State University of New York

College at Brockport
Department of Nursing

NUR 462: CLINICAL REQUIREMENT/DAILY WORKSHEET

Name: Viktoria Lipke Date 9-18-07

Client’s Initials: HS Diagnoses: Small bowel resection with necrotic small bowel

Assigned Nurse & Unit: 4400 with Alan Smith

• How was your learning expanded or reinforced today? In other words, report on
what you learned, not on what you did. (Refers to Application of Theory on
Level III Clinical Evaluation Tool)

I learned the difference between a central line and a peripheral line also that the
one difference among them is that the flush amount for each one. How to properly
administer medication through a central line.

• What assessments did you make today that led to the client’s priority nursing
diagnoses? In addition to the usual assessment data, be sure to include
assessments specific for that client and the diagnosis, lab work, telemetry, etc.
(Assessment)

After the clients surgery her troponin I level was high indicating that she had a
heart attack. This led me to the nursing diagnose of risk for tissue perfusion. The
second priority diagnoses being alteration in GI function because the patient has not
passed gas/bowel movement which is why she is still NPO which will then lead to the
priority diagnoses of alteration in fluid and electrolyte balance.

• List the priority nursing diagnoses for your client. (Diagnosis)

1. Safety, potential for injury r/t falls as evidence by patient needs assistance
2. Risk for post-op infection r/t abdominal wound
3. Alteration in GI function r/t pacing gas and bowel movement
4. Alteration in comfort r/t incisional pain as evidence by patient states she’s in pain
wants no medication
5. Alteration in fluid and electrolyte balance r/t NPO status as evidence by has no
pass gas or bowel movement yet
6. Anxiety r/t disease process as evidence by she has concerns about the future
outcome
7. Knowledge deficit r/t post-op routines and home care
8. Risk for tissue perfusion r/t MI as evidence by troponin I level was high
• Which relevant goals/outcomes did you establish for these nursing diagnoses?
(Goals/Outcomes)

1. Goal: patient will remain free of infection

Outcome: she didn’t have a increase in temperature, her wound stayed clean dry
and intake, urine was clear to yellow w/out odor, no elevation of WBC.
2. Goal: patient will have a return in bowel function: check abdomen for sounds,
swelling and pain
Outcome: patient has not have positive bowel sounds, however she has remained
free of nausea, vomiting, and abdominal distention
3. Goal: Patient will experience relief or decrease pain/discomfort
Outcome: patient felt discomfort however didn’t want pain medication, used other
coping mechanisms instead
4. Goal: patient urine output will be at least 30ml/hour
Outcome: patient urinated 800ml in 6 hours
5. Goal: patient will be free from falls
Outcome: patient had no falls or injury d/t patient called staff for assistance and
had staff assistances for every time she got OOB.
6. Goal: patient will be free of fears and concerns
Outcome: staff explained all routines, procedures and treatments prior to
implementation, we encouraged verbalization of feelings/fears/concerns, and
assist patient to identify sources of support: family/ friends
7. Goal: patient will verbalize understanding of follow-up care and home care
management
Outcome: patient was taught proper education and verbalized understanding.
8. Goal: monitor telemetry strip and troponin I level for evidence of another MI
occurring
Outcome: patient remained in normal sinus rhythm with no ECG changes
reflecting ischemia.

• Which interventions were performed to achieve these goals/outcomes? These

include skills such as IV's, ECGs, tubes, dressings, etc. Don’t forget the
medications that were given to your client. (Intervention and Skill Sections-
Interventions are preventions that you would list on a NCP and skills are
procedures that you actually did.)

Patient had a central line placed; we used it to administer Heparin to prevent

existing clots from getting bigger and new ones from forming. Also we administered
lasix to help kidney get ride of excess fluid. Also we flushed the second line. Other
medication I administered were:
• Valsartan (diovan) which is a angiotensin II receptor
• Aspirin to prevent platelet from aggregating
• Nitroglycerin patch to promote peripheral vasodilatation
• Protonix a proton pump inhibitor, GERD
• Lopressor a beta blocker
Her ECG remain in normal sinus rhythm with no ECG changes, I changed her
abdomen dressing, which was dry and intact.

• Which interpersonal communication interventions did you do with the client and
family in order to achieve these goals/outcomes? (Helping
Relationship/Communication)

Have a social worker meet the patient to help plan for home care management.
We discussed pain management to have pain score of less than 4 so this way she will
feel better and look forward to going home. We went other fears and concerns she had
about her surgical procedure and disease process.

• What client teaching interventions (including meds and primary, secondary, or

tertiary preventions) were performed to achieve these goals/outcomes? (Client
Teaching/Learning Needs)

I told the patient that it was important to sit in a chair for 45 minutes or more at
least 3 times a day, walk in the hallway with a staff assistances BID, this will help
decrease gas pain and stimulate the return to normal bowel function. Explained to the
patient that the catheter will be removed when she is able to walk to the bathroom.
She had to wear leg sleeves to help with circulation and prevent blood clots.
Important to perform breathing exercises. It’s important to review information about
her diet, medications and activities and exercises before she goes home. Also
explained that it’s important to call the doctor if she feels bloated or have stopped
passing gas, feels nauseous, has fever or chills, experience redness or burning at the
incision site.

• What documentation (including report, flow sheets, notes, Clinical Pathways, etc.)
was performed in order to achieve these goals/outcomes? (Documentation)

Patient I & O's, daily weight, VS, monitor telemetry strip and document
rhythm strip, documented physical assessment on patient.

• How did you evaluate the client's response to these interventions? (Evaluation)

Patient communicated with the staff when she need something, felt pain, had
questions or concerns. She was overall in a pleasant mood. Patient verbalized
understanding of procedures and teaching opportunities. Patient cooperated with the
staff when it came to post-op guidelines such as ambulating, OOB to chair, and deep
breathing.

• How did your understanding increase today? (Critical Thinking)

I am more aware of what to assess for with a post-op small bowel resection
patient. I know what to the daily goals and priorities are.

• What references did you use today in the care of your client and/or when
preparing this DWS? (Nursing Research)

Medical encyclopedia: small bowel resection

Nurse Alan Smith

• Give examples of how you interacted with other members of the health care team
when you were providing care to your client. Were you able to organize your
care? (Management and Organization)

I worked with my nurse and the tech’s to make sure the client’s procedure &
priorities were accomplished.

• How did you demonstrate professionalism today? (Responsibility, Accountability,

Autonomy, and Ethical Decision Making)

I was on time. I helped my nurse whenever I could help out. I applied my

knowledge to the client’s priority diagnoses, goals, and interventions

• Don’t forget to include a diary card. (Personal and Professional Growth)

I am very concerned if I’m going to succeed in this clinical because I’m struggle on how to pull it all
together at clinical and I keep making stupid mistakes that I’m made at myself for because I’m really
trying hard and I want to be here. My nurse Alan is great and is helping me a lot. Hopefully I’ll do
much better next week.