Female/78 yr

Female/78 yr

1. DX: Bowel Preparation/Colonoscopy

   • Risk for electrolyte imbalance
     • r/t preparation for colonoscopy
       • AEB fluid and dietary restriction
         • 1) Monitor vital signs Q4h and PRN
           • Vital Signs: Temp: 92 P: 61 RR: 18 BP: 150/78 O2: 100%
         • 2) Monitor cardiac rhythm and rate Q4h and ORN
           • Assessment: P: 61 BP: 150/78
         • 3) Monitor intake and output by measuring weight Q am and on a consistent scale
           • Assessment: Patient maintains a consistent weight of 121 pounds
         • 5) Review labs within 1 hour of updated chart and report and alterations from the baseline to the healthcare provider
           • Labs: All labs came back within the normal ranges
         • 4) Monitor patient for abdominal distention and discomfort Q4h and PRN
           • Assessment: + bowel sounds Soft & Non-tender Last BM 9/4/2017
         • 6) Maintain a clutter free are to avoid falls
           • 60 Second Scan: Room is safe and free of clutter
   • Risk of activity intolerance
     • r/t acute abdominal pain
       • AEB inability to walk without pain
         • 1) Determine cause of activity intolerance within first 2 hours of shift
           • Assessment: Patient is up out of bed walking around unit when arrived. Patient rates pain a 0/10
         • 2) Assess patient within first 2 hours of shift for appropriateness of activity and bed rest orders, try to mobilize patient with assistance twice a day.
           • Assessment: Patient had no difficulty or pain while ambulating
         • 3) Assess patient when mobilizing to observe any signs and symptoms of nausea, dizziness, impaired consciousness, or any changes in vital signs.
           • Assessment: Patient reports no signs and symptoms of nausea or dizziness, Patient is oriented to person, place, and time. Patient has no change in vitals signs.
         • 4) Monitor and record patient’s ability to tolerate activity: note pulse rate, blood pressure, respiratory pattern, dyspnea, use of accessory muscles, and skin color before, during, and after activity.
           • Vital Signs: Temp: 92 P: 61 BP: 150/78 O2: 100% RR: 18 Patient tolerates activity well & without pain.
         • 5) Instruct patient to immediately stop activity if experiencing new or worsening intensity and frequency of pain.
           • Educated patient to report any pain while being active

2. DX: Anxiety

   • Anxiety
     • r/t health status
       • AEB patient rating a high anxiety level prior to procedure
         • 1) Assess the patients level of anxiety and physical reactions to anxiety Q4h and PRN.
           • Assessment: Patient reports level of anxiety to be at a 4/10. Vitals signs are maintained at baseline level.
         • 2) If irrational thoughts or fears are present, offer patient accurate information and encourage her to talk about the meaning of events that are contributing to her anxiety.
           • Assessment: Patient reports feeling oriented with positive thoughts. Patient expresses feelings of anxiety which allowed the patients anxiety to reduce. Patient reports feeling better and ready for discharge.
         • 4) Intervene when possible to remove any environmental sources of anxiety as needed.
           • Assessment: Patient reports a lower level of anxiety of 2/10 when asked before discharge. Patients level of anxiety had decreased.
         • 3) Monitor patient for depression Q shift.
           • Assessment: Patient reports no feelings of depression or self harm
         • 5) Explain all activities, procedures, and issues that involve the patient as needed: make sure to use nonmedical terms and calm, slow speech.
           • Discharge Assessment: Educated patients on upcoming appointments and signs and symptoms of any abdominal pain and discomfort.