Mapa mental
Abdominal Pain
Conteúdo do mapa
Abdominal Pain
Pain
- assess level of pain
- pt at 7
- nonverbal signs of pain: griamcing
- meds
- administer PRN
- Oxycodone HCl 10mg PO
- reassess level of pain
- pt at 5
- determine any alleviating measures to aid with pain control
- get pt to pain level of 1 or 2 by end of shift
- determine any alleviating measures to aid with pain control
- pt at 5
- S/E: N/V, constipation, lightheadedness, drowsiness
- nursing implications: monitor for respiratory dysfunction. Notify prescriber if <10 BPM
- reassess level of pain
- Oxycodone HCl 10mg PO
- administer PRN
- meds
- assess abdominal area
- abdomen distended, rigid and tender
- pt had paracentesis 10/10/14 on R side of abdomen
- assess site of paracentesis
- area is not red or swollen
- assess site of paracentesis
- pt had paracentesis 10/10/14 on R side of abdomen
- abdomen distended, rigid and tender
- assess level of pain
labs/diagnostics
- monitor fluid and electrolytes
- potassium
- 3.5 mEq @ 0430 hrs
- administer 20 mEq po K+
- monitor for signs/symptoms of hyperkalemia: paresthesias, irritability, dysrhythmias
- Reassess: 3.7 mEq @ 1130 hrs
- maintain pt's fluid and electrolyte balance throughout shift
- monitor signs and symptoms for adverse effects
- teach pt s/s of fluid and electrolyte imbalances
- monitor signs and symptoms for adverse effects
- maintain pt's fluid and electrolyte balance throughout shift
- Reassess: 3.7 mEq @ 1130 hrs
- monitor for signs/symptoms of hyperkalemia: paresthesias, irritability, dysrhythmias
- administer 20 mEq po K+
- 3.5 mEq @ 0430 hrs
- magnesium
- 1.6 mEq @ 0430 hrs
- administer 2g Mg IV
- monitor for signs of hypermagnesemia: hypoactive DTR, decreased rate and depth of respirations
- Reassess: 2.1 mEq @ 1130 hrs
- monitor for signs of hypermagnesemia: hypoactive DTR, decreased rate and depth of respirations
- administer 2g Mg IV
- 1.6 mEq @ 0430 hrs
- potassium
- Physician recommended pt have another paracentesis and endoscopic procedure
- Liver function tests
- AST: 50 units per liter
- ALT: 116 units per liter
- continue to monitor
- monitor glucose levels
- 116 mg/dL @ 1130 hrs
- monitor fluid and electrolytes
assessment
- paracentesis site
- area not red or swollen
- site is weeping fluids
- fluid color is pinkish
- dressing saturated, gown and sheets wet
- change dressing, gown and sheets
- monitor dressing q2hrs
- change dressing, gown and sheets PRN
- monitor dressing q2hrs
- change dressing, gown and sheets
- site is weeping fluids
- area not red or swollen
- abdomen
- rigid, distended, tender
- hypoactive bowel sounds x 4 quadrants
- had pt walk with assistance to enhance GI motility
- hypoactive bowel sounds x 4 quadrants
- rigid, distended, tender
- respiratory
- clear lung sounds
- difficulty breathing r/t distended abdomen
- monitor O2 sats and respirations
- O2 sat:98%
- resp: 16 BPM
- elevate head of bed 30 degrees
- monitor O2 sats and respirations
- difficulty breathing r/t distended abdomen
- clear lung sounds
- circulatory
- monitor B/P
- 120/73 @ 1400 hrs
- pulses
- 79 BPM @1400 hrs
- regular and bounding
- bilateral pitting edema +1 feet
- monitor edema
- had pt walk with assistance to enhance circulation
- edema will not radiate during my shift
- had pt walk with assistance to enhance circulation
- monitor edema
- bilateral pitting edema +1 feet
- regular and bounding
- 79 BPM @1400 hrs
- monitor B/P
- paracentesis site
medications
- amiloride
- K-sparing diuretic
- S/E: headache, orthostatic hypotension, N/V/D, polyuria
- adverse effects: hyperkalemia
- monitor K levels
- adverse effects: hyperkalemia
- S/E: headache, orthostatic hypotension, N/V/D, polyuria
- K-sparing diuretic
- furosemide
- loop diuretic
- S/E: hypokalemia, hypomagnesemia, hyperglycemia, polyuria
- adverse effects: circulatory collapse, renal failure
- Monitor K levels, B/P, I&O's and other electrolyte levels
- adverse effects: circulatory collapse, renal failure
- S/E: hypokalemia, hypomagnesemia, hyperglycemia, polyuria
- loop diuretic
- propranolol
- antihypertensive
- S/E: fatigue, bronchospasm
- adverse effects: laryngospasm, bradycardia, CHF, pulmonary edema, dysrhythmias
- Assess B/P and pulse before administering, monitor AST, ALT, daily weights
- adverse effects: laryngospasm, bradycardia, CHF, pulmonary edema, dysrhythmias
- S/E: fatigue, bronchospasm
- antihypertensive
- lactulose
- laxative
- S/E: N/V, anorexia, abdominal cramps
- assess stool: amount, color and consistency, monitor blood ammonia level
- Panic ammonia 86 mcg/dL @ 0630
- alerted physician
- continue to monitor
- alerted physician
- Panic ammonia 86 mcg/dL @ 0630
- assess stool: amount, color and consistency, monitor blood ammonia level
- S/E: N/V, anorexia, abdominal cramps
- laxative
- ceftriaxone
- antibiotic
- S/E: N/V/D, anorexia, oral candidiasis
- adverse effects: phlebitis, anaphlaxis
- monitor electrolytes, AST, ALT, overgrowth of infection
- adverse effects: phlebitis, anaphlaxis
- S/E: N/V/D, anorexia, oral candidiasis
- antibiotic
- lorazepam
- anti-anxiety
- S/E: dizziness, drowsiness, orthostatic hypotension, blurred vision
- assist with ambulation, evaluate therapeutic response, assess therapeutic response
- adverse effects: apnea, tachycardia
- S/E: dizziness, drowsiness, orthostatic hypotension, blurred vision
- anti-anxiety
- ALLERGY: ACETAMINOPHEN
- amiloride
Pt history
- ETOH abuse, Hepatitis C, cirrhosis, appendectomy, HTN, GERD
MELISSA FERRELL 10/11/2014 clinical
Informações
- Descrição
- Mapa Mental sobre Abdominal Pain, criado por blinn.melissa em 28-09-2014.
- Criado por
- blinn.melissa
- Visualizações
- 9
- Avaliação