Sample Diagnosis Plan
C: CIRCULATION
PLAN
* Prevention of fluid and electrolyte imbalance, dehydration and sepsis (IV fluids) *Jean is vomiting* (check vomitus for blood) * Fluid balance chart * The insertion of IV cannula * Remains Nil by Mouth-insertion of NG tube * Central Pulse - rate, volume & regularity * Pulse rate on admission – 98 beats/min * Peripheral pulses * Blood pressure * *Respiratory rate* * Capillary refill (teach importance of removal of nail polish/make up – circulatory assessment) * Skin colour, appearance, texture and turgor. *Jean was hot & clammy on admission- Temp 38.1* * Assessment for DVT (prophylaxis, e.g antiembolic stockings stockings) *Jean is on oral contraceptive, a risk factor …show more content…
Jean’s abdominal status should also be assessed frequently, including distension, bowel sounds, and tenderness. Increasing generalised pain, a rigid, boardlike abdomen, and abdominal distension may indicate developing peritonitis Smeltzer et al., (2008). Jean’s abdomen should also be frequently assessed for tenderness and increased generalised pain which may indicate perforation (Smeltzer et