726 Carplan Essay examples

Submitted By Achrollins
Words: 1844
Pages: 8

Nursing Diagnosis
Subjective/Objective Data (AEB)
Nursing Interventions
Rationale(s)
Goals
Outcome(s) Evaluations Infection Actual, related to, inadequate primary defense occurring with disruption of the GI tract, disruption of the integument and underlying tissue, multiple indwelling catheters and drainage tubes, compromised immune state caused by invasion on pathogenic bacterium secondary to bacteremia and endocarditis as evidence by:
Tachycardia (HR 106)
Varying fever (99-102)
Decrease Albumin(2.9)
Positive Blood cultures (Staph and Klebsiella)
Echocardiogram and Transesophogeal-
Echocardiogram showing vegetation in the right atrium.
Increased WBC (16.5) Neutrophil (89) and Monocyte (15.7)

52 yo female
Presented to ER on 8/12/14 c fever of 104 and abdominal pain, had a peg tube, endocutaneous abdominal fistula and colostomy bag in place.

C/O Fever
Admitting Dx: Small bowel obstruction , Sepsis

PMHx: Back Problems, GERD, Hypothyroidism, Pancreatitis, Anemia

Surgical Hx: Gallbladder, Hysterectomy,

Current physician: Ratliff, Fadi, Wright

Assessment:
A&O x3

Pain 4/10 abdomen, “ dull constant pain”

Speech clear and appropriate
Skin very warm , feel feverish to the touch, dry and pink Temperature 102.4

Perrla

Nares, clear, symmetrical

Mucous membranes pink moist intact

No swelling in face

Right jugular central line 18 guage lumen infusing TPN ( Aminosyn 10% with ½ NS @ 50 ml/ hr)

Chest symmetrical

Respirations even and unlabored rate of 14

Patient is eupneic

O2 sat 98 room air

Absent of retractions and nasal flaring

Apical pulse 106

Heart sounds audible S1 and S2

Turgor elastic, no tenting

Cap refill 3 sec nail beds pink skin warm and dry

Hand grips strong and equal bilateral

Radial/ brachial pulses strong and palpable +2

Full active Range of motion

Bowel sounds presents, hypo active.

Abdominal Fistula draining to colostomy bag mid abdomen, drainage is yellow and cloudy. Intact no redness or edema noted around fistula no skin break down noted

RUQ Peg tube draining to cath bag with 800 ml of yellow cloudy drainage in bag, insertion site of peg tube is covered with 4x4 there is no redness or leakage around site, bandage is dry.

3cm x 4 cm area of skin break down in the epigastric region, covered with wet sterile gauze and 4x4, no drainage or odor from the wound the edges are well approximated.

No abdominal distention

No constipation or diarrhea

Urine is yellow an clear, freely voids and is continent no pain on urination

No skin breakdown on back or buttock

No edema or redness on legs,

Inguinal pulses strong and equal bilateral, Popliteal pulse strong equal bilateral +2.

Skin warm dry and pink,

Cap refill 3 sec Nail beds pink ,
Pedal pulses strong and equal bilateral rate of 106

Pedal pushes strong and equal.

No edema in lower extremity

Vital signs : 1005 am
BP: 110/63
HR:106
R: 14
O2: 98 room air
Temp 102.4
Pain 4/10

Wt: 150#
Ht: 5ft 2in
BMI 27.6

Intake and out put

Patient in NPO
Intake 2552ml from TPN and IV fluids in 24h
Output: 2650ml/24h
Subjective data:
Patient explained how she got the fistula “ I had a gallbladder surgery in February, the surgeon cut my bowel and my bowel content spilled over into my gut causing me all kinds of issues, I have been in and out of the hospital since then I was in the hospital several times during the month of July at UK, I to have the peg to up in to drain the fluid off of me the fistula developed because of the complications from the gallbladder surgery, I have to have the picc line put in and the the tpn bc of all the infections and I just can’t eat any more, But im still tankful I am alive”

Diagnostic testing:

8/12/14
Blood Cultures: Gram positive Tetrads and Clusters non hemolytic staphylococcus. Aerobic Culture: Moderate growth of lactose fermenting Gram negative rod Klebsiella Pneumonia Bacteremia.

CXR: No acute cardiopulmonary process. Stable heart size. RUE picc