Question

PN 200 Fundamentals of Nursing II Concept Map: Care of the Surgical Patient: Acute Pancreatitis Betty Boop is a 72 y/o woman is admitted to your unit from the Emergency Room with the chief complaint of constant, severe abdominal and lower back pain for two days and shortness of breath over the past 24 hours. She tells you "I've had to rest four or five times just walking back to the house from my yard storage shed. It's gotten real hard to manage by myself A niece stopped by to visit the patient and insisted she go to the hospital to be evaluated. Betty Boop has not received medical care of any kind. She lives by herself in a remote area of the county off of a dirt road in rural Florida. She is restless, nauseated, and in pain. Everything around her in the hospital is new and frightening to her. Vital signs are 108/72, 128, 30, 96.8. 02 sats are 84% and was started on 02 at 2L/min. She is admitted to your unit at 7PM. Ms. Boop arrives on your unit. As she is getting into bed, you notice that her eyes are very wide and she is looking all around. She seems totally overwhelmed in response to the nurse's explanation of how to operate the bed. You complete your assessment and note the following abnormalities: restlessness prefers to sit on the edge of the bed leaning forward and tightly clutching her purse. States that the pain has decreased ever since that nurse jabbed me with that needle downstairs." Skin is cool, diaphoretic, and pale. Heart rate is 126 and irregular and tacky. Peripheral pulses weakly palpable X 4 extremities. Respirations are rapid at 26 /min but unlabored on O2 at 2L/min via nasal cannula, SaO2 is 85%, breath sounds absent at the base of the left lower quadrant posterior. Reports marked nausea without emesis. Bowel sounds hypoactive all 4 quadrants. Abdomen distended and exquisitely tender throughout the abdomen to light palpation, guarding noted. She has not voided since arriving on the unit but states "I have made less water than usual." Further assessment reveals poor skin turgor, dry mucus membranes, and mild sclera jaundice. Na Ms. Boop's admission labs return 148 WBC 17,200 AMYLASE 200 4.2 Hgb 12.5 Hct. 38% Lipase 375 114 LDH 160 HCO3 Platelets 308 AST BUN ALT Creatinine 1.0 Glucose 185 98 26 46 Reviewed 1/20

Answer 1

Care of the Operative Patient : Acute Pancreatitis

	NURSING DIAGNOSIS Acute pain related to Extension of inflammation to the retro-peritoneal nerve plexus as evidenced by reports of pain.	NURSING DIAGNOSIS Risk for infection
	INTERVENTIONS Investigate verbal reports of pain, noting specific location and intensity (0–10 scale). Note factors that aggravate and relieve pain. Maintain bed rest during acute attack. Provide quiet, restful environment. Promote position of comfort on one side with knees flexed, sitting up and leaning forward. Provide alternative comfort measures (back rub), encourage relaxation techniques (guided imagery, visualization), quiet diversional activities (TV, radio). Keep environment free of food odors. Administer analgesics in timely manner (smaller, more frequent doses).	INTERVENTIONS Use strict aseptic technique when changing surgical dressings or working with IV lines, indwelling catheters and tubes, drains. Change soiled dressings promptly. Stress importance of good hand washing Observe rate and characteristics of respiration, breath sounds. Note occurrence of cough and sputum production. Encourage frequent position changes, deep breathing, and coughing. Assist with ambulation as soon as stable. Observe for signs of infection: Fever and respiratory distress in conjunction with jaundice; Increased abdominal pain, rigidity and rebound tenderness, diminished and absent bowel sounds; Increased abdominal pain and tenderness, recurrent fever (higher than 101°F)leukocytosis,hypotension, tachycardia, and chills. Obtain culture specimens (blood, wound, urine, sputum, or pancreatic aspirate). Administer antibiotic therapy as indicated: cephalosporins, cefoxitin sodium (Mefoxin); plus aminoglycosides: gentamicin (Garamycin), tobramycin (Nebcin). Prepare for surgical intervention as necessary.
	POSITIVE OUTCOMES Pain may reduce with the help of analgesics and relaxation techniques will Promotes relaxation and enables patient to refocus attention; may enhance coping.
	NEGATIVE OUTCOMES Side effects of analgesics may include: Constipation. Drowsiness. Dizziness. Upset stomach. Ringing in your ears. Skin itching or rash. Dry mouth sometimes patients can't tolerate pain with analgesia or else addicted to analgesia or may need surgical intervention.	POSITIVE OUTCOMES Can reduce infection with the help of aseptic techniques and antibiotics May need surgical interventions
	EVALUATION Report pain is relieved/controlled. Follow prescribed therapeutic regimen.	NEGATIVE OUTCOMES Side effects of antibiotics Vomiting. Severe watery diarrhea and abdominal cramps. Allergic reaction (shortness of breath, hives, swelling of lips, face, or tongue, fainting) Rash. Vaginal itching or discharge. White patches on the tongue. Sometimes with the help of surgical interventions also we can't control infections due to secondary diagnosis or surgery related complications will occur. EVALUATION Achieve timely healing, be free of signs of infection. Be afebrile Participate in activities to reduce risk of infection.