Student Name: Christine Rombawa

Date Submitted: 4/15/15

History of Present Illness

Patient scheduled for surgery for
sigmoidectomy with end sigmoid
colostomy, lysis of adhesions and
transverse loop colostomy
takedown for rectosigmoid
stricture and retracted ostomy
secondary to prior pelvic
radiation.
Age: 74
Male or Female: Female
Cultural: Japanese
Spiritual: Buddhist
Marital Status: Widow
Living condition: Patient lives in
apartment alone. Son lives in
separate location in Oahu

Code status: FULL CODE

Medical Dx: Radiation colitis
Surgical Procedure and date:
04/07/15: Sigmoidectomy with end sigmoid
colostomy and transverse loop colostomy
takedown for rectosigmoid stricture.
Past Medical Hx:
Chronic Pain
Cervical Cancer
Hyperlipidemia
Small bowel obstruction
Pre-diabetes
HTN
CKD
General appearance and behavior:
1. Affect
2. Mood
3. Thought Process
4. Thought Content
5. Cognitive Evaluation
6. Insight
7. Judgment
8. Level of Function
9. Psychiatric status

Interdisciplinary referrals (state one

appropriate referral with rationale)
An appropriate referral for my patient would
be a home health services to assist with
colostomy care, bathing, cooking, shopping,
laundry and medical appointments.

Allergies: NKDA
Allergy:
Type of reaction:

10. Psychotropic Medications

Type of IV solution & Rate:

NaCl 0.9% 30mL/hr.

Psychosocial assessment:
1.Housing
2. Transport
Type of IV Access & Location:
3. Financial
PICC Right Arm Double Lumen
4. Support
5. Follow-up
List all IV medications (research compatibility &
Diagnostic tests including test results (pre- and postinfusion rate for each med.)
procedures nsg. implications later in CIS)
Chest X-ray Med./dose
Time
Infusion rate Compat.
Nacl 0.9%
Cont.
30ml/hr.
Yes

Treatment
-Incentive spirometry
-Flowtron
Discharge Planning (write one or two of patient's discharge
needs or summarize case management's notes regarding
discharge)
Pt. will be discharged to home once weaned off IV pain
medications. Pt. currently has home health care BID.

Type of Diet: Soft food, low fiber, boost supplements BID

Fluid Restriction: N/A
Enc. Fluids: Yes
Activity (ability to walk - gait):
Type of activity: Up in chair for meals
Use of assistive device: Walker

Weight/height:110lbs/ 52
Elimination (continent/incontinent): Incontinent/continent
Colostomy
**For insulin: needs to state the peak and duration; also indicate short-acting, rapid acting or intermediate-acting or longacting.
**May tab drug book for clinical days; when turn in your written work on Sat, needs to complete all columns listed below:
List all p.o. & s.c., newly ordered & prns Meds
Ordered
Time
Mechanism of
Med/dose/frequency
action
(what is the usual
dose and frequency
for this med.)
Atenolol tab 25 mcg QD 1000
Beta-Adrenergic
antagonist;
Antihypertensive

Indication
(how is this med
relate to your pt.s
condition)

Major Side effects

HTN

Bradycardia
hypotension

AntilipemicIncreases LDL
receptors
Reduces LDL and
total triglyceride
production.
Increases HDL
plasma levels

Hypercholesterolemi
a

Back pain
Myalgia

Atorvastatin 20 mg QD

1000

Omeprazole 20 mg QD
before meals
Morphine SR tab 15mg
Q12hrs

1000
1400

Narcotic Analgesic

Moderate and severe

pain(4-10)

Bradycardia
Respiratorydepression
Nausea
Miosis

Heparin Porcine(PF)
5,000 units SUBQ
Q12hrs
Hydromorphone in NS
(Dilaudid) 100mg/100ml
(1mg/1ml) Resv Pump
PCA Premix
Loading dose: 0.4 mg
PCA Bolus: 0.2 mg
Interval: 8 minutes

1000

anticoagulant.

