Critical Thinking Map

Name____________ _____________ Critical Thinking Map Medical Diagnosis: Pathophysiology (In your own words): Intestinal obstruction Significant mechanical impairment or complete arrest of the passage of contents through the intestine due to the pathology that causes blockage of the bowel Concept(s): The client seems to be experiencing pain in the umbilicus area of the abdomen, client is hunched over with arms around abdomen, Exemplar(s): Client is experiencing abdomen pain of 8/10, explains it as a cramping feeling. The client has been vomiting a lot and hasn’t been able to eat much Complications/Potential Complications (Physiologic Adaptation(s)/Reduction of Risk Potential): Intraluminal pressure increases. Bowels can become extremely extended, hypotension, hypovolemic shock, increase permeability of capillaries Date______________ Psychosocial Concerns (Psychosocial Integrity): Altered body images because of the distending of the stomach, some may become dependent on NG tubes and may need alternative solutions Name____________ _____________ Critical Thinking Map Date______________ Assessment (Physiological Adaptation) **performed by the student Upon assessment determine if abdomen seems to be extended, how patient is walking with pain, and how the patient looks; do they look malnourished? Etc. Take a careful history to obtain information about current symptoms and previous disease manifestations. Labs and Diagnostics (Reduction of Risk Potential) Abdominal X-rays or CT scans Complete blood count and serum electrolyte amylase and blood Urea, nitrogen Barium Enema Sigmoidoscopy/ Colonoscopy Planning and Goals (short term and long term goals) **Actual priority problems with prioritized goals 1. Acute pain related to abdominal distension and increased peristalsis GOAL - To relief pain 2. Deficient fluid volume related to decrease in intestinal fluid absorption and loss of fluids secondary to vomiting. GOAL: - To maintain the fluid volume. Nursing Interventions (Basic Care and Comfort, Safety and Infection Control) **What did the student/nurse perform throughout the day 1 PLAN OF INTERVENTION - Assess the level of pain, location, intensity, duration. Provide comfortable position and promote restful environment. Administer analgesics as advised by the physician 2 PLAN OF INTERVENTION - Monitor patient for signs of dehydration and electrolyte imbalance - A strict intake and output record should be maintain Fluids should be administered as ordered. Evaluation of Interventions 1. Pain is controled AEB client pain is 4/10 2. Fluid and electrolyte balance is maintained AEB lab results Name____________ _____________ Critical Thinking Map Date______________ Name____________ _____________ Medication Name (Generic) and Drug class Metronidazole Ciprofloxacin Critical Thinking Map Date______________ Nursing considerations (labs, assessment, etc.) Side effects and Patient Teaching Major adverse effects 1200 mg IV infused Antibiotics for over 1 hr for 1 dose intestinal obstruction and then 500 mg IV q 6 hr 400 mg IV q 12 hr After diagnosis of intestinal obstruction Dizziness, headache, stomach upset, nausea, vomiting, loss of appetite, diarrhea, constipation, or metallic taste in your mouth may occur 400 mg IV q 12 hr After lab work was completed and WBC numbers were still elevated Patient’s Dose, Route, and Frequency Why is patient receiving this medication? Needs another antibiotic to help infection         Morphine sulfate 2 mg IV q 2–4 hr prn pain pain Patients pain level was 8/10  nausea. vomiting. stomach pain. heartburn. diarrhea. vaginal itching and/or discharge. pale skin. unusual tiredness. Medication should be taken with food because it could cause nausea/vomiting Medication should be taken with food because it could cause nausea/vomiting drowsiness Patient should only , dizziness, take this with chronic Name____________ _____________ Critical Thinking Map Date______________    pain, can become tiredness; constipatio addictive n, stomach pain, nausea, vomiting; sweating; or. feelings of extreme happiness or sadness. Name____________ _____________ Critical Thinking Map Date______________ Patient Teaching (Health Promotion, Safety and Infection Control, and Management of Care):      how to change ostomy pouch explaining the full liquid diet how to get in and out bed after surgery low-fiber diet wet-to-dry dressing change Patient Summary (SBAR Format): S- client is a 52 year old male who came into the emergency room early this afternoon complaining of pain, nausea and vomiting over the past few days. In the emergency room the client was diagnosed with a possible preoperative intestinal obstruction B- client was admitted early this afternoon, client needs to be ruled out for a preoperative intestinal obstruction. Radiology results show finds to be consistent with a small intestinal obstruction. Client has standing order for saline fluid bolus 500 ml/30 min Name____________ _____________ Critical Thinking Map Date______________ A- when client was admitted early this afternoon their pain was 8/10, after administration of morphine patient says their pain is about a 4/10. Vitals signs: respiratory rate- 18, pulse ox-98% heart rate-112, blood pressure- 106/76 R- client should continue to have vitals monitored, abdominal pain reassess after surgery and follow up with a nutritionist and counseling if needed