Nursing Npr
PRIMARY NURSING CARE PLAN
15. Client Information Sheet
Student name: _Scott Watson_ Clinical Date: _02/20/07_ * Reminder: Do not remove the patient care summary or other documents from the hospital!
Room/Bed Age: Gender: Marital Status:
632A 60 F Married
Admit Date: 2/17/07 Reason for Admit:
Pt presented to the ED with complaints of abdominal distention and pain along with bilateral lower extremity swelling and erythema for several weeks. Pt also has jaundice. Pt came into the ED for increasing jaundice and abdominal pain secondary to increasing distention of the abdomen. This has not been acute but has been an accumulative process.
Significant Medical History:
Significant for liver cirrhosis, diabetes mellitus type 2, alcohol abuse, and chronic pancreatitis. Pt states she has not been on medications for one year.
Primary Diagnosis:
Tense ascites due to cirrhosis
Surgical Procedure and Date (if any at this admission):
Diet Ordered: Rationale:
Diab-sodium control 1800cal, 2 gm NA Low NA to reduce fluid retention (ascites)
Activity Level: Rationale:
Bed rest To get rid of the fluid from lower extremities
Lab Procedures ordered: (Results on back)
Xtra pink-draw & hold; LDH, peritoneal; Albumin, peritoneal; Protein total, peritoneal; Hemoglobin A1C; Culture bacterial, U midstream; Sodium, random UR
Other Tests: (Results on back)
DUS: Paracentesis (Dx ascites)
DUS: leg-useven, bilateral, eval for DVT
Allergies: (Include reaction) Code Status:
No known
15. Client Information Sheet
Student name: _Scott Watson_ Clinical Date: _02/20/07_ * Reminder: Do not remove the patient care summary or other documents from the hospital!
Room/Bed Age: Gender: Marital Status:
632A 60 F Married
Admit Date: 2/17/07 Reason for Admit:
Pt presented to the ED with complaints of abdominal distention and pain along with bilateral lower extremity swelling and erythema for several weeks. Pt also has jaundice. Pt came into the ED for increasing jaundice and abdominal pain secondary to increasing distention of the abdomen. This has not been acute but has been an accumulative process.
Significant Medical History:
Significant for liver cirrhosis, diabetes mellitus type 2, alcohol abuse, and chronic pancreatitis. Pt states she has not been on medications for one year.
Primary Diagnosis:
Tense ascites due to cirrhosis
Surgical Procedure and Date (if any at this admission):
Diet Ordered: Rationale:
Diab-sodium control 1800cal, 2 gm NA Low NA to reduce fluid retention (ascites)
Activity Level: Rationale:
Bed rest To get rid of the fluid from lower extremities
Lab Procedures ordered: (Results on back)
Xtra pink-draw & hold; LDH, peritoneal; Albumin, peritoneal; Protein total, peritoneal; Hemoglobin A1C; Culture bacterial, U midstream; Sodium, random UR
Other Tests: (Results on back)
DUS: Paracentesis (Dx ascites)
DUS: leg-useven, bilateral, eval for DVT
Allergies: (Include reaction) Code Status:
No known
References: Ackley, B., & Ladwig, G. (2006). Nursing Diagnosis Handbook (7th ed.). St. Louis, MO: Mosby, Inc. Black, J., & Hawks, J. (2005). Medical-Surgical Nursing (7th ed.). St. Louis, MO: Elsevier, Inc Kee, J. (2005). Laboratory and Diagnostic Tests (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc. Swearingen, P. (2007). Medical-Surgical Nursing Care (6th ed.). St. Louis, MO: Mosby, Inc