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I am sorry, I do not know why my posts are looking so weird... hopefully this time it will work
I am not done yet but this is what I have so far....
I think that I am going overboard... I cared for a patient with pancreatitis who is also an alcoholic so I need to include a CIWA assessment
My priority nursing diagnosis is:Ineffective breathing pattern r/t sedating effects of medication secondary to PCA analgesic administration, AMB alterations in depth of breathing and bradypnea seen as respiration rate of 10/min.
Assess patient for: pain level, CMS checks
Integumentary:
flushing diaphoresis, discoloration of abdomen and flanks, cyanosis, jaundice, dry mucus membranes,
Respiratory : Lung sound, rate, rhythm, depth of respirations, o2 saturation
Monitor for dyspnea, tachypnea, use of accessory muscles, basilar crackles, O2 saturation, SOB
Cardiovasular, BP, Pulse, heart rate, rhythm, pattern,
Monitor for: Tachycardia, hypotention, dizziness
Gastrointestinal: bowel sounds in all quadrants, light palpation, I & O, urine color, BM, flatus present
monitor for; distention of abdomen, tenderness upon palpation, muscle guarding, diminished or absent bowel sounds, nausea, vomiting
I am sorry, I do not know why my posts are looking so weird... hopefully this time it will workI am not done yet but this is what I have so far....
I think that I am going overboard... I cared for a patient with pancreatitis who is also an alcoholic so I need to include a CIWA assessment
My priority nursing diagnosis is:Ineffective breathing pattern r/t sedating effects of medication secondary to PCA analgesic administration, AMB alterations in depth of breathing and bradypnea seen as respiration rate of 10/min.
Assess patient for: pain level, CMS checks
Integumentary:
flushing diaphoresis, discoloration of abdomen and flanks, cyanosis, jaundice, dry mucus membranes,
Respiratory : Lung sound, rate, rhythm, depth of respirations, o2 saturation
Monitor for dyspnea, tachypnea, use of accessory muscles, basilar crackles, O2 saturation, SOB
Cardiovasular, BP, Pulse, heart rate, rhythm, pattern,
Monitor for: Tachycardia, hypotention, dizziness
Gastrointestinal: bowel sounds in all quadrants, light palpation, I & O, urine color, BM, flatus present
monitor for; distention of abdomen, tenderness upon palpation, muscle guarding, diminished or absent bowel sounds, nausea, vomiting
I may be missing something, but it seems to me that your nursing diagnosis, while very possibly an accurate one though you give me no evidence for it, has no plan of care attached to it that relates to altered breathing, except the resp assessment. So where are the rest of his nursing diagnoses that justify all those other things you are assessing and monitoring? Any alcoholic c pancreatitis can be reasonably be expected to have a lot more wrong with him from a nursing assessment standpoint. What else do you have? Why do you think so?
cherylb2
6 Posts
Hi everyone...
This is my first post.
Can anyone help me describe the nursing assessment for a patient with pancreatitis? I am doing my LAST care plan as a student!! My instructor is very critical of our work (which is good). I need to write a comprehensive nursing assessment but with abbreviations....CMS, VS, etc.
I have always written out everything but she graded my last project and didn't like "my style".
Can anyone help? Thank you so much!!