DONNA MAE V.

LUCI
BSN 4 - NIGHTINGALE

CASE STUDY #1

T.H., a 57-year-old stockbroker, has come to the gastroenterologist for treatment of recurrent mild to severe cramping in his
abdomen and blood-streaked stool. You are the registered nurse doing his initial workup. Your findings include a mildly obese man
who demonstrates moderate guarding of his abdomen with both direct and rebound tenderness, especially in the left lower quadrant
(LLQ). His vital signs are 168/98, 110, 24, 100.4° F (38° C), and he is slightly diaphoretic. T.H. reports that he has periodic
constipation. He has had previous episodes of abdominal cramping, but this time the pain is getting worse.
Past medical history reveals that T.H. has a “sedentary job with lots of emotional moments,” he has smoked a pack of cigarettes a day
for 30 years, and he has had “2 or 3 mixed drinks in the evening” until 2 months ago. He states, “I haven't had anything to drink in two
months.” He denies having regular exercise: “just no time.” His diet consists mostly of “white bread, meat, potatoes, and ice cream
with fruit and nuts over it.” He denies having a history of cardiac or pulmonary problems and no personal history of cancer, although
his father and older brother died of colon cancer. He takes no medications and denies the use of any other drugs or herbal products.
 DONNA MAE V. LUCI
BSN 4 - NIGHTINGALE

NURSING CARE PLAN

Identified Problem: Acute Diverticulitis

Name: DONNA MAE V. LUCI Section: BSN 4- NIGHTINGALE Date/Time:

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

RATIONALE

Independent:
Short term Goal:
Subjective: Diverticulosis Short term Goal: Assess the patient's vital To monitor effectiveness of
involves small signs and characteristics of medical treatment for the relief After 4 hours of nursing
The client Acute pain abscesses or After 4 hours pain at least 30 minutes after of abdominal pain. The time of
care the patient's
experienced recurrent related to infection in one or of nursing care, administration of medication. monitoring of vital sins may
mild to severe cramping infection/ more divercula or the patient depend on the peak time of the
abdominal pain was
in his abdomen, direct inflammation of perforation in the demonstrates drug administered. relieved. Goal met.
and rebound tenderness divercula as bowel. It is the relief from
in LLQ and constipation. evidence by fever, thickening of the abdominal pain.
blood-streaked outer wall of the Elevate the head of the To increase the oxygen Long term Goal:
stool, abdominal intestine that causes Long term Goal: bed and position the patient in level by allowing optimal lung
cramping, direct narrowing, making semi Fowler's. expansion. Within 18 hours of
Objective: and rebound it difficult for stool Within 18 receiving nursing care, the
tenderness in LLQ to move through hours of receiving patient verbalized his
- Fever abdomen of the which creates nursing care, the During episodes of To reduce gastrointestinal understanding of proper
patient. pockets in the patient must abdominal cramping, Place stimulations thereby decreasing diet and medication
- moderate guarding intestinal wall verbalize his the patient in complete bed Gastrointestinal activity regimens, as well as the use
called divercula. It understanding of rest during severe episodes of of pharmacological and
- blood-streaked stool also occurs when proper diet and pain non-pharmacological
stool passes slowly medication treatments. Goal Met
- slightly diaphoretic through the intestine regimens, as well Perform non- To provide optimal comfort to
and deposits fecal as the use of pharmacological pain relief the patient.
matter into the pharmacological methods: relaxation
Vital Signs As Follows: divercula. Over time and non- techniques such as deep
this causes bacterial pharmacological breathing exercises, guided
T: 100.4° F (38° C) growth and treatments. imagery and provision of
- Febrile inflammation. distractions such as TV or
radio.
 DONNA MAE V. LUCI
BSN 4 - NIGHTINGALE
PR: 110 bpm
Encourage increase oral
RR: 24 cpm fluid intake as tolerated, To help soften and make it
ideally at least 2L per day. easier to pass.
BP: 168/98 mmHg Check if the patient is in any
fluid restriction before doing
so.