Prevent clotting

Prolonged bleeding
Swelling
Pain

Continuou
s

Opioid analgesic Moderate to severe

PRN
Alteplase Inj. 2mg
(Cathoflo Activase)
Intracatheter
D50W Inj. Syg 125g
25ml IV

pain

PRN
PRN

Nsg. Implications
(what
preparations do
you need prior to
administration)
Measure trough
BP
Prior to determine
efficacy.
Check apical
pulse. Hold if
<60bpm
No grapefruit
Monitor lipid levels
Monitor for muscle
pain, tenderness,
weakness

respiratory
depression,
mood changes,
mental clouding,
euphoria,
dysphoria,
nausea, vomiting

Obtain baseline
respiratory rate,
depth, and rhythm
and size of pupils
before
administration.
Report resp. of
12/min and below
Monitor for s&S of
bleeding and lab
values PT/PTT
Obtain baseline
respiratory rate,
depth, and rhythm
and size of pupils
before
administration.
Report resp. of
12/min and below

Hyperglycemia,
phlebitis at site

May cause
phlebitis;

Clotted catheter
Increase blood
glucose levels

Hypoglycemia

Glucagon Inj, 1mg

Intramuscular

PRN

Stimulates hepatic
production of
glucose from
glycogen stores

Instaglucose oral gel

15g PO

PRN

Rapidly increases
blood glucose levels

Lidocaine 10mg/mL 1%
inj. 0.1ml intradermal
Ondansetron (PF) Inj.
4mg IV Q6hrs/PRN

PRN
PRN

Antiemetic

administer slowly
Assess for signs of
hypoglycemia prior
to and periodically
during therapy;
assess for N/V

Hypoglycemia
If patient NPO
without IV access.
Give as needed for
glucose bellow 70; or
below 990 if s&s of
hypoglycemia and
notify MD. May
repeat x1 in
15minutes if s&s of
hypoglycemia persist.
Repeat glucose in 1
hour and notify MD if
less than 90
Hypoglycemia
If patient can take
oral/NG
Give as needed for
glucose bellow 70; or
below 990 if s&s of
hypoglycemia and
notify MD. May
repeat x1 in
15minutes if s&s of
hypoglycemia persist.
Repeat glucose in 1
hour and notify MD if
less than 90.
PICC local anesthetic

Hypotension, N/V,
anaphylaxis

Hyperglycemia (not
common)

Use caution when

administering to
patients with
altered mental
status or impaired
swallowing ability

Nausea/vomiting

HA
Diarrhea

Monitor F&E, vs
tachycardia

Nursing Diagnosis (complete ONE nursing diagnosis of highest priority for the first day of clinical.(for Thursday) Also include
expected outcome and nursing interventions. Nursing interventions should include assessment, interventions and teaching.
Gulanick,
M., &day
Myers,
RN, (Friday).
MSN, J.Evaluate
L. (2011).
Nursing
care plans:
nd
Complete
the 2PhD,
planAPRN,
of care FAAN,
for the second
of clinical
patients
responses
during Diagnoses,
clinical.

interventions,
and outcomes Missouri: Elsevier Mosby.
#1 Nursing
dx:
Deficient fluid volume related to post -operative bleeding, fluid diet, poor intake, and sigmoid colostomy AEB abnormal lab values.
Lab Test
Expected outcome:
Normal
Range/
Unit
Patient is normovolemic, as evidenced by stable BP at or above 90/60 mm
Hgoformeasure
patient's baseline, HR of 60 to 100 beats/min, urine output of
Date/ Result
at least 30 mL/hr, and normal skin turgor.
04/15/15
Date/ Result
Date/
Result
Patient
Responses to interventions
Rationale
for abnormalities
specific
to Denies
your client
Monitor, record, and report output from colostomy,
and incisional
Patient is
POD #9.
any nausea or vomiting. Abdominal incision is clean,
CHEM 25

Nursing Interventions

1.
drainage.
2. Monitor blood pressure and heartrate, skin turgor, mucous
membranes , and urine output
Hypotension and tachycardia may indicate fluid volume deficit.

