Pancreatitis care map

[W'sMama]

hellooo everyone! first time asking for help with this stuff. usually i'm a-ok in this area, but i have some major senioritis and anal/cranial syndrome going on.

i had a 57 y/o make with acute pancreatitis. he was able to provide all his own care. .. really the perfect patient. he didn't ask alot of questions and let me do my whole student nurse shindig without any problems.

he came in with the typical severe epi-gastric pain after eating. he drinks an average of 2 beers in the evening. he does smoke. he had been npo for the 3 days of his admission. he had several tests run of course... ct, mri, a million labs, egd.

i have to have 4 physiological dx's.. so far i have:

acute pain r/t irritation of inflamed pancreas

noc: client will state pain is at an acceptable level (less than 6, as determined by client)

nic: nurse will assess pain frequently using numerical pain scale

- educate patient about s/e of pain medications

- instruct client to request pain relief at the onset of discomfort

- administer pain meds as prescribed

eval: patient reports pain as 3/10

justification: inflammation of the pancreas can cause severe abdominal pain. it is crucial to control pain levels to allow for optimal healing.

imbalanced nutrition r/t npo status, increased nutritional needs as a result of acute illness

noc: client will maintain electrolyte levels wnl

nic: nurse will administer parenteral nutrition as ordered

- monitor fluid and electrolytes, note any changes

- weigh client daily

- report to physician any variances that cause concern

- maintain iv flow rate

- maintain accurate i&o record

eval: patient has maintained admission weight of 196 pounds. lab results show no variance from normal baseline

justification: patient has been npo since admission to allow the pancreas to rest. this places the patient at risk for malnutrition.

i want to do risk for infection and risk for injury for the other 2 dx. but, my r/t would basically be the same for both... the invasive edg. i can't really pull that off...

for once the 4 other knowledge/psychosocial/socioeconomic dx's where super easy ... any ideas?