Nursing Care Plan
Nursing care plan (Colonoscopy)
S.E is a 59 year old African-American male admitted to the critical care unit because of his left lower quadrant (LLQ) abdominal pain. S.E had a colonoscopy 2 days ago. He has a family history of hypertension (HTN) and a medical history of HTN and anemia. He is alert and oriented ×3 (time, place, and person). S.E has no known drug allergy and he is NPO except for medicine.
Problem: LLQ abdominal pain
Acute pain | Assessment | Planning/Nursing Goals | Intervention/Implementation | * Physiological variables, such as age and pain tolerance * Descriptive characteristics of pain, including location, quality, intensity on a scale of 1 to 10, temporal factors, and sources of relief. * Environmental variables, such as setting and time. | * Patient will rate pain on scale of 1-10 and Verbalizes reduced pain level * Patient will report more than 4 hours of sleep nightly. * Patient will express feeling of comfort and relief from pain | * Administer prescribed analgesic * Perform comfort measures to promote relaxation, such as massage, bathing, repositioning, and relaxation techniques. * Reassess pain frequently using pain scale. | Risk for bleeding related to colonoscopy | Assessment | Planning/Nursing Goals | Intervention/Implementation | * Cardiovascular status, including blood pressure, cardiac output, Vital signs, patient and family history of Cardiovascular disease, peripheral pulses and smoking history. * Presence of health condition that may interfere with bleeding, such as coagulopathies * History of GI problems,disease, or surgery; bowel sound | * Patient will receive adequate screening/monitoring to alert clinicians of existing risk factor for bleeding. * Patient vital signs and tissue perfusion will remain within expected ranges during episodes of risk. | * Screen each patient for risk factor for bleeding. * Obtain clinical laboratory test and point of care tests (urine
S.E is a 59 year old African-American male admitted to the critical care unit because of his left lower quadrant (LLQ) abdominal pain. S.E had a colonoscopy 2 days ago. He has a family history of hypertension (HTN) and a medical history of HTN and anemia. He is alert and oriented ×3 (time, place, and person). S.E has no known drug allergy and he is NPO except for medicine.
Problem: LLQ abdominal pain
Acute pain | Assessment | Planning/Nursing Goals | Intervention/Implementation | * Physiological variables, such as age and pain tolerance * Descriptive characteristics of pain, including location, quality, intensity on a scale of 1 to 10, temporal factors, and sources of relief. * Environmental variables, such as setting and time. | * Patient will rate pain on scale of 1-10 and Verbalizes reduced pain level * Patient will report more than 4 hours of sleep nightly. * Patient will express feeling of comfort and relief from pain | * Administer prescribed analgesic * Perform comfort measures to promote relaxation, such as massage, bathing, repositioning, and relaxation techniques. * Reassess pain frequently using pain scale. | Risk for bleeding related to colonoscopy | Assessment | Planning/Nursing Goals | Intervention/Implementation | * Cardiovascular status, including blood pressure, cardiac output, Vital signs, patient and family history of Cardiovascular disease, peripheral pulses and smoking history. * Presence of health condition that may interfere with bleeding, such as coagulopathies * History of GI problems,disease, or surgery; bowel sound | * Patient will receive adequate screening/monitoring to alert clinicians of existing risk factor for bleeding. * Patient vital signs and tissue perfusion will remain within expected ranges during episodes of risk. | * Screen each patient for risk factor for bleeding. * Obtain clinical laboratory test and point of care tests (urine
References: Carpenito-moyet, LJ. (2010). Nursing Diagnosis. Applications to clinical practice. (13th edition) Philadelphia: Wolters kluwer/Lippincott Williams and wilkins. Ignatavicius, D.D, and Workman, L.M. (2010) Medical-surgical nursing. Patient-centered collaborative care. (6th edition) St. Louis, Missouri: Saunders Elsevier. Sheila Sparks Ralph, Cynthia M. Taylor. (2011). Nursing Diagnosis reference manual. (8th edition) Philadelphia: Wolters kluwer/Lippincott Williams and wilkins.