3. Monitor lab values; Hbg, Hct, electrolytes, BUN creatinine, WBC,

Glucose, fasting
and65-100
RBC
4. Educate patient on importance of post-op sequential compression
device and Incentive spirometer use
BUN
Educate
6-23 and encourage fluid intake.

intact and dry. Colostomy output is minute watery brown stool. 220mL output.
VS: 140/73BP, 84 Apical HR, 14 R, 98% SpO2 RA, 98.6F oral
Mucous membranes are moist, skin turgor is poor with tenting.

Lab values: 04/15/15

10.5 Hgb, 30.7 Hct, 5 BUN, 0.5 Creatinine, 135 sodium, 3.3 potassium, 100
chloride, WBC 6.1, 3.28 RBC. Potassium chloride supplement given, K lab level
never reordered.
Pt. receptive to teaching. New flowtron device ordered, incentive spirometer use
demonstrated and pt instructed on technique and usage. Pt. verbalized and
demonstrated proper use.
Consistently
encouraged pt. to drink fluids of choice and boost supplement.
5L

Evaluation of whether outcome(s) are met::

Patient is POD #9. Denies any nausea or vomiting. Abdominal incision is clean, intact and dry. Colostomy output is minute watery brown stool. VS:
CKD 84 Apical HR, 14 R, 98% SpO2 RA, 98.6F oral. Mucous membranes are moist, skin turgor is poor with tenting. Urine output is adequate, urine
140/73BP,
Creatinine
is clear
yellow. Lab values: 04/15/15: 10.5 Hgb, 30.7 Hct, 5 BUN, 0.5 Creatinine, 135 sodium, 3.3 potassium, 100 chloride, WBC 6.1, 3.28 RBC
0.6-1.4
Potassium chloride supplement given, K lab level never reordered by physician.
0.5 LSodium chloride 0.9% IV 30mL.hr. Consistently encouraged pt. to drink
fluids of choice and boost supplement. Pt. prefers milk, green tea and her supplement.
BUN/Creatinine

#2 10-20:1
Nursing dx:
Acute pain r/t sigmoidectomy with end sigmoid colostomy AEB guarding behavior and protecting abdomen along with verbalizing
pain, and decreased activity tolerance.
Expected Outcome: Patient reports satisfactory pain control at a level less than 6 on a scale of 1-10.
Sodium
135-145
Nursing
Interventions

Monitor Severity of pain, Location, Onset, Duration Precipitating or

relieving factors.
Potassium
3.5-5

Assess for signs and symptoms associated with pain. The patient in
acute pain may have an elevated BP, HR, and temperature .
Provide periods of rest, comfort, relaxation
Colostomy
Monitor
effectiveness of pain medication
Chloride
Anticipate
the need for pain relief
98-107

Educate pt. regarding pain control and teach the patient effective
timing of the medication dose in relation to potentially uncomfortable
activities and the prevention of peak pain periods

Patient Responses to interventions

135

Pain level 6-8 on scale of 1-10. Pt. has chronic and acute sharp gastrointestinal
pain. POD 9, Ongoing x 2 years, increased pain with movement, and ingestion
of fluids and food.
Pt. verbalizes pain, along with facial expressions (grimacing) Pt. is afebrile,
elevated
blood pressure and HR during transfer to chair or bed repositioning.
3.3 L
Provided periods of rest, comfort and relaxation breathing with providing care.
Pt. currently on PCA dilaudid, 0.2mg Q8minute interval. Pt. used PCA 13/17.
Morphine 15mg PO q 12hrs. Pain level range 7-8 on a scale of 1-10. Pt.
referred
to pain nurse specialist. Pain level decreased to 6 after morphine
100
increased to 30 mg Q 12hrs as recommended by the Pain nurse specialist. Plan
to d/c PCA and restart pt. on oxycodone PO, amount and frequency yet to be
determined by MD and pain nurse specialist.
Patient attempted to use PCA 17 times per night shift with 13 successful doses.
Pt. is knowledgeable about medications and usage. Encouraged pt. to utilize
PCA prior to increased activity and repositioning.

