Associate Degree Nursing Program

Student: Date:
12/19/2010
Client Initials: Medical Diagnosis: Chronic Pancreatitis
Clinical Week:_5__

Assessment Nursing Planning Evaluation

Diagnosis
---48yr male presents BHN:Physiologic Goal/Outcome Plans Implementation
with severe chronic al Client will: Remain 1) Assess temperature 1)900,1000,1100, Goal Met:
pancreatitis Comfort free from of client; Q hourly; 1200
symptoms of report a single Temperature Client
---Client admitted infection thru temperature of greater taken with no remained
on Priority Dx: 1200 on than (100.5 F). indication of free of
10 /29/2010 with ---Risk for 12/19/2010 1R)Pyrexia is often the pyrexia. temperatur
severe infection R/T to first sign of an e, Had
chronic extended infection 1200mL
pancreatitis inpatient intake in
hospital 4hr
---Client has history confinement 2) Encourage fluid period,and
secondary to 2)900,1000,1100, used
of heart arrythmia intake of a minimum of
Chronic 1200 incentive
240mL hourly (unless
Disease Offered and spirometer
---Client shows contraindicated).
(Pancreatitis) encouraged client with deep
signs of confusion
to drink his breathing &
2R) Fluids promote
preference of productive
---Client diluted urine and
fluids in 240mL cough each
Spontanously frequent emptying of
amounts. hour.
uncooperative bladder; reducing
stasis of urine, in turn,
---Lab values now reduces risk of bladder Client
WNL infection or urinary symptom
tract infection. free from
---Client responding 3)900,1000,1100, infections
slowly to recovery 3) Encourage 1200
of condition coughing and deep Encouraged and
breathing and use of assisted client
incentive spirometer Q with incentive
hourly. spirometer, deep
breathing &
3R) These measures coughing
reduce stasis of
secretions in the lungs
 and bronchial tree.
When stasis occurs,
pathogens can cause
upper respiratory
Subjective:
infections, including
“I will do whatever
pneumonia
is needed to get
better”