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n360 wk06 Mini Care Plan - Patient A
n360 wk06 Mini Care Plan - Patient A
Date: 11/18/2014-11/19/2014
N256 Mini Care Plan- Patient A
Expected
(complete before assessment)
Found
(complete after assessment)
1. SAME
2. Risk for bowel perforation r/t POD #15 & 16 for
ileostomy takedown, abdominal distention, hypoactive
bowels and no BM since admission.
3. SAME
Need more
information
from
patient/family/
doctor about:
SAME
Top three
priorities (goals)
for patient care
1. SAME
2. Pt remains free from bowel perforation AEB absence of
N/V, fever, chills and severe abdominal pain.
3. SAME
Nursing
Diagnoses
(NANDA)
Focus of physical
assessment
Nursing
Interventions
Teaching
needed/provided
SAME
1. SAME
2. SAME
3. Perform a focused abdominal assessment.
4. Have pt on intermittent NG suctioning to remove excess
bile secretions. Check placement of NG tube using chest-x
ray, aspirating stomach contents, checking pH of stomach
acid, pushing air and auscultating or current length of NG
tube vs length of NG tube post insertion.
5. SAME
6. SAME
Discharge
planning