Evaluation of whether outcome(s) are met:

Pain level 6-8 on scale of 1-10. Pt. has chronic and acute sharp gastrointestinal pain. POD 9, Ongoing x 2 years, increased pain with movement, and
ingestion of fluids and food. Pt. verbalizes pain, along with facial expressions (grimacing) Pt. is afebrile, elevated blood pressure and HR during transfer to
chair or bed repositioning. Provided periods of rest, comfort and relaxation breathing with providing care. Pt. currently on PCA dilaudid, 0.2mg Q8minute
interval. Pt. used PCA 13/17. Morphine 15mg PO q 12hrs. Pain level range 7-8 on a scale of 1-10. Pt. referred to pain nurse specialist. Pain level
decreased to 6 after morphine increased to 30 mg Q 12hrs as recommended by the Pain nurse specialist. Plan to d/c PCA and restart pt. on oxycodone
PO, amount and frequency yet to be determined by MD and pain nurse specialist.Pain must be managed PO prior to discharge home per MD.

POD #9 and #10

Sigmoidectomy with end sigmoid

colostomy and transverse loop
colostomy takedown for rectosigmoid
stricture.
Fluid volume deficit and poor PO inta
ke. Possible enteral nutrition will be
considered if PO intake doesnt
improve with better pain control.
Soft diet, low fiber with Boost
protein supplements BID and magic
cup BID to encourage nutrition.
TCO2
23-27

BMI=20.1
Magnesium
1.8-3.0

Phosphorus
2.5-4.5

Calcium
8.5-10.2

29

1.9

4.0

8.1 L

CRP
<0.8
1.4 H
Pre-Albumin
18-38
9.7 L
Malnutrition, cancer

 After assessment, identify important

physical assessment findings in the
above diagram & below

Clinical Day #1 VS 140/73BP, 84 Apical HR, 14 R, 98% SpO2 RA, 98.6F oral ,7/10 pain_________________
Neurological/Mental Status
A&O x4: oriented to person, place, time and situation
Pupils: PERRLA
Speech: Responds to questions appropriately and articulates well.
Motor & strength: Generalized weakness
Psychosocial Assessment
Mental Status Exam
Respiratory System
Depth, rate, rhythm: 14 resp/min shallow
Uses of accessory muscles/cyanosis: n/a
Breath sounds: Anterior and posterior bilateral upper lobes are clear to auscultation with diminished lung
sounds bilateral lobes.
Pulse oximeter: Continuous monitoring, 98% SpO2 RA
Incentive spirometer 10x q1hr 500
Cardiovascular System
Pulses: radial, brachial, post tib, dorsal pedis RRR 1+
Edema: Bilateral ankle non-pitting edema
Heart sounds: S1 S2 audible
Capillary refill: <3seconds
Gastrointestinal System
Abdomen: Abdominal incision clean dry and intact. Non distended, soft with tender and pain.
Last BM: Colostomy, stoma pink/red, surrounding skin intact and free from redness. Stoma draining watery
brown colored stool.
Bowel sounds: Hypoactive x 4quadrants

Genitourinary System
Pain or burning sensation with urination: n/a
Urine: Clear yellow
Occasional incontinence with urine and occasional continence with bed pan
Skin & Wounds
Color, turgor: Dry, pink, with poor skin turgor. Scar tissue to bilateral LE pt states hx of accidental burn
Bruises/rash: Multiple bruises to bilateral arms.
Describe wounds (size, location): Abdominal incision clean dry and intact.
Dressing: covered with gauze dressing
IV site (peripheral, PICC, TLC): Double lumen PICC to right arm, patent, non-tender, no s&s of infiltration

