A CLIENT WITH A DIGESTIVE ALTERATION: ACUTE CHOLECYSTITIS

INTRODUCTION

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. The most common cause of cholecystitis is gallstones (90% of the cases). The bile becomes concentrated in the gallbladder. This later causes irritation and is probably the leading cause of inflammation. People who have a history of gallstones are at increased risk for cholecystitis.

In the international level, cholecystitis has an increased prevalence among people of Scandinavian descent, Pima Indians, and Hispanic populations, whereas cholelithiasis is less common among individuals from sub-Saharan Africa and Asia. It affected 20.5 million people (1988-1994) with a mortality record of 1,077 deaths in 2002.

Hospitalizations total up to 636,000 in the same year and over 500,000 have undergone cholecystectomies. In the Philippines alone, an extrapolated prevalence of 5,073,040 people are affected by the disease last 2007. (http://digestive.niddk.nih.gov/statistics)

Gallstones are crystalline structures formed by concretion (hardening) or accretion (adherence of particles, accumulation) of normal or abnormal bile constituents. According to various theories, there are four possible explanations for stone formation.

First, bile may undergo a change in composition. Second, gallbladder stasis may lead to bile stasis. Third, infection may predispose a person to stone formation. Fourth, genetics and demography can affect stone formation.

RISK FACTORS

Risk factors associated with development of gallstones include: heredity obesity rapid weight loss, through diet or surgery age over 40 Native American or Mexican American racial makeup female gender (where gallbladder disease is more common in women than in men)

SIGNS AND SYMPTOMS

Sometimes, persons with gallbladder disease have few or no symptoms. Others, however, will eventually develop one or more of the following symptoms; (1) Frequent bouts of indigestion, especially after eating fatty or greasy foods, or certain vegetables such as cabbage, radishes, or pickles (2) Nausea and bloating

(3) Attacks of sharp pains in the upper right part of the abdomen. This pain occurs when a gallstone causes a blockage that prevents the gallbladder from emptying (usually by obstructing the cystic duct). (4) Jaundice (yellowing of the skin) may occur if a gallstone becomes stuck in the common bile duct, which leads into the intestine blocking the flow of bile from both the gallbladder and the liver. This is a serious complication and usually requires immediate treatment.

TREATMENT
The only treatment that cures gallbladder disease is surgical removal of the gallbladder, called cholecystectomy. Generally, when stones are present and causing symptoms, or when the gallbladder is infected and inflamed, removal of the organ is usually necessary. When the gallbladder is removed, the surgeon may examine the bile ducts, sometimes with X-rays, and remove any stones that may be lodged there.

The ducts are not removed so that the liver can continue to secrete bile into the intestine. Most patients experience no further symptoms after cholecystectomy. However, mild residual symptoms can occur, which can usually be controlled with a special diet and medication.

ETIOLOGY
When the outflow of bile from the gallbladder is obstructed, it becomes distended. This distension causes a compromise of blood flow and lymphatic drainage. This eventually leads to mucosal ischemia and finally necrosis. In 2000, the ability of endotoxin to cause necrosis, hemorrhage, areas of fibrin deposition, and extensive mucosal loss was demonstrated.

Later, endotoxin was shown to have the capacity to abolish the gallbladders ability to contract in response to cholecystokinin (CCK), worsening gallbladder stasis and accelerating the process of infection. (Bile cultures are often positive for bacteria, but bacterial proliferation may be a more appropriate description of the overall process.)

II. SUMMARY OF THE CASE

Ms. Gina Hasa, 52, female, is admitted to the hospital with acute abdominal pain. She complains of RUQ pain radiating to the back. She has had prior episodes, usually occurring about two hours after eating. This episode, however, is not resolving. Ms. Hasa also complains of nausea. Her vital signs are as follows: BP, 152/88; pulse, 92; and respirations, 24 and shallow.

Ms. Hasa is a slightly obese female who states that she has recently been dieting to lose weight. Laboratory analysis includes a CBC with slightly elevated WBCs; elevated bilirubin; and elevated alkaline phosphatase. An IV is started and Ms. Hasa is given IV morphine for pain. She has also been placed on NPO status. An ultrasound of the gall bladder is ordered.

