III.

NURSING CARE PLAN :

NAME : MS DIAGNOSIS : Intestinal obstruction

AGE: 80 years . SERVICE: Surgery

GENDER: Female

Altered pattern Dx. of nursing Goals Nursing interventions theoretical foundation Assessment

Cognitive- Alteration of the comfort Elderly adult  Assess verbal and non- The pain experienced by patients who Patient verbally
perceptual pattern pattern: pain r/c section patient will not verbal signs of pain. have undergone major abdominal expresses feeling
of nerve endings and present pain, surgery is due to the distension of the pain relief.
physiological processes expressing relief. tissues and muscles during the
manifested by verbal intervention and the manipulation of
expression, I have pain in the abdominal viscera.
my wound.
If a person tries to convince
healthcare professionals that they are
 Tell the patient that the in pain, they will experience more
cause of their pain is pain.
known.
People who are prepared for painful
procedures because they have
 Clearly explain the received explanations of the real
procedure to be carried sensations they will experience will
out. feel less stress than those who have
received vague explanations about the
treatment.

Indicated in cases of pain

(postoperative or post-traumatic, colic
type or tumor origin) and severe and
 Administer analgesics: resistant fever.
metamizole 1gr IV.

Activity and Alteration of physical Promote mobility  Assess the patient's The deterioration of physical mobility The patient
exercise pattern. mobility r/c post- where the patient ability to move. forces the patient to maintain the progressively makes
 operatively evidenced by can make
the presence of a Foley movements
catheter, colostomy bag
and manifested by pain
that prevents him from
mobilizing
Stress tolerance Anxiety r/c ignorance of Patient will not
pattern your illness m/p verbal appear anxious.
expression: I don't know
what I have, my stomach
just hurts.
Nutritional – Risk of hydroelectrolyte Maintain
metabolic pattern. alteration related to loss nutritional pattern
of fluids and electrolytes,
decreased appetite,
nausea and vomiting.
small same body posture for long periods. movements.
Changes in position when the patient
 Make position changes does not do so because he or she is in
a lot of pain will allow me to maintain
joint mobility, improve muscle tone,
and maintain and improve
cardiovascular function.
 Introduce yourself to the A calm, professional admission Patient appears
patient and to the other process and a warm introduction can calm.
health members. put the patient at ease and set a
positive tone for their hospital stay.
Pain, fatigue, or other symptoms can
 Assess physical condition. increase a patient's anxiety and hinder
their motivation to learn, ability to
concentrate, and retention of
learning.
Every patient experiences some
 Specify the stress factors, emotional reaction to illness and
the nature of your hospitalization. The nature and degree
concerns. of his reaction depends on how the
patient perceives his situation and its
anticipated effects.
Giving correct information can help
 Explain hospital rules and reduce the patient's anxiety
routines. associated with the unknown and the
strange.
 Assess the color of the Upper intestinal obstruction is Patient maintains his
vomit: dark green. characterized by vomiting that tends adequate nutritional
to be persistent, even if oral intake pattern.
has ceased, and may not
there is abdominal distension. If the
obstruction is distal to the ampulla of
Vater (as is often the case), the
 vomiting will be bilious.
 Perform water balance.
It is a very important instrument that
will allow me to evaluate the patient's
income and expenses with a certain
value.
 Control the patient's
weight Controlling the patient's weight daily
will allow me to obtain a strict water
balance.

 Replenish fluids: Moisturizing and energy solution,

Dextrose 5% to 40 drops. indicated as a source of water and
calories in cases of deficiency in
plasma volume and serum
concentration of electrolytes.
 Assess skin and mucous
membranes. Thorough and continuous assessment
is of utmost importance since it shows
us the alterations in the skin and
mucous membranes, avoiding
dryness, otherwise we must act
promptly.
Dry mucous membranes and turgor of
the skin show us signs of dehydration.
PHARMACOLOGICAL SHEETS

METAMIZOLE:

Presentation:
Antalgin: drops, syrup, drop solution, suppository, injection.
Sanitas: drops, syrup, ampoule, tablet.
Phenalgin: injectable.
Magnopyrol: drops, syrup
Metamizole sodium: drops, injections.

Indications:
Treatment of symptoms of any condition characterized by acute pain and fever, general relief of acute or chronic pain of
mixed etiology: administered in postoperative and dental procedures.
The injectable solution should be used only when it is not possible to use it orally, such as in the case of intense, acute or
chronic pain. Intense, acute or chronic spastic pain.

Adverse reactions:
Hypersensitivity: itching and respiratory hyperactivity. Predisposed people can develop asthma. It can cause
agranulocytis, sometimes fatal. Facial edema, itching, oppressive sensation in the precordial region, tachycardia and a
sensation of coldness in the arms and legs may occur.
Shock can often manifest itself during the injection due to the following alarm systems: cold sweat, dizziness, obtundation,
nausea, hair discoloration and difficulty breathing.

Dosage:
Drops:
Adults: 20 drops (500 mg) 3 or 4 times a day.

Syrup:
Adults: 2 tsp of 5 ml (300 to 600 mg)

Parenteral: 2 ml to 5 ml

Tablets:
Adults: 1 or 2 tablet. 3 or 4 times a day
Children: ½ tablet 2 or 3 times a day.

Nursing care :
When administered intravenously, it should be administered slowly.
It should not be administered for prolonged periods.
Assess the patient once the medication has been administered as they may have an adverse reaction.
Do not administer to patients with allergies to any type of analgesic.
5% DEXTROSE

Synonyms: Dextrose.

Glucose.

Therapeutic action: Dextrose: Energizing. Antihypoglycemic.

Properties: Dextrose.

Dextrose is a simple carbohydrate (d-glucose) that is metabolized in the body to carbon dioxide and water. Dextrose
solutions administered parenterally constitute a source of water and carbohydrates. Parenteral dextrose contributes to
the restoration of blood glucose levels, minimizes hepatic glycogen expenditure and decreases the destruction of proteins
as a source of energy. Orally it is an important source of calories (carbohydrates).

Indications: Dextrose.

Parenteral route: fluid replacement and provision of calories such as carbohydrates.

Dosage: Dextrose.

According to medical criteria. The daily water requirement for loss through urine and respiration in adults is 1.0 to 1.5
liters.

Precautions and warnings: Dextrose.

Use with caution in patients with diabetes mellitus. Monitor hydroelectrolyte balance.

Interactions: Dextrose.

Incompatibility with some additives for parenteral administration.

Contraindications: Dextrose.

Dextrose solutions that do not contain electrolytes should not be administered simultaneously with blood in the same
infusion line, due to the risk of pseudoagglutination of red blood cells. Mellitus diabetes.

Overdose: Dextrose.

In the case of overhydration or severe hyperglycemia, the patient's condition should be evaluated and acted accordingly
(diuretics, insulin).

Bibliographic references:

 Brunner s. (2005) medical surgical nursing manual, 9th edition. edit. Mexican.
 Carpenito l. (1994), care plans and documentation in nursing, nursing diagnoses and associated
problems, 1st edition. edit. Mc Graw hill – interamerican. Spain.