Clinical Day #2 VS_120/67BP, 80 Apical HR, 16 R, 94%SpO2 RA, 98.5 F_______

Neurological/Mental Status
A&O x4: oriented to person, place, time and situation
Pupils: PERRLA
Speech: Responds to questions appropriately and articulates well.
Motor & strength:
Respiratory System
Depth, rate, rhythm: 16 resp./min shallow
Uses of accessory muscles/cyanosis:
Breath sounds: : Anterior and posterior bilateral upper lobes are clear to auscultation with diminished lung
sounds bilateral lobes
Pulse oximeter: Continuous monitoring, 98% SpO2 RA
Cardiovascular System
Pulses: radial, brachial, post tib, dorsal pedis palpable 1+
Edema: Bilateral ankle non-pitting edema
Heart sounds: S1 S2 audible
Capillary refill: <3 seconds
Gastrointestinal System
Abdomen: Abdominal incision clean dry and intact. Non distended, soft with tender and pain.
Last BM: Colostomy, stoma pink/red, surrounding skin intact and free from redness. Stoma draining watery
brown colored stool. Colostomy wafer and bag changed. Stoma diameter 32mm.
Bowel sounds: Hypoactive x 4quadrants

Genitourinary System
Pain or burning sensation with urination: n/a
Urine clear yellow
Occasional incontinence with urine and occasional continence with bed pan
Skin & Wounds
Color, turgor: Dry, pink, with poor skin turgor Scar tissue to bilateral LE pt states hx of accidental burn
Bruises/rash: Multiple bruises to bilateral arms. Multiple red, elevated, and itchy lesions to back. Pt stated that
she was scratching. Demontarted capability to reach affected area. MD notified and Benadryl order po with
relief.
Describe wounds: Abdominal incision clean dry and intact
Dressing: Covered with gauze dressing
IV site (peripheral, PICC, TLC): Double lumen PICC to right arm, patent, non-tender, no s&s of infiltration

Pathophysiology

Small bowel obstruction

Mechanical obstruction may be caused

by:
Adhesions (scar tissue from
Intestinal contents accumulate at or above area
surgeries or pathology)
of obstruction
Benign or malignant
tumor and distention occurs along with
bowel
edematous. Increasing capillary
Complications of
appendicitis
permeability,
plasma leaking into peritoneal
Hernias
cavity(especially
and fluids trapped
Fecal impactions
in in intestinal lumen
decrease
absorption
of fluid and electrolytes
older adults)
causing reduced circulatory blood volume and
Strictures from radiation
electrolyte imbalance.

Clinical Manifestations:
Abdominal cramping
Abdominal pain
Lower abdominal distention
Obstipation
Ribbon like stool

Medical Treatment:
- NPO
- Nasogastric suctioning
- Abdominal x-ray and CT scan
- Sigmoidoscopy or colonoscopy
- Disimpaction
- Enema
- IV fluid and electrolyte replacement
Surgical Treatment:
Exploratory Laporotomy

Nursing Interventions (should be cited from the textbook):

Interventions are aimed at finding the cause of the obstruction and eliminating it.
Lifestyle changes: -Instruct patient to eat a high fiber diet with raw vegetables, fruit, and whole grain products.
Encourage increased fluid intake, especially water.
Inform MD if abdominal pain, distention
Exercise daily
Do not use routine laxatives
References:

Gulanick, M., Myers, J. (2014) Nursing Care Plans: Diagnoses, Interventions, and Outcomes,
(8) Mosby, Vital Book file
Ignatavicius, D. D., & Workman, M. L. (2013). Medical-surgical nursing: Patient-centered collaborative care (7th
ed.). St. Louis, MI: Elsevier.

Student Name _Christine Rombawa_________________________________

Date___04/17/15_______________
NURS 220 Weekly Self-Evaluation.

Complete each item (1 8) with three to four complete sentences.

