heart sounds: S1 S2 Regular
Irregular
No murmurs, clicks, or adventitious heart sounds
Rhythm (for patients with ECG tracing tape 6 second strip below and analyze)

No JVD

Calf pain bilaterally negative

Pulses bilaterally equal [rating scale: 0-absent, 1-barely palpable, 2-weak, 3-normal, 4-bounding]
Apical pulse: 3 Carotid: 3
Brachial: 3 Radial: 3
Femoral: 3
Popliteal: 3
DP: 3 PT: 3
No temporal or carotid bruits
Edema:
0
[rating scale: 0-none, +1 (1-2mm), +2 (3-4mm), +3 (5-6mm), +4(7-8mm) ]
Location of edema:
pitting
non-pitting
Extremities warm with capillary refill less than 3 seconds

GI/GU:
Bowel sounds active x 4 quadrants; no bruits auscultated
No organomegaly
Percussion dull over liver and spleen and tympanic over stomach and intestine
Abdomen non-tender to palpation
Urine output:
Clear
Cloudy
Color:
Pale yellow
Previous 24 hour output:
mLs N/A
Foley Catheter
Urinal or Bedpan
Bathroom Privileges without assistance or with assistance
CVA punch without rebound tenderness
Last BM: (date 3 / 9 / 15 )
Formed
Semi-formed
Unformed
Soft
Hard
Liquid Watery
Color: Light brown
Medium Brown
Dark Brown
Yellow
Green
White
Coffee Ground
Maroon
Bright Red
Hemoccult positive / negative (leave blank if not done)

Genitalia:
Clean, moist, without discharge, lesions or odor
Other Describe:

Not assessed, patient alert, oriented, denies problems

Musculoskeletal: X Full ROM intact in all extremities without crepitus

Strength bilaterally equal at ___5____ RUE ____5___ LUE ___5____ RLE

& ____5___ in LLE

[rating scale: 0-absent, 1-trace, 2-not against gravity, 3-against gravity but not against resistance, 4-against some resistance, 5-against full resistance]

vertebral column without kyphosis or scoliosis

Neurovascular status intact: peripheral pulses palpable, no pain, pallor, paralysis or parathesias

Neurological: Patient awake, alert, oriented to person, place, time, and date
Confused; if confused attach mini mental exam
CN 2-12 grossly intact
Sensation intact to touch, pain, and vibration
Rombergs Negative
Stereognosis, graphesthesia, and proprioception intact
Gait smooth, regular with symmetric length of the stride
DTR: [rating scale: 0-absent, +1 sluggish/diminished, +2 active/expected, +3 slightly hyperactive, +4 Hyperactive, with intermittent or transient clonus]
Triceps:

+2

positive

negative

Biceps:

+2

Brachioradial:

+2

Patellar: +2

Achilles:

+2

Ankle clonus: positive negative Babinski:

10 PERTINENT LAB VALUES AND DIAGNOSTIC TEST RESULTS (include pertinent normals as well as
abnormals, include rationale and analysis. List dates with all labs and diagnostic tests):
Pertinent includes labs that are checked when on certain medications, monitored for the disease process, need
prior to and after surgery, and pertinent to hospitalization. Do not forget to include diagnostic tests, such as
Ultrasounds, X-rays, CT, MRI, HIDA, etc. If a lab or test is not in the chart (such as one that is done preop) then
include why you expect it to be done and what results you expect to see.
Lab
Hemoglobin

Dates
(03/10/2015)
(03/11/2015)

Hematocrit

(03/10/2015)
(03/11/2015)

Trend
Upon admit, patients
hemoglobin level was
11.6, and today the
patients hemoglobin was
even lower at 10.2. The
normal range for
hemoglobin is 12.2
16.2.

Upon admit, patients

hematocrit level was
36.1, and today pts level
is at 32.0. Normal levels
for hematocrit are 37.7
47.9, so patient has low
levels of hematocrit.

Analysis
Patient is displaying
evidence of anemia, or
low hemoglobin. This
indicates the patient is
experiencing nutritional
deficiencies or GI blood
loss due to ulcer. Because
patient has had normal
bowel movements with
no evidence of blood,
patient is most likely
experiencing nutritional
deficiencies of iron.
Patients low levels of
hematocrit are parallel
with her low hemoglobin
levels; both indicate that
red blood cell count is
low. This is most likely a
result of her nutritional
deficiencies.

+2 CURRENT HEALTHCARE TREATMENTS AND PROCEDURES: (Diet, vitals, activity, scheduled

diagnostic tests, consults, accu checks, etc. Also provide rationale and frequency if applicable.)
NPO diet, laprascopic cholecystectomy, vitals taken every four hours, up ad lib, inpatient consult to
internal medicine, accu-checks before meals to monitor glucose levels.

8 NURSING DIAGNOSES (actual and potential - listed in order of priority)

1. Acute pain r/t obstruction and inflammation.
2. Acute pain r/t irritation and edema of inflamed pancreas.
3. Abdominal pain r/t peritoneal irritation
4.
5.

 15 CARE PLAN
Patient Goals/Outcomes
-Comfort maintained

Nursing Diagnosis: (Acute pain related to obstruction and irritation)

Nursing Interventions to Achieve
Rationale for Interventions
Goal
Provide References
-Analgesic administration
Analgesics manage pain level and
maintain patient comfort

-Pain controlled

-Anxiety reduction

-Symptom severity decreased

-Environmental reduction

Anxiety effects digestion processes

and reduction is an important part
of pain management.
Replacement of fat-soluble
vitamins, bile salt supplements to
help digestion and vitamin
absorption, contributing to the
destruction of gallstones causing
cholecystitis.

Evaluation of Goal on Day care is

Provided
Patients pain lowered from a level
5 to a level 3 after pain medications
administered.
Patient was calm and relaxed on
day of care.
Patients pain level lowered, patient
is NPO as she is prepared for
laprascopic cholecystectomy as a
surgical intervention for symptoms.

2 DISCHARGE PLANNING: (put a * in front of any pt education in above care plan that you would include for discharge teaching)
Consider the following needs:
SS Consult
Dietary Consult
PT/ OT

Pastoral Care
Durable Medical Needs
F/U appts
Med Instruction/Prescription
are any of the patients medications available at a discount pharmacy? Yes No
Rehab/ HH
Palliative Care

References
Sommers, M.S. (2013). Cholecystitis: Genetic Considerations and Causes in Diseases and Disorders: A
Nursing Therapeutics Manual (Fourth Edition). F.A. Davis Company
Vallerand, A.H., Sanoski, C.A., Deglin, J.H. (2015) Brand Index in Daviss Drug Guide for Nurses, 14th Edition,
F.A. Davis Company