Ms. Nichols Dx: Metastatic Peritoneal Disease and Colorectal Cancer Hx: Colon Cancer (2019) - (20...
1. Acute Pain
1.1. Risk for actual acute pain as related to recent right hemicolectomy as evidenced by pain scale of 4-6/10 consistently, pt has been complaining of new increased pain on lower abdomen by the surgical site, and continuous use of PCA machine.
1.1.1. Risk For Infection
1.1.1.1. Interventions 1. Swab surgical site and send to lab
2. Impaired Skin Integrity
2.1. Risk for Impaired skin integrity related to hospital stay as evidenced by patient is on bedrest, patient is diabetic, NPO (no fluids -> lower perfusion)
2.1.1. Skin Ulcers
2.1.1.1. Interventions: 1. Rotate every 2 hours 2. Promote mobility 3. Moisturize/Barrier Cream the area
3. Impaired Perfusion
3.1. Risk for DVT/clot related to HTN as evidenced by BP of >200/>100 before meds, lack of mobility, bedridden, NPO
3.1.1. Stroke
3.1.1.1. Interventions 1. Code Blue 2. Apply O2 3. Call for help 4. Push Fluids 5. Administer antigoagulant
3.1.2. Heart Attack
3.1.2.1. Interventions 1. Code Blue 2. Oxygen 3. Call for help
3.1.3. PE
3.1.3.1. Interventions 1. Code Blue 2. Administer O2 3. Call for Help 4. Keep patient calm
3.1.4. DVT
3.1.4.1. Interventions: 1. Promote Mobility 2. Administer Enoxaparin when due
3.2. Interventions: 1. Administer Amlodapine, Metoprolol, enoxaparin at appropriate times 2. Promote mobility
4. Impaired Elimination
4.1. Risk for impaired elimination related to recent bowel surgery as evidenced by pt has catheter, was administered Glycerin SUP yesterday evening, not passing BM just flatus, dx of large bowel obstruction
4.1.1. Interventions: 1. Ensure IV is running at appropriate rate 2. Check labs 3. Encourage gum chewing 4. Promote mobility 5. Consider adding PEG to medications
5. Impaired Fluid and Electrolytes
5.1. Risk for impaired F+E related to NG tube as evidenced by patient is on TPN, NG tube is sucking nutrients out, patient is NPO, patient vomits peridocially
5.1.1. Interventions 1. Check labs 2. SBAR Doc if lab abnormal
6. Impaired Mobility
6.1. Risk for impaired mobility related to recent sx as evidenced by Braden scale of 1 on mobility, patient is in pain and does not want to move
7. HTN
8. Right Hemicolectomy
8.1. Remove a part of the colon
9. Medications
9.1. Metformin
9.2. Acetaminophen
9.3. Insulin Regular
9.4. Enoxaparin
9.5. Metoprolol
9.6. Amlodapine
9.7. PCA
10. LSV + Pain
10.1. BP: 156/99
10.2. HR: 100
10.3. Temp: 36.7
10.4. Resp: 16
10.5. O2: 96% on 1L NP
10.6. Pain: 4-6/10 consistently
11. Impaired Gas Exchange
11.1. Impaired GE related to hospital stay as evidenced by patient has O2 sat of 93-96% on 1L NP, Doctors orders to keep patient on 1L NP, pt is continuously SOB
11.1.1. Interventions 1. Administer O2 2. Administer Bronchodilator if wheezing 3. Sit up right 4. Encourage DB+C
12. Impaired Nutrition
12.1. Impaired Nutrition related to patient's status of NPO as evidenced by patient is on TPN, is NPO, patient vomits periodically, patient has lost 20 pounds in 30 days
12.1.1. Interventions 1. Include nutritional contents in TPN 2. Replace loss fluids through vomit 3. Inquire when pt can eat food orally
13. Impaired Mental Health
13.1. Impaired self image/mental health that could lead to anxiety and or depression related to metastatic carcinoma breast cancer as evidenced by patient has reportedly lost 20 pounds in 30 days and reports not wanting to leave bed
13.1.1. Interventions 1. Thereupatic communication 2. Involve Psych 3. Discuss ways to improve mental health (capacity building, empowerment)