III. DEFINITION OF TERMS

DEFINITION OF TERMS

INTERPRETATION

INFERENCE

CONCLUSION

1.

Nausea

1. Feeling of wanting to vomit.

1.Is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit (http://en.wikipedia.org/wiki/Naus ea)

The interpretation made was related to the inference.

Obese

2.Weight above the normal range2. Above ones normal weight. A or beyond overweight person has traditionally been considered to be obese if they are more than 20 percent over their ideal weight. (http://en.wikipedia.org/wiki/obes e)

1.

The interpretation made has the same idea with the inference.

3.CBC

3. Complete Blood Count, done3. Is the calculation of the cellular1. to assess blood components. (formed elements) of blood. These calculations are generally determined by special machines that analyze the different components of blood (http://www.medicinenet.com/co mplete_blood_count/article.htm)

The interpretation was the same as the inference, however, it lacks details.

DEFINITION OF TERMS

INTERPRETATION

INFERENCE

CONCLUSION

4.WBC

4. White blood cells, involved in protecting the body against microorganisms. Elevated levels indicate infection.

4. White blood cells are the1. infection-fighting cells in the blood and are distinct from the red (oxygen-carrying) blood cells known as erythrocytes. (http://www.medterms.com/script/ main/art.asp?articlekey=9983) 5.A yellow-orange compound1. produced by the breakdown of hemoglobin from red blood cells (http://search.medicinenet.com/s earch/search_results/default.asp x? Searchwhat=1&query=bilirubin&I 1=Search)

The interpretation made has the same idea with the inference.

5. Bilirubin

5.A by product of

hemoglobin

The interpretation made has the same idea with the inference.

6. Alkaline Phosphatase

6. An enzyme

6. An enzyme made in the liver, 6. bone, and the placenta and normally present in high concentrations in growing bone and in bile. (http://search.medicinenet.com/s earch/search_results/default.asp x? Searchwhat=1&query=alkaline+p hosphatase&I1=Search)

The interpretation was related to with inference. However in lacks in details.

DEFINITION OF TERMS

INTERPRETATION

INFERENCE

CONCLUSION

7.NPO

7. Nothing per , a diet7. A patient care7. The interpretation made restricting food and fluidinstruction advising thathas the same idea with intake. the patient is prohibitedthe inference. from ingesting food, beverage, or medicine. (http://medicaldictionary.thefreedictionar y.com/nothing+by+mouth)

IV. LEARNING ISSUES

LEARNING ISSUE

HYPOTHESES

INFERENCE

CONCLUSION

1. What is the possible 1. The possible diagnosis of diagnosis of Ms. Hasa given Ms. Hasa given the stated the stated signs and signs and symptoms she symptoms she experienced? experienced is Acute Cholecystitis.

1. Cholecystitis is an 1. ACCEPT. The signs and inflammation of thesymptoms manifested by the gallbladder wall and nearbyclient are congruent with abdominal lining. Riskthat of the researched factors associated with thisinference. disease include heredity, obesity, rapid weight loss through diet or surgery, age over 40, Native American or Mexican American racial makeup, female gender where gallbladder disease is more common in women than in men. (http://emedicine.medscape. com/article/171886overview)

LEARNING ISSUE

HYPOTHESES

INFERENCE

CONCLUSION

2. What are the risk factors that may have contributed to the development of Acute Cholecystitis by Ms. Hasa?

2. The risk factors that2. Risk factors for2. ACCEPT. The may have contributedcholecystitis mirrorhypothesis made was to the development ofthose for cholelithiasiscongruent with the Acute Cholecystitis byand include increasinginference. Ms. Hasa areage, female sex, gender(female), age (ofcertain ethnic groups, over 40 years old),obesity or rapid weight obesity. loss, drugs, and pregnancy. (http://emedicine.meds cape.com/article/17188 6-overview)

