S. E is a 59-year-old African-American male admitted to the critical care unit because of his left lower quadrant (LLQ) abdominal pain. S. E had a colonoscopy 2 days ago. He has a family history of hypertension (HTN) and a medical history of HTN and anemia. He is alert and oriented ? 3 (time, place, and person). S. E has no known drug allergy and he is NPO except for medicine. Problem: LLQ abdominal pain Acute pain |
Assessment| Planning/Nursing Goals| Intervention/Implementation| * Physiological variables, such as age and pain tolerance * Descriptive characteristics of pain, including location, quality, intensity on a scale of 1 to 10, temporal factors, and sources of relief. * Environmental variables, such as setting and time. | * Patient will rate pain on scale of 1-10 and Verbalizes reduced pain level * Patient will report more than 4 hours of sleep nightly. Patient will express feeling of comfort and relief from pain| * Administer prescribed analgesic * Perform comfort measures to promote relaxation, such as massage, bathing, repositioning, and relaxation techniques. * Reassess pain frequently using pain scale. | Risk for bleeding related to colonoscopy| Assessment| Planning/Nursing Goals| Intervention/Implementation| * Cardiovascular status, including blood pressure, cardiac output, Vital signs, patient and family history of Cardiovascular disease, peripheral pulses and smoking history. Presence of health condition that may interfere with bleeding, such as coagulopathies * History of GI problems,disease, or surgery; bowel sound| * Patient will receive adequate screening/monitoring to alert clinicians of existing risk factor for bleeding. * Patient vital signs and tissue perfusion will remain within expected ranges during episodes of risk. | * Screen each patient for risk factor for bleeding. * Obtain clinical laboratory test and point of care tests (urine dip test, gastroccult). Examine surgical and wound dressings. * Perform vital signs and basic physical assessments according to evidence-based protocols for patient at risk for bleeding. | Deficient fluid volume related to blood loss secondary to colonoscopy| Assessment| Planning/Nursing Goals| Intervention/Implementation| * History of fluid loss, including vomiting, diarrhea or hemorrhage. * Assess vital signs. * Fluid and electrolyte status, including weight, urine specific gravity, intake and output. * Laboratory studies. * Patient’s vital signs will remain stable. * Patient’s fluid volume will remain adequate. * Patient will produce adequate urine volume. * Patient’s fluid and blood volume will return to normal. | * Monitor and record vital signs every 2 hours or as often as necessary until stable. Then monitor and record vital sign every 4 hrs. * Measure intake and output every 1 to 4 hrs, record and report significant changes. * Administer fluid, blood or blood product. Monitor and record effectiveness and any adverse effects. References: Carpenito-moyet, LJ. (2010). Nursing Diagnosis. Applications to clinical practice. (13th edition) Philadelphia: Wolters kluwer/Lippincott Williams and wilkins. Ignatavicius, D. D, and Workman, L. M. (2010) Medical-surgical nursing. Patient-centered collaborative care. (6th edition) St. Louis, Missouri: Saunders Elsevier. Sheila Sparks Ralph, Cynthia M. Taylor. (2011). Nursing Diagnosis reference manual. (8th edition) Philadelphia: Wolters kluwer/Lippincott Williams and wilkins.