Question

Patient Introduction A 52-year-old patient has just arrived in the Emergency Department with complaints of severe abdominal pain, nausea, and vomiting over the last few days. His abdomen is distended. He has poor skin turgor and dry mucous membranes. He has not urinated since yesterday. He has felt “dizzy” and “weak” all evening. He thought it might be the flu, but decided to come in because the stomach pains were getting worse. He has signed informed consent for treatment and labs have been drawn.

patient is diagnosed with bowel obstruction

list 2 medical priority nursing diagnosis and an educational nursing diagnosis with goals 3 intervention and rational ?

(Medical Priority) Nrsg Dx #1 Goal: Nursing Intervention # 1 with rationale:

Nursing Intervention # 2 with rationale:

Nursing Intervention # 3 with rationale:

Evaluation: Was your goal met? If yes, explain how you know this. If not, explain what you would need to see to have your goal met.

(Medical Priority) Nrsg Dx #2 Goal: Nursing Intervention # 1 with rationale:

Nursing Intervention # 2 with rationale:

Nursing Intervention # 3 with rationale:

Evaluation: Was your goal met? If yes, explain how you know this. If not, explain what you would need to see to have your goal met.

(Education Priority) Nrsg Dx #3 Goal:

Nursing Intervention # 1 with rationale:

Nursing Intervention # 2 with rationale:

Nursing Intervention # 3 with rationale:

Evaluation: Was your goal met? If yes, explain how you know this. If not, explain what you would need to see to have your goal met.

Answer 1

Nursing diagnosis:1

1. Acute pain due to abdominal distension and increase peristalsis

Goal: Reduce pain

Intervention:

1. Provide a cozy environment
2. Administer analgesic as per the doctor's order
3. Keep the patient mind engaged by talking to him/her (To divert attention)

Assess whether goals are met by - assessing the pain severity on the pain scale - visual analog scale - if the goal is not achieved, it should be informed to the doctor and a decision regarding stepping up analgesic should be taken (opioid analgesic)

Nursing diagnosis 2: Reduce fluid volume due to excessive vomiting

Goal - to reduce dehydration

Intervention:

1. Secure wide bore intravenous access for intravenous fluid infusion.
2. Maintain input-output charting.
3. Watch for breathlessness and regular chest auscultation to keep a watch on the development of pulmonary edema

Assessment - look for signs of rehydration

• Reduce irritability
• improved alertness
• improved skin turgor
• Reduced tachycardia
• Improved blood pressure.

If goals are not achieved - plan central line insertion, urinary catheterization. attach the patient to multipara monitors to get accurate data regarding heart rate, blood pressure, respiratory rate

Educational Nursing Diagnosis - Proper diet

Goal - Avoid constipation

Intervention:

1. Balanced diet
2. Should be high in dietary fiber
3. Reduce the intake of greasy foodstuff (oily)

If the patient has regular bowel movement with well formed stools the goals are achieved. If this hasn't occured consider prescribing laxatives.(syrup lactulose)