LEARNING ISSUE

HYPOTHESES

INFERENCE

CONCLUSION

3. What is the 3. Cholecystitis is the3. The most common3. ACCEPT. The connection between inflammation of thepresenting symptom ofhypothesis made was cholecystitis and the gall bladder andacute cholecystitis isrelated to the RUQ pain radiating to anatomically, it isupper abdominal pain.inference. the back experienced located on the RUQ ofThe physical by the client? the abdomen whereexamination may pain is experienced. reveal fever, tachycardia, and tenderness in the RUQ or epigastric region, often with guarding or rebound. However, the absence of physical findings does not rule out the diagnosis of cholecystitis. (http://emedicine.meds cape.com/article/17188 6-overview)

LEARNING ISSUE

HYPOTHESES

INFERENCE

CONCLUSION

4. What indicates a lab result of elevated bilirubin and alkaline phosphatase?

4. Elevated bilirubin and alkaline phosphatase in the labs results indicates increase hepatocellular damage.

4. An examination of the level of4. ACCEPT. The hypothesis this enzyme is a part of liver testsmade was related to the or liver function tests, as elevatedinference. However, it lacks alkaline phosphatase levels candetails. indicate liver dysfunction. It can also indicate biliary obstruction or obstruction of the bile duct, which can be caused by stones or sludge. (http://www.buzzle.com/articles/el evated-alkaline-phosphataselevels.html) Bilirubin is the breakdown product of heme, with the majority coming from senescent RBC's and (to a lesser extent) from cytochromes and myoglobin. Unconjugated bilirubin is hydrophobic and transported in the blood (reversibly) bound to albumen. It is taken up by liver cells, converted to conjugated bilirubin, and actively secreted into the biliary canaliculi.

LEARNING ISSUE

HYPOTHESES

INFERENCE

CONCLUSION

5. What is the importance 5. The importance of of administering morphine administering morphine intravenously? intravenously is to relieve the pain experienced by the client quickly.

5. Morphine is used to5. ACCEPT. The treat moderate to severehypothesis made was pain. It works by dullingrelated to the inference. the pain perception center in the brain. Short-acting formulations are taken as needed for pain. Extended-release formulations are used when around-the-clock pain relief is needed. (http://www.drugs.com/mor phine.html)

LEARNING ISSUE

HYPOTHESES

INFERENCE

CONCLUSION

6. Why is the client placed 6. The client is placed on 6. The patient should fast 6. ACCEPT. on NPO status? NPO status because she and restrict fluids for 8 hr hypothesis made is to undergo ultrasound of prior to the procedure. congruent with the gall bladder. (http://www.unboundmedic inference. ine.com/nursingcentral/ub/ view/Davis-Lab-andDiagnosticTests/425315/all/Ultrasoun d__Liver_and_Biliary_Syst em_)

The was the

V. ANATOMY AND PHYSIOLOGY

HEPATOBILLARY

Click to edit Master text styles Second level Third level Fourth level Fifth level

LIVER :
A.

Location and size of the liver- largest gland in the body, weighs approximately 1.5 kg; lies under the diaphragm; occupies most of the right hypochondrium and part of the epigastrium.

B. Liver lobes and lobules- two lobes separated by the falciform ligament 1.Left lobe- forms about one sixth of the liver 2.Right lobe- forms about five sixths of the liver; divides into right lobe proper, caudate lobe, and quadrate lobe 3. Hepatic lobules- anatomical units of the liver; small branch of hepatic vein extends through the center of each lobule

C. Bile ducts 1. Small bile ducts form right and left hepatic ducts 2. Right and left hepatic ducts immediately join to form one hepatic duct 3. Hepatic duct merges with cystic duct to form the common bile duct, which opens into the duodenum

D. Functions of the liver 1. Glucose Metabolism -after a meal, glucose is taken up from the portal venous blood by the liver and converted into glycogen (glycogenesis), which is stored in the hepatocytes. Glycogen is converted back to glucose (glycogenolysis) and release as needed into the blood stream to maintain normal level of the blood glucose. -glucose can be synthesized by the liver through the process gluconeogenesis

