Please Help!!!

leslie :-D · Feb 7, 2006

Can anyone please help me with my 1st NCP that is due soon, I have been tring to get it straightened out but I fear I am drowning in wrong answers...Please I am desperate. (as if you can not tell)

can you elaborate a little?

what is your pt's current dx? pmh?

lesllie

megsmommy04 · Feb 7, 2006

Hi thank you sooooooo much for helping

Her Dx is acute cholecystitis and she is 2nd day post op, I am not sure what pmh is though, this is my 1st nursing class and I am still a bit flustered.

Dawn

truern · Feb 7, 2006

Dawn, pmh=past medical history.

Give us a few more details...age, other currect medical problems, medications, etc...

Did she have alot of nausea and vomiting?? That could lead you to Risk for Fluid Volume Deficit

Ummmm....is she in alot of pain?? What kind of relief is she getting on her pain meds??

Are you having problems getting her to cough and deep breathe?? There's an ineffective breathing pattern because of the guarded breathing due to the surgical pain and the location of the surgery.

Does she have a NG tube?? She's at risk for altered oral mucus membranes.

You always want to think your ABCs: airway, breathing, circulation...then safety. Once you've determined that there aren't any actual problems or potential complications related to the ABCs, then you can address some lower level needs.

See if this isn't enough to get you started...sometimes we just need a nudge in the right direction

leslie :-D · Feb 7, 2006

Hi thank you sooooooo much for helping
Her Dx is acute cholecystitis and she is 2nd day post op, I am not sure what pmh is though, this is my 1st nursing class and I am still a bit flustered.
Dawn

ok....you know that ALWAYS the priority diagnoses are airway, breathing, circulation.

is this pt effectively able to breath or is her breathing shallow, impaired because of pain?

is her pain effectively being managed?

what about her incision site? any s/s of infection?

mobiity? has p/t been in and gotten her up and ambulating?

what about nutrition? is it altered/restricted?

i've just given you a few dx's to think about.

it's up to you to prioritize them, ok?

and pmh is past medical history.

good luck!!!

leslie

megsmommy04 · Feb 7, 2006

Ok this will be a bit long, sorry

44 y/o 2nd day post op on prevacid, zestril, celebrex. Did c/o nausea and vomitting on admit, weak stressed and has 90% ROM after previous knee surguery c steady gait. Pt states incisonal pain to be at 4 when not moving but 8 when out of bed, she is using a PCA morphine machine. Free from redness and edema but incision is tender and sore. TCBD is good, no NG tube but there is a right subcostal incision c a T tube insertion site.Had 50 ml of bile from T tube c scant serosanguineous drainage. She is using incentive spirometer q 2 h c exchanging 1200 ml of air.

Sorry for all the info but I have more if you need it.

thanks for your help

avery · Feb 7, 2006

Do you have a nursing diagnosis? Is she NPO or eating? Any lab values to note? Any IV fluids?

Avery

B.S.N. May 2006!

megsmommy04 · Feb 7, 2006

Her nursing dx open cholecystecomy, on a full liquid diet her lab values are as follows:

RBC 4.6

WBC 16500

HGB 14.5 g/dl

HCT 42%

Serum bilirubin 1.7 mg/dl

Serum amlase 125 somgyi units/dl

IV fluids

1000ml D5 1/2 NS @50 ml/h

Thanks

Dawn

leslie :-D · Feb 7, 2006

Her nursing dx open cholecystecomy, on a full liquid diet her lab values are as follows:
RBC 4.6
WBC 16500
HGB 14.5 g/dl
HCT 42%
Serum bilirubin 1.7 mg/dl
Serum amlase 125 somgyi units/dl
IV fluids
1000ml D5 1/2 NS @50 ml/h
Thanks
Dawn

are all these labs wnl?

serum bilirubin is a little up....expected?

wbc of 16.5k....is it lower than admitting/pre-op labs?