CRITICAL THINKING SUMMARY

Student: _Kassie Herp______________________ Clinical Group/Day: ___Mon. 7a7p_______________

Patient Diagnosis: small bowel obstruction_________________________
Age: 43 _____

Patient

Patient Allergies: morphine, contrast dye, ileostomy restricted foods,

hydromorphone, iodine, shell fish, sulfa drugs____________________________________
MEDICAL DIAGNOSIS that pt was diagnosed with upon admission to the hospital,
including dx that were added after admission: small bowel obstruction, anal odeno
cancer, 2 possible abscesses, placing drain, leukocytosis_____
PAST MEDICAL DIAGNOSIS: Found on History and Physical in chart, or upon interview
with pt:
Crohns disease, j pouch, endometriosis, fibromyalgia, arthritis, asthma, total
abdominal colectomy with ileal pouch, anal anastomosis and diverting ileostomy
with subsequent ostomy take down.
PATHOPHYSIOLOGY of ADMISSION MEDICAL DIAGNOSIS: (not quoted, but YES
APA cited)
A partial or complete blockage of the lumen of the large or small intestine.
______________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
SYMPTOMS typically seen with this diagnosis include: (not quoted, but YES
APA cited)
Abdominal pain, nausea, vomiting, inability to pass gas or stool
_______________________________
_____________________________________________________________________________________
PATIENTS SYMPTOMS: How do they differ or are similar to expected symptoms?
Abdominal pain, inability to pass gas or stool.________________
____________________
_____________________________________________________________________________________
NUTRITIONAL ASSESSMENT: (helpful site is www.eatright.org)
Pt HEIGHT: 157.48______
Index):27__________

Pt WEIGHT: 68.1________

Pt BMI (Body Mass

What BMI Category does your pt. fall into? (Underweight, Normal, Overweight,
Obese):overweight__
How much weight would this pt have to gain/lose to have a normal BMI? 14 lbs or
64. kg_____________

How could pt achieve this? By changing diet and increasing exercise

___________________________
WHAT AGE /PSYCHOSOCIAL RELATED CONCERNS does your pt have? Inability to
create or nurture things because patient has been in hospital and not able to spend
time and energy on those things.

CRITICAL THINKING SUMMARY

NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
#1 NURSING DIAGNOSIS (including R/T): _deficient fluid volume r/t fluid loss in
bowel___________
DEFINING CHARACTERISTICS (S/SX) that support pt diagnosis: decreased blood
pressure decreased urine output, increased body temp.
_________________________________________________
OBJECTIVE/PATIENT OUTCOME for this diagnosis: maintain 0.5 ml/kg/hr of
urine__________
NURSING INTERVENTIONS that will assist the pt to resolve the above dx or to meet
objectives:
#1: monitor fluid intake and output every 4 hours
_______________________
#2: provide oral replacement therapy
#3: administer antidiarrheals prn

____________________________
________________________

----------------------------------------------------------------------------------------------------------------------------------------#2 NURSING DIAGNOSIS (including R/T): actue pain related to

abscess_________________
DEFINING CHARACTERISTICS (S/SX) that support pt diagnosis: client stating pain,
wincing when moving and clutching stomach or site
__________________________________________________________
OBJECTIVE/PATIENT OUTCOME for this diagnosis: pain management regimen
achieves comfort function goal____________
NURSING INTERVENTIONS that will assist the pt to resolve the above dx or to meet
objectives:
#1: manage acute pain using a multimodal approach_________
#2: monitor pain rating with numeric scale every 2 hours
_____________________
#3: come up with 2 non pharmacological pain relievers and try them everyday until
you find one that works _________
-----------------------------------------------------------------------------------------------------------------------------------------

COMPLICATIONS: If pt condition were to worsen, what would be the most likely

reason and why?
Abscess if untreated could lead to
sepsis__________________________________________________
What symptoms would pt exhibit if this happens? Fever hypothermia, tachycardia,
tachypnea, evidence of inadequate blood flow to internal
organs________________________________________________
What nursing interventions would you exercise and what Dr. orders would you
anticipate?
Antibiotics, ICU, intubated, warming and cooling measures, frequent checks on
patient. _____________
_____________________________________________________________________________________
Patients Medications/Doses: circle those meds that you anticipated with this
diagnosis:
_____________________________________________________________________________________
_____________________________________________________________________________________

ANALYSIS OF DIAGNOSTIC TESTS

Diagnostic / Lab Test

Patient Value

Na (sodium)

138

134-146

K+ (potassium) 3.4-5.0

4.5

Chloride

101

98-112

CO2 (serum) 22-32

22

Anion Gap 4-15

15

Phosphorus 2.5-4.5

3.3

Urea nitrogen (bun)

Cr (creatinine)

8-20

16

0.5-1.1

0.53

Glucose

65-99

133

Calcium

8.6-10.4

9.1

Magnesium

1.6-2.5

Albumin

3.5-5.0

Bili Total

0.2-1.0

Alk Phos

30-120

AST

10-40

ALT

10-40

B Natiuretic Peptide (BNP)

Analysis of Value

2.2

0-99

Inadequate renal function due to

deficient fluid volume

WBC (White Blood count)

Hgb (Hemoglobin)

4-10.8

12-16

14.53

Infection rom abscess

10.3

Nutritional deficit from small bowel

obstruction
Acute infection from abscess

Platelet

140-400

512

PT / INR

9.3-12 / 0.9-1.2

11.4/1.1

ABG: ph Art

7.35-7.45

ABG: pCO2
ABG: pO2

35-45
75-100

ABG: HCO3
ABG: O2 Hmg

22-32
94-97

Blood Cultures (Microbiology)

negative
UA (urinalysis)

Negative

Cat Scan (CT)

Negative

CXR (Chest X-Ray)

negative

Negative

Please list any Misc labs; i.e. D-Dimer Quant 0-500, Hct 37-47, Influenza A or B, CDiff, MRSA, AFB

Medications
Ibuprofen: 400 mg PO q6, nosteriodal antiiflammatory drug, treat pain, adverse
reactions-diarrhea, constipation, bloating, gas dizziness, headache, nervousness,
blurred vision, take with food or milk, may cause heart or circulation problems.
Piperacillin tazobactam: 3.375 Gm IVPB q6, penicillin antibiotics treat infections,
adverse reactions- nausea, vomiting, diarrhea, constipation, headache, runny nose,
skin rash, pain or swelling, do not take if allergic to penicillins
Acetaminophen: 1000mg, PO q8hr, pain reliever and fever reducer treat pain,
adverse reactions- skin reactions, nausea, loss of appetite, liver disease no alcohol
Rivaroxabin: 10 mg, PO, daily, anticoagulant, prevents formation of blood clots,
adverse reactions- muscle pain, itching, pain in you arms and legs, can cause blood
clot around spinal cord if spinal tab at risk for bleeding.
Duloxetine: 60 mg, PO, daily, Cymbalta, fibromyalgia, adverse reactions- fatigue,
drowsiness, insomnia, dysuria, sweating, monitor BP assess for rash.
Albuterol: 5 mg, NEB once, PRN, wheezing, bronchodilator treat and prevent
bronchospasm, adverse reactions- headache, dizziness, insomnia, cough,
hoarseness, nausea, vomiting, caution with inpatients that have dysrhythmias and
hypertension.

Hydromorphone: 0.5 mg IVpush q3 PRN, opioid rain medication treat moderate to

severe pain, adverse reactions- constipation, nausea, vomiting, dizziness,
drowsiness, sweating, can slow or stop your breathing no MAO inhibitor