Encourage physical To increase bowel

mobility and exercise when peristaltic movement.
the free from pain to avoid
constipation.

Encourage fiber intake To help the food move

at least 38 grams as through the intestines.
recommended by dietitian

Dependent:

Administer prescribed To alleviate the symptoms

pain medications. of acute abdominal pain. Pain
medication may include
narcotics, anticholinergic or
smooth muscle relaxants.

To provide a more
Refer the patient to the specialized care for the patient
dietitian. in terms of nutrition and diet

Collaborative:

Help the patient to select Low-fat high fiber diet is

appropriate dietary choices to ideal for patients with
follow a low-fat high fiber diverticulitis.
diet.
DONNA MAE V. LUCI
BSN 4 - NIGHTINGALE

CASE STUDY #2

M.R. is a 56-year-old general contractor who is admitted to your telemetry unit directly from his
internist's office with a diagnosis of chest pain. On report, you are informed that he has an intermittent 2-
month history of chest tightness with substernal burning that radiates through to the mid-back
intermittently, in a stabbing fashion. Symptoms occur after a large meal; with heavy lifting at the construction
site; and in the middle of the night when he awakens from sleep with coughing, shortness of breath, and a
foul, bitter taste in his mouth. Recently, he has developed nausea, without emesis, that is worse in the
morning or after skipping meals. He complains of “heartburn” three or four times a day. When this
happens, he takes a couple of Rolaids or Tums. He keeps a bottle at home, at the office, and in his truck. Vital
signs (VS) at his physician's office were 130/80 lying, 120/72 standing, 100, 20, 98.6° F (37° C), SpO2 92%
on room air.
A 12-lead ECG showed normal sinus rhythm with a rare premature ventricular contraction (PVC).
 DONNA MAE V. LUCI
BSN 4 - NIGHTINGALE

Name: DONNA MAE V. LUCI Section: BSN 4- NIGHTINGALE Date/Time:

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

RATIONALE

Gastric Short term Goal: Independent:

Subjective: ulcers are caused by Pain is not always present, should be Short term Goal:
Deficient a combination of After 4 hours of Note reports of pain, compared with patient’s previous pain
acid, pepsin, and nursing interventions including location, duration, and symptoms. The comparison may assist in The Patient was
knowledge able to verbalize
The patient related to Helicobacter the patient verbalize intensity (0-10 scale). diagnosis of etiology of bleeding and
infection. The pain relief and development of complications. pain relief,
complains of gastrointestinal
epithelium is demonstrate relaxed
"heartburn" 3-4 bleeding as demonstrate relaxed body posture
times a day evidence by covered by the body posture. Review factors that aggravate Helpful in establishing diagnosis and properly after 4
over gastric mucosal or alleviate pain. treatment needs. hours of nursing
consumption of barrier. Mucus and interventions.
Objective: Rolaids and bicarbonate Long term Goal: Note nonverbal pain cues. Non-verbal cues may be both
inappropriate secretion serves as physiological and psychological and may Long term Goal:
sedentary a first line of be used in conjunction with verbal cues
defense in keeping After 8 hours of to evaluate extent and severity of the The patient
- Pt. vomits lifestyle.
the pH of the nursing interventions problem. was able to
coffee gastric epithelium patient is able to verbalize
ground near normal and verbalize Provide small frequent Food has an acid neutralizing effect and understanding of
emesis protecting the understanding of meals. dilutes the gastric contents. the causes and
mucosal barrier causes and management of
from acid. management of GI Identify and limit foods that Small meals prevent distention and the GI bleeding after
Vital Signs As Prostaglandins in bleeding. create discomfort. release of gastrin. 8 hours of nursing
Follows: the gastrointestinal interventions.
mucosa increase the
T: 98.6° F (37° barrier's resistance Assist with active and Specific foods that cause distress vary
C), to ulceration. The passive range of motion exercises. among individuals. Spicy foods, alcohol,
PR: 100 bpm rich blood supply of and coffee can precipitate dyspepsia.
SpO2: 92% the stomach and
RR: 20 cpm duodenal mucosa Provide frequent oral care Reduces joint stiffness, minimizing pain
BP: 130/80 helps to maintain and comfort measures including and discomfort. Halitosis from stagnant
mmHg when the barrier's back rub and position change. oral secretions is unappetizing and can
lying integrity. aggravate nausea.
DONNA MAE V. LUCI
BSN 4 - NIGHTINGALE