2.Ammonia Conversion use of amino acids from protein for gluconeogenesis result in the formation of ammonia as a by product. Liver converts ammonia to urea 3.Protein Metabolism Liver synthesizes almost all of the plasma protein including albumin, alpha and beta globulins, blood clotting factors plasma lipoproteins 4.Fat Metabolism Fatty acid can be broken down for the production of energy and production of ketone bodies

5.Vitamin and Iron Storage stores vitamin A, D, E, K 6.Drug Metabolism 7.Bile Formation -bile is formed by the hepatocytes -composed of water, electrolytes such as sodium, potassium, calcium, chloride, bicarbonate, lecithin, fatty acids, cholesterol, bile salts -collected and stored in the gallbladder and emptied in the intestine when needed for digestion

a. Lecithin and bile salts emulsify fats by encasing them in shells to form tiny spheres called micelles b. Sodium bicarbonate increases pH for optimum enzyme function c. Cholesterol, products of detoxification, and bile pigments (e.g. bilirubin) are wastes products excreted by the liver and eventually eliminated in the feces

GALLBLADDER The gallbladder (or cholecyst, sometimes gall bladder) is a small organ whose function in the body is to harbor bile and aid in the digestive process. Anatomy The cystic duct connects the gall bladder to the common hepatic duct to form the common bile duct. The common bile romero duct then joins the pancreatic duct, and enters through the hepatopancreatic ampulla at the major duodenal papilla.

The fundus of the gallbladder is the part farthest from the duct, located by the lower border of the liver. It is at the same level as the transpyloric plane. Microscopic anatomy The different layers of the gallbladder are as follows: The gallbladder has a simple columnar epithelial lining characterized by recesses called Aschoff's recesses, which are pouches inside the lining.

Under the epithelium there is a layer of connective tissue (lamina propria). Beneath the connective tissue is a wall of smooth muscle (muscularis externa) that contracts in response to cholecystokinin, a peptide hormone secreted by the duodenum. There is essentially no submucosa separating the connective tissue from serosa and adventitia.

Size and Location of the Gallbladder The gallbladder is a hollow, pear-shaped sac from 7 to 10 cm (3-4 inches) long and 3 cm broad at its widest point. It consists of a fundus, body and neck. It can hold 30 to 50 ml of bile. It lies on the undersurface of the livers right lobe and is attached there by areolar connective tissue.

Structure of the Gallbladder Serous, muscular, and mucous layers compose the wall of the gallbladder. The mucosal lining is arranged in folds called rugae, similar in structure to those of the stomach.

Function of the Gallbladder

The gallbladder stores bile that enters it by way of the hepatic and cystic ducts. During this time the gallbladder concentrates bile fivefold to tenfold. Then later, when digestion occurs in the stomach and intestines, the gallbladder contracts, ejecting the concentrated bile into the duodenum. Jaundice a yellow discoloration of the skin and mucosa, results when obstruction of bile flow into the duodenum occurs.

Bile is thereby denied its normal exit from the body in the feces. Instead, it is absorbed into the blood, and an excess of bile pigments with a yellow hue enters the blood and is deposited in the tissues. The gallbladder stores about 50 mL (1.7 US fluid ounces / 1.8 Imperial fluid ounces) of bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin (CCK).

The bile, produced in the liver, emulsifies fats and neutralizes acids in partly digested food. After being stored in the gallbladder the bile becomes more concentrated than when it left the liver, increasing its potency and intensifying its effect on fats. Most digestion occurs in the duodenum.

BILIRUBIN PRODUCTION AND Click to edit Master text styles ELIMINATION Second level

Third level Fourth level Fifth level

Bilirubin is the substance that gives bile its color. It is formed from senescent red blood cells. In the process of degradation, the hemoglobin from the red blood cell is broken down from biliverdin, which is rapidly converted to free bilirubin thru biliverdin reductase. Free bilirubin, which is not soluble in plasma, is transported in the blood attached to plasma albumin. Even when it is bound to albumin, this bilirubin is still called free bilirubin.

As it passes through the liver, free bilirubin is released from its albumin carrier molecule and moved into the hepatocytes. Inside the hepatocytes, free bilirubin is converted to conjugated bilrubin thru glucoronyl transferase, making it soluble to bile. Conjugated bilirubin is secreted as a constituents of bile, and in this form, it passes through the bile ducts into the small intestine.

