Student Name: Lisa Chee

Date: 11/18/2014-11/19/2014
N256 Mini Care Plan- Patient A

Expected
(complete before assessment)

Found
(complete after assessment)

1. Risk for respiratory depression r/t to PCA use

2. Risk for aspiration r/t continuous NG TF at 75
mL/hr
3. Risk for infection r/t NG tube, peripheral IV
access, PICC access and abdominal surgery
Focused respiratory assessment, assess IV sites for
infiltration/phlebitis, focused abdominal assessment,
monitor VS for s/s infection

1. SAME
2. Risk for bowel perforation r/t POD #15 & 16 for
ileostomy takedown, abdominal distention, hypoactive
bowels and no BM since admission.
3. SAME

Need more
information
from
patient/family/
doctor about:

When was 1st PCA dose given? How often does pt

push the button? Passing flatus? BM?

SAME

Top three
priorities (goals)
for patient care

1. Pt maintains an effective breathing pattern, AEB

relaxed breathing at normal rate and depth, and
absence of dyspnea, cyanosis, or use of accessory
muscles.
2. Pt maintains a patent airway AEB normal breath
sounds, absence of coughing, no SOB and no
aspiration
3. Pt is free from s/s infection AEB healing wound,
incision clean/dry/intact, well approximated, no
redness or purulent drainage, clear breath sounds
w/o cough/sputum.
1. Assess for s/s of PCA complications (e.g.
respiratory distress/depression, urinary retention,
N/V, constipation, IV site pain, infiltration or
phlebitis)
2. Conduct a focused respiratory assessment (RR,
and absence of dyspnea, cyanosis, or use of
accessory muscles)
3. Elevate the HOB to 30 to 45 degrees while
feeding the patient and for 30 to 45 minutes
afterward if feeding is intermittent. Turn off the
feeding before lowering the HOB.
4. Check placement before feeding, using tube
markings, x-ray study, pH of gastric fluid and color
of aspirate as guides. Check residuals before feeding,
or every 4 hours if feeding is continuous. Hold
feedings if amount of residuals is large, and notify
the physician.
5. Assess surgical site for redness, swelling, warmth,
pain.
6. Maintain asespsis and proper hand hygiene.
Administer ABX as prescribed.
Dressing changes if necessary, educate pt on s/s
infection, SE of PCA use, SE of prescribed
medications. Infection prevention.

1. SAME
2. Pt remains free from bowel perforation AEB absence of
N/V, fever, chills and severe abdominal pain.
3. SAME

Nursing
Diagnoses
(NANDA)

Focus of physical
assessment

Nursing
Interventions

Teaching
needed/provided

SAME

1. SAME
2. SAME
3. Perform a focused abdominal assessment.
4. Have pt on intermittent NG suctioning to remove excess
bile secretions. Check placement of NG tube using chest-x
ray, aspirating stomach contents, checking pH of stomach
acid, pushing air and auscultating or current length of NG
tube vs length of NG tube post insertion.
5. SAME
6. SAME

SAME, report flatus or BM, report s/s of N/V, fever, chills or

severe abdominal pain indicating possible bowel perforation.
Function and purpose of NG tube. NG tube care.

Discharge
planning

Home. PT, OT, medication instructions, follow up

instructions w/ PCP

SAME, but pt does not need PT/OT. Should not be on NG tube

upon discharge, BUT if pt has NG tube in place upon
discharge, home health nurse to evaluate NG tube placement,
function. Abdominal wound care.