DATA| ANALYSIS| NURSING DIAGNOSIS| PLANNING|
Group significant data according to needs, patient concerns.| Compare with normal standards, knowledge, and interpret the meaning of the data and knowledge.| State problem or concern according to needs with reasons and related factors.| Outcomes/ Objectives. A goal with more detailed objectives.| | Reference| | |
Ms. C.M62 years oldDiagnosis:RT lung CancerSx:RLL&RML wedge, RLLwedge+mediastinal lymphadectomy plus subtotal R pleurectomyPmhx:Rib resection (april 2011), Mild AsthmaDouble Lumen Picc LineTPN50cc/hrLipids8cc/hrIV D5NS 42cc/hrNPOInput/OutputChest tube to leg bag drainageMeds: Heparin, colace, oxycontin, oxycodone, lyrica, pantoloc, Tylenol. Positive Family supportObjective:Subjective:| Lung Cancer:Right Lower Lobe Resection:Chest Tube:Chylothorax:| | Pt. will state that he is passing flatus by the end of the shift.Pt will no longer complain of nausea and vomiting by the next day.Pt will state pain is 0-1/10 in abdomen by the end of the shift. Pt will progress from NPO to clear fluids to soft foods by the end of the week. Pt will continue to ambulate as much as possible.|
PLANNING| IMPLEMENTATION| EVALUATION|
InterventionsSuggested nursing approaches and care-giving skills.| Rationale for InterventionsEvidence or knowledge based reason for selecting the intervention| What you actually did – compared to what you planned to do| Whether or not the goals and objectives were met and suggestions for modification.| a) Assess patient’s abdomen for tenderness. Auscultate for bowel sounds in all 4 quadrants, palpate for distention and inquire whether patient is passing flatus or has had bowel movements qshift. b) Instruct patient to report any abdominal cramping, nausea or vomiting. c) Administer meds for pain and nausea as per patient request and MD order. d) Monitor and record patient’s intake and output, noting the color and consistency of any...