In the intestine, approximately one half of the bilirubin is converted into a higly soluble substance called urobilinogen by the intestinal flora. Urobilinogen is either absorbed into the portal circulation or excreted in the feces. Most of the urobilinogen that is absorbed is returned to the liver to be re-excreted into the bile. A small amount of urobilinogen, approximately 5% is absorbed into the general circulation and then excreted by the kidney.

VI PATHOPHYSIOLOGY

MODIFIAB LE RISK FACTOR Slightly obese

NON-MODIFIABLE RISK FACTOR AGE: 52 FEMALE

Bile must become supersaturated with cholesterol and calcium

The solute precipitate from solution as solid crystals

Crystals must come together and fuse to form stones

Gallstone s
Sharp pain in the right part of abdomen
Acute pain related to inflammatory process as evidenced by reports of pain

Jaundice

Ineffectivve breathing pattern related to pain as manifested by objectives.

Obstruction of the cystic duct and common bile duct Distention of the gall bladder

Venous and lymphatic drainage is impaired

Proliferation of bacteria

Localized cellular irritation or infilration or both take place

Areas of ischemia may occur

Inflammation of gall bladder

Ineffective tissue perfusion related to interruption of blood flow as manifested by nausea.

CHOLECYSTITIS Knowledge deficit related to lack of knowledge

LEGEND:

PATHOLOGY NCP RISK FACTOR SIGN AND SYMPTOMS

VII. NURSING PRIORITIZATION

NURSING PROBLEM IDENTIFIED

CUES

JUSTIFICATION

1.

Acute pain related inflammatory process evidenced by reports of pain

toSUBJECTIVE: as Verbal reports of pain OBJECTIVE: Facial mask of pain Guarding behavior VITAL SIGNS: BP:158/88 mmHg T:38.7 o C PR:92 bpm RR:24 cpm

According to Maslows Hierarchy of Needs, physiological needs such as being in a state of homeostasis should be a priority because if a person is deprived of all needs, the physiological ones would come first in the persons search for satisfaction. Acute pain is defined as pain that comes on quickly and usually lasts a short time. It serves as a warning of injury or illness. Acute pain can range from mild to severe and is often caused by an injury or sudden illness. Since the client is suffering from RUQ pain brought about by cholecystitis, it would be necessary for the pain to be relieved in order for the client to be comfortable. (http://dying.about.com/od/glossary/g/ acute_pain.htm)

NURSING PROBLEM IDENTIFIED

CUES

JUSTIFICATION

2.

Ineffective breathing pattern SUBJECTIVE: related to pain as manifested Shallow breathing by verbal reports of the client. OBJECTIVE: VITAL SIGNS: BP:158/88 mmHg T:38.7 o C PR:92 bpm RR:24 cpm

According to the ABCs of life, Breathing is the second priority next to Airway. Ineffective breathing pattern is defined as inspiration and/or expiration that does not provide adequate ventilation. It plays a major role in surviving life, thus, being a high nursing priority problem. (http://www1.us.elsevierhealth.com/ MERLIN/Gulanick/Constructor/inde x.cfm?plan=08)

NURSING PROBLEM IDENTIFIED

CUES

JUSTIFICATION

3.

Ineffective tissue perfusionSUBJECTIVE: related to interruption of blood Verbal reports flow as manifested by nausea. nauseated OBJECTIVE: VITAL SIGNS: BP:158/88 mmHg T:38.7 o C PR:92 bpm RR:24 cpm

of

According to Maslows Hierarchy of Needs, another priority which falls being under the physiologic need is wellbeing of the body including its internal organs, which the problem ineffective tissue perfusion falls. Ineffective Tissue Perfusion is defined as decrease in blood supply resulting in the failure to nourish the tissues at the capillary level. It may lead to further complications if not properly managed, so this problem needs to be attended and hence, a high priority nursing problem. (http://www1.us.elsevierhealth.com/ MERLIN/Gulanick/Constructor/inde x.cfm?plan=55)