Assess the patients Knowing this information

understanding of the cause and provides the starting base for
treatment of GI bleeding education sessions. During the acute
stage the patient requires the most
teaching)

Determine the patient’s Self-efficacy refers to a person

self-efficacy to learn and apply confidence in his ability to perform a
new knew knowledge needed behavior. Prevention of the
for follow-up care. recurrence of bleeding may require
health behavior changes by the
patient. Some lifestyle changes may
be difficult to make. )

Explain the importance of The use of these products is

avoiding substances containing known to damage the mucosal layer
aspirin, alcohol, non-steroidal and predispose to bleeding. The
anti-inflammatory drugs, and patient will need to make health
steroids. behavioral changes to limit use of
those substances.

Review factors that Helpful in establishing diagnosis

aggravate or alleviate pain. and treatment needs.

Provide and implement Oral intake is allowed, food

dietary modifications. choices depend on the diagnosis and
etiology of the bleeding.

Dependent:

Administer medications as Helps relive acute or severe pain.

indicated by the physician such as
analgesics.
DONNA MAE V. LUCI
BSN 4 - NIGHTINGALE
Collaborative: Client may receive nothing by mouth
initially. When oral intake is allowed,
Provide and implement dietary food choices depend on the diagnosis
modifications. and etiology of the bleeding.

Fat in regular milk may decreases gastric

secretions. The calcium and protein
Use regular than skim milk, if content especially in skim milk increases
milk is allowed. secretions.
 DONNA MAE V. LUCI
BSN 4 - NIGHTINGALE

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
Use pulse oximetry to It is used to identify early hypoxia in patients and
The patient's monitor oxygen saturation; evaluate the effectiveness of oxygen therapy. It also
The patient states Impaired SPO2 shall assess ABGs (pulse oximetry allows for quick and reliable retrieval of oxygen M.R. Sp02 is
"in the middle of the is a useful tool to detect early saturation and heart rate values.
gas exchanged increase from 92 changes in oxygen saturation; at 94% on room
night awakes from
Oxygen saturation should be
SOB" related to percent to 98 kept >90%) air, and
abnormal percent within an
Alterations to the rhythm and depth of breathing is
Assess for respiratory rate,
breathing as hour of receiving respirations may indicate a change in the patient's
Objective: rhythm, and depth (pt will
condition. Use of the accessory muscles suggests that unlabored. Goal
evidence by Oxygen. adapt breathing patterns over
the diaphragm and intercostal muscles are not being
time to facilitate gas
used efficiently. was met.
- SPO2 of 92% decreased oxygen exchange)
on room air saturation. It helps to determine the adequacy of respiration and
Assess the patient’s breath enables the identification of changes to respiratory
sounds. function. It contributes to the diagnosis and
Vital Signs As management of a variety of pathological conditions
Follows: and helps the practitioner to evaluate therapeutic
interventions.
T: 98.6° F (37° C), Assess cough for signs of
PR: 100 bpm bloody sputum (changes of It can be alarming to cough up a significant amount
breath sounds may reveal the of blood in sputum or to see blood in mucus
SpO2: 92% cause of impaired gas frequently. In severe cases, this can result from a lung
RR: 20 cpm exchange; Hemoptysis is a or stomach condition.
BP: 130/80 mmHg sign on bleeding)
when lying