1. Describe your ability to develop a professional relationship with your client, their family and the hospital
staff. Provide an example of how you used therapeutic communication this week.
I was able to develop a professional relationship with my client by introducing myself and informing her of
what I will be doing throughout my shift and making myself available to her. I was able to develop a
professional relationship with the hospital staff by communicating effectively with the primary nurse and
nurse assistant. I used therapeutic communication with my patient when I commiserated with her regarding
her home situation. I was able to also communicate her needs with the primary nurse.
2. Describe one assessment skill you performed well and another you need to improve. Include your plan for
improvement.
An assessment skill that I performed well was assessing my patients colostomy. A skill that I need to
improve on is administering subcutaneous heparin injections. I was not comfortable holding the insulin
syringe because the plunger was pulled out so far. I will continue to practice in-order to get more
comfortable.

3. Describe a new skill you implemented this week and evaluate your performance in completing it.
A new skill that I implemented this week was administering a normal saline and heparin flush to a PICC
line. I feel that I did well. I learned how to use positional flushing to assist with patency under the direction
of my CI.
4. Identify time management strategies that were and were not effective.
Time management strategies that were effective was communicating early with the primary nurse and nurse
assistant I informed the primary nurse first thing in the morning what I would be doing and asked for her
input regarding what she wanted to get accomplished for my patient. I also informed the Nurse assistant
about what I will be doing and that I needed her assistance transferring the patient to the chair for breakfast
after I complete VS, head to toe assessment and bed bath.
5. Were you involved in using interdisciplinary resources for your client? What resources could your client
have benefitted from?
My patient had a referral to a pain nurse specialist. She informed me of the plan to increase the patients
morphine and restarting her oxycodone, along with weaning her off the dilaudid PCA.
6. Describe an actual or potential legal or ethical issue related to the care of the client. What is your response to
the issue you identified?
An ethical issue related to the care of my patient is discharging a patient back to home when they are unable
to care for themselves thoroughly. I know that the world that we live in today is mandated my companies,
the government and their policies, yet I feel that it is so unfortunate that the elderly especially are put in a
desperate position. After working hard all their lives and then when they are at their most vulnerable time in
their life, not having enough support to ensure their safety, health, and overall wellbeing is sad. My patient
is currently receiving home health services twice a week and I hope that they will approve the increase to at
least five times a week or I a rehabilitation hospital.

7. Identify a safety risk for your client (using the safety rubric) and describe how you reduced the clients risk
for injury.

A safety risk for my patient occurred when PT was working with her. After transferring the patient to the chair,
the PT forgot to reconnect and turn on her continuous pulse oximeter. As I did my hourly rounding I was double
checking my patient and her surroundings, and I noticed that it was not connected. I reconnected it and turned it
on, fortunately my patient was not in distress. I informed the physical therapist and she thanked me for catching
it and apologized. Hourly rounding is a nursing actions that promotes the prevention of negative conditions
8. Reflect on your professional growth (using the professionalism rubric). What can you do continue your
professional growth outside of the clinical setting? What professional or unprofessional behaviors did you
see in the clinical setting, and how did you feel about it
As this semester progresses, I feel more competent. When I reflect back on last semester and compare what
I knew, and what I have learned, I know that I am making a lot of progress. I am so very grateful of the
teaching, guidance and knowledge that I have gained from my professors, CI, and clinical staff at Kaiser. I
can see myself in the role as a registered nurse and I am excited to continue to learn and apply what I have
learned by providing excellent, quality, thorough patient care. I will continue to study, research, and learn
more throughout school and throughout my career as an RN. Professional behaviors that I have seen in the
clinical setting is team work. Assisting each other and communicating effectively to obtain a mutual goal of
proving safe quality care to patients at Kaiser Moanalua Hospital is vital.
1

Competence

Consistently competent
in performing nursing
care

Inconsistently competent
in performing nursing
care

Uncertain about nursing

skills and nursing process