i see that you are new to allnurses. there are several sticky threads in the student forums on how to put together a nursing care plan. the nursing process needs to be followed. you can see how this is done on this thread (http://allnurses.com/general-nursing...ns-286986.html
- help with care plans
) in the general nursing student discussion forum. you cannot begin diagnosing the patient's nursing problems until you have completed an assessment of the patient which is the first step of the nursing process. the entire care plan (diagnosis, goal determination and nursing interventions) is based on what is found from assessing the patient.
step 1 assessment
- assessment consists of these components:
step #2 determination of the patient's problem(s)/nursing diagnosis
- a health history (review of systems) - nothing is provided. does this patient have a prior history of abdominal surgery? any history of gi disease? what other medical problems does this patient have? did you read the doctor's progress notes? what does the doctor suspect might be going on?
- performing a physical exam - no physical exam information was posted. did you listen to the patient's bowel sounds? what was the abdominal assessment? any distension? rebound tenderness? where is the patient's abdominal pain? any nausea (you want to use the nursing diagnosis of nausea so there must be symptoms of this)? any diarrhea? what labs and tests were done and what were the results?
- assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - what adls does the patient need help with?
- reviewing the pathophysiology, signs and symptoms and complications of their medical condition - small bowel obstruction creates a number of problems in patients. reading about the pathophysiology, signs and symptoms is necessary to understand the symptoms the patient has and in order to develop the etiologies for the nursing diagnostic statements you will have.
- http://www.merck.com/mmpe/sec02/ch011/ch011h.html - intestinal obstruction - "the most common causes of mechanical obstruction are adhesions, hernias, and tumors. . . diverticulitis, foreign bodies (including gallstones), volvulus (twisting of bowel on its mesentery), intussusception."
- reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - none listed. is the patient npo? have ivs? on pain medication? the ng tube was a medical intervention. the doctor also treats the patient's symptoms with interventions of his own. as nurses we work in a collaborative role to care for things like ng tubes and keep them patent.
- make a list of the abnormal assessment data gathered from assessment. just as a doctor makes a medical diagnosis based on the history he takes of the patient, the physical examination and results of tests performed, our nursing diagnoses are also based upon the data collected during assessment activities listed in step #1 above. every nursing diagnosis has a set of defining characteristics (signs and symptoms) just like every medical diagnosis has a list of signs and symptoms. you can find these lists in a nursing diagnosis reference book, in the appendix of taber's cyclopedic medical dictionary
, and information about 80 of the most commonly used nursing diagnoses can be accessed on these 2 web sites:
step #3 planning (write measurable goals/outcomes and nursing interventions)
- nursing interventions specifically target the abnormal assessment data that you gathered from assessing the patient. this abnormal assessment data is actually evidence that proves the existence of each nursing problem, so it is logical that nursing interventions will treat them. a care plan is all about developing strategies to solve the patient's nursing problems. in step #2 you identified the problems based on the evidence you had to support them. now, in step #3 you chip away at the evidence and attempt to change or alter these signs and symptoms in order to do the following to the problem (nursing diagnosis):
- improve it
- stabilize it
- support its continuation (some problems cannot be "resolved")
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you were specifically asking about pain. the nursing diagnosis for this is acute pain r/t abdominal distension.
assessment and description of pain includes the following:
- where the pain is located
- how long it lasts
- how often it occurs
- a description of it (sharp, dull, stabbing, aching, burning, throbbing)
- have the patient rank the pain on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain
- what triggers the pain
- what relieves the pain
- observe their physical responses
- behavioral: changing body position, moaning, sighing, grimacing, withdrawal, crying, restlessness, muscle twitching, irritability, immobility
- sympathetic response: pallor, elevated b/p, dilated pupils, skeletal muscle tension, dyspnea, tachycardia, diaphoresis
- parasympathetic response: pallor, decreased b/p, bradycardia, nausea and vomiting, weakness, dizziness, loss of consciousness
examples of some interventions that may or may not apply to your patient are:
- assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
- assess and document where the pain is located and what, if anything, makes it worse or better
- observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
- give pain medication as ordered
- provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain
- reposition the patient
- give a back massage
- use short, simple relaxation exercises to distract the patient's attention
- dim the lights in the room and keep noise down
- play soft, soothing music
- reassess and evaluate the patient's response to each method employed. ask the patient which techniques work better for them.
- monitor for side effects of narcotic therapy: respiratory depression, constipation, nausea/vomiting
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here are previous student care plan threads that are about small bowel obstruction cases that you should look at: