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Nursing Care Pl Nursing

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Nursing Care Plan

STUDENT-Cassandra Varnum____COURSE-NURS 101L DATE March 14, 2015 FACULTY Anna Tevosyan Patient Initial N.L Age -48 Ht/Wt-162.56cm/72.3kg Unit -Medical/Surgical Unit Room-# 234 Code Status-No Code Allergies- Penicillin

Temp (C/F Site) Pulse (Site) Respiration Pulse Ox (O2 Sat) Blood Pressure Pain Scale 1-10
98.3 F/Orally 92 Beats per Minute 26 Breaths per minute 94% 168/98 9/10

History of Present Illness Including Admission Diagnosis
Relevant Physical Assessment Findings (normal & abnormal) Relevant Diagnostic Procedures/Results & Surgeries
(include dates. If not found, state so.)
Admission Diagnosis- Patient…show more content…
Her mother had a history of diabetes and hypertension and died of Cerebrovascular accident (CVA) at age 63. Her younger brother currently has Diabetes Mellitus and hypertension.

Abnormal Physical Assessment Findings- Patient N.L had respiratory rate of 26 beats per minute (RR), Blood pressure of 168/98 (BPM), and Oxygen Saturation of 94%, complaining of moderate to severe distressed abdominal pain. Palpating abdomen shows distentions and bowel sounds are absent in the lower quadrants with tenderness in the peri-umbilical area.

Normal Physical Assessment Findings- Patient N.L was afebrile with temperature of 98.3 orally and 92 pulse beats per minute. General appearance reveals a pleasant AA female. She is awake and oriented. There was no trauma to the head and her skin was warm, dry and intact. Lung and heart sounds were normal. Chest X-Ray (CXR)
This is a non-invasive procedure that is performed in order to view the through the chest cavity including the heart, lungs, blood vessels, and chest bones. (National Heart, Lung, and Blood Institute, 2010)

Patient’s Chest x-ray came back normal two days ago.

Abdominal and Pelvic CT
This procedure is a diagnostic test that is used to view and diagnose abdominal and pelvic pain and diseases that are located in those internal organs. (Radiology Info, 2014)

Patient’s CT shows dilated small bowel with focalization identified in the distal small bowel with a
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