MEDGAR EVERS COLLEGE

CITY UNIVERSITY OF NEW YORK

SCHOOL OF SCI ENCE, HEALTH AND TECHNOLOGY
DEPARTMENT OF NURSING AAS/PN

Student: Lothiare Germain

Date:

Patient Initials: LJM

Diagnosis:

Vital Signs:

BP: 116/72

T: 99.4 F P: 87

R: 18

NCP# 1 2 3 4 56 7 8 9 10

WEIGHT:
HEIGHT:

Pain Score:

AGE: 59

Medication(s):Exonaxaprin 30mg inj SQ, Docusate sod 100mg PO BID, Lidocane HCL 10ml mouth rinse
INTRAVENOUS: Dextrose 5% NS 83 ml/hr

ASSESSMENT

NURSING DIAGNOSIS

PLAN/Expected
Outcome

IMPLEMENTATION
with rationale

EVALUATION

Pt 59 y/o c/o vague

non-radiating pain in
RUQ, LJM had previous
admissions for same
symptoms with
intermittent ABD
distress. Pt also has
intermittent fevers
and has a temperature
of 99.4 F at present.
ABD is soft nondistended with bowel
sounds heard during
auscultation. Pt has
poor oral intake with
associated weight
loss of 15 lbs. pt.
denies N/V. Pt has
jaundice, with
scleral icterus. Pt
urine output is dark
yellow due to
inadequate fluid
intake.

Pain related to
inflamed bile ducts
associated with
biliary tract disease
AEB fever, yellow
sclera and RUQ ABD
pain.

Patient will report a

reduction an ABD pain
associated with
cholangitis within 5
days of continued
treatment.

Prep pt for ERCP

(endoscopic retrograde
cholangiopancreatography
)

Pt verbalizes an
understanding for
procedure

Endoscopic
visualization of
common bile,
pancreatic and
hepatic duct for
obstruction,
tumors, bile duct
strictures or
injury

Obtain consent for

procedure and address
any concerns pt may
have.
Administer medications
for pain as ordered.
NPO for 4 hours before
procedure.
Assess allergies to
iodine or seafood.

Iodine contrast is
used for enhanced
visualization of

Order for stat and

PRN pain medications

structure.

ASSESSMENT

NURSING DIAGNOSIS

PLAN/Expected
Outcome

IMPLEMENTATION
with rationale

EVALUATION

59 year old male

admitted to med surg
unit with complaints
of ABD pain o RUQ for
4 weeks. Bowel sounds
are hear over all four
quadrants. Pt sts he
moves his bowels
infrequently and has
difficulty, stating he
has episodes of
straining to pass
stools. Pt sts his
bowel movements are
yellow in color. Pt
has lost 15 lbs.
within one months
time and has
intermittent fevers.

Impaired bowel
elimination R/t
inflammatory bowel
disease AEB: Hard stools;
painful defecation.

The patient will

report an increase in
frequency of stools,
with a return of
normal consistency
within 3 days of
treatment.

Asses for causal

factors such as fever,
emotional strain,
abdominal pain,
physical exertion,
bloody stools, and
cramping.

An assessment of
medication profile
reveal no drugs that
would exacerbate
gastrointestinal side
effects.

*helps to understand
causative factor and
etiology of problem
Observe and record
stool frequency,
characteristics and
amount
*helps identify and
differentiate severity
of episode or disease.
Increase fluid intake
to 2000 to 3000 ml
daily

Despite the use of

stool softeners the
constipation still
persists. The patient
is encouraged to
follow medication
regiment Rx by the
doctor.
Pt diet reflects a
high fiber and
increased fluid intake
to manage bowel
movements.

Give stool softeners

to aid in bowel
movements.

ASSESSMENT

NURSING DIAGNOSIS

PLAN/Expected
Outcome

IMPLEMENTATION
with rationale

EVALUATION

Mr. L J-M expresses

discouragement with
medication (Docusate)
he is on and has
refused it several
times. He requests an
enema instead. He is
preoccupied with his
physical self and is

Ineffective coping
related to
unpredictable nature
of disease process.

The patient will

verbalize an
understanding of his
disease process and
possible complication
upon discharge. The pt
will also verbalize an
understanding of his
therapeutic regimen.

Determine both the

patients and his
significant others
understanding and
methods of dealing
with the disease
process.

Pt has a better
understanding of the
need to continue
medication regiment
and allowing the drugs
to work.

*this enables the

Pt understands that
talking with staff and

chronically worried
about using the
bathroom.

nurse to deal more

effectively with the
current problems.
Anxiety may interfere
with patient teaching.
Help patient identify
his own effective
coping skills.

family about his fears

promotes better
coping.