NURSING PROBLEM IDENTIFIED

CUES

JUSTIFICATION

4. Hyperthermia related to infectionSUBJECTIVE: as manifested by the objectives Verbal reports of feeling hot OBJECTIVE: Flushed skin, warm to touch. VITAL SIGNS: BP:158/88 mmHg T:38.7 o C PR:92 bpm RR:24 cpm

According to Maslows Hierarchy of Needs, this problem falls under the physiological needs. Hyperthermia is defined as unusually high body temperature. This problem should also be addressed to enhance the clients well-being. (http://www.yourdictionary.com/hyp erthermia)

NURSING PROBLEM IDENTIFIED

CUES

JUSTIFICATION

5. Knowledge deficit related toSubjective: Deficient knowledge is defined as difficulty understanding disease verbalization of difficulty absence or deficiency of cognitive process and its effect on selfunderstanding disease process information related to specific topic. care as evidenced by and its effect on self-care This is a state where an individual verbalization of the client. lacks specific information necessary to make choices regarding condition/therapies/treatment. (http://www1.us.elsevierhealth.com/ MERLIN/Gulanick/Constructor/inde x.cfm?plan=34)

VIII. NURSING CARE PLANS

ASSESSMENT`

NURSING DIAGNOSIS Acute pain related to inflammatory process as evidenced by reports of pain

PLANNING

NURSING INTERVENTION Independent: 1. Observe and document location of pain, severity (010scale), and character of pain.

RATIONALE

EXPECTED OUTCOMES After 8 hours of nursing interventions, the patient will report that the pain is relieved or controlled.

SUBJECTIVE: Verbal reports of pain OBJECTIVE: Facial mask of pain Guarding behavior VITAL SIGNS: BP:158/88 mmHg T:38.7 o C PR:92 bpm RR:24 cpm

After 8 hours of nursing interventions, the patient will report that the pain is relieved or controlled.

1.

2. Promote bed rest, allowing patient to assume position of comfort.

2.

Assist in differentiating cause of pain and provides information about disease progression, development of complications and effectiveness of intervention. Bed rest in low fowlers position reduces intra abdominal pressure; however, patient will naturally assume least painful position.

ASSESSMENT`

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTION

RATIONALE

EXPECTED OUTCOMES

ASSESSMENT`

Independent: 3. Encourage use of relaxation techniques, 3. Promotes rest, redirects e.g., guided imagery, attention, may visualization, deepenhance coping. breathing exercises. Provide diversional activities. Collaborative: 4.Administer medications as 4. Given to reduce severe pain. indicated: Morphine is used Narcotics,e.g. with caution meperidine because it may hydrochloride increase spasms (Demerol), of the sphincter morphine sulfate of Oddi, although nitriglycerin may be given to reduce morphineinduced spasms if they occur.

ASSESSMENT`

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTION

RATIONALE

EXPECTED OUTCOMES

SUBJECTIVE: Shallow breathing OBJECTIVE: VITAL SIGNS: BP:158/88 mmHg T:38.7 o C PR:92 bpm RR:24 cpm

Ineffective breathing After 2 hours ofIndependent: pattern related to pain nursing interventions1. Assess for pain as manifested by the patient will be able every 3 hours. verbal reports of the to achieve comfort client. without depressing respirations. 1. Provide rest periods between breathing enhancement measures. 2. Teach relaxation techniques to help reduce anxiety. 3. Change patients position frequently.. Collaborative: 5. Give pain medication as ordered..

1.

2.

After 2 hours of nursing interventions Pain reduces the patient will be able respiratory effort to achieve comfort and ventilation. without depressing To avoid fatigue. respirations.

1.

2.

Reduce pain and anxiety and enhance patients sense of selfcontrol. To maximize comport.

1.

To allow maximal chest expansion.

ASSESSMENT`

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTION

RATIONALE

EXPECTED OUTCOMES

SUBJECTIVE:

Ineffective tissue After 3 hours ofIndependent: perfusion related tonursing interventions, Verbal reports ofinterruption of bloodthe patient will have1. Monitor patients being nauseated flow as manifested by no more nausea and vital sign1. including verbal reports ofvomiting . OBJECTIVE: temperature feeling nauseated. every 4 hours. VITAL SIGNS: BP:158/88 mmHg 2. Monitor complete T:38.7 o C blood count,2. PR:92 bpm serum electrolyte RR:24 cpm level and liver function daily as ordered.

After 3 hours of nursing interventions, the patient will have To detect no more nausea and possible vomiting . hypovolemia and screen for infection. To detect ischemia cause by low hematocrit and hemoglobin level, monitor for improvement in organ function and screen for infection.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTION Independent:

RATIONALE

EXPECTED OUTCOMES

3.Encourage rest 3.To after meals.

maximize blood flow to stomach. Enhancing digestion. To decrease tention level.

4.Demonstrate 4. encourage use of relaxation activity.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTION

RATIONALE

EXPECTED OUTCOMES

SUBJECTIVE: Verbal reports of feeling hot OBJECTIVE: Flushed skin, warm to touch. VITAL SIGNS: BP:158/88 mmHg T:38.7 o C PR:92 bpm RR:24 cpm

Independent: 1. Take temperature every 1 to 4 hours. 1. Hyperthermia related to After 8 hours of nursing 2. Use noninfection as manifested by interventions, the patient pharmacologic the objectives will demonstrate measures to reduce 2. temperature within normal fever, such as range. removing sheets, blankets ad most clothing; placing ice bags on axillae and groin; and sponging with tepid water. Explain these measures to patient.

To obtain an After 8 hours of nursing accurate core interventions, the patient temperature. will demonstrate Non-pharmacologic temperature within normal measures lower range. body temperature and promote comfort. Sponging reduces body temperature by increasing evaporation from skin, tepid water is used because cold water increases shivering, thereby increasing metabolic rate and causing temperature to rise.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTION

RATIONALE

EXPECTED OUTCOMES

Independent: 3. Have the patient lightly 3. Facilitate heat . loss by dressed. radiation and conduction. 4. Maintain bed 4. To reduce rest metabolic demands. Collaborative: 5. Antipyretics act 5.Administer on antipyretic hypothalamus medications to regulate as prescribed, temperature. and record effectiveness.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTION

RATIONALE

EXPECTED OUTCOMES

Independent: Subjective: 1. Select a Knowledge deficit After 8 hours of 1.Use of different After 8 hours of verbalization of variety of related to difficulty nursing means of nursing difficulty teaching understanding interventions, the accessing interventions, the understanding strategies, e.g. disease process client will express information client will express disease demonstrate and its effect on understanding of promotes learner understanding of process and its needed skills self-care as disease process, retention. disease process, effect on selfand have evidenced by medication 2.To enable the pt. medication care patient do verbalization of the regimen and to process regimen and return client. treatment plan. information without treatment plan. demonstration distraction from . background noise 2. Provide a or stress. quiet, calm 3.To avoid environment information for learning. overload. 3. Limit the length of each teaching session.

ASSESSMENT

NURSING DIAGNOSIS

PLANNING

NURSING INTERVENTION Independent: 4.When teaching, build on the clients literacy skills.

RATIONALE

EXPECTED OUTCOMES

. 4.In clients with low literacy skills, materials should be short and have culturally sensitive illustrations.

5.Create an environment of trust by listening 5.Rapport and respect need to be to concerns being available. established before pt. will be willing to take 6. Work with patient in part in the learning setting mutual process. goals for learning. 6.Participation in the planning promotes enthusiasm and cooperation with the principles learned.

IX. LABORATORY RESULTS

Diagnostic/ Laboratory Procedures Complete Blood Count (CBC)

Indication or Purpose

Results

Normal Values

Analysis and Interpretation of results The result is above the normal range, indicative of infection.

CBC consists of a >5.0 10.0 x series of tests that 103/mm3 determine the number, variety, percentage, concentration and quality of blood cells. It gives valuable diagnostic information about the hematologic and other body systems, prognosis, response to treatment, and recovery.

5.0 10.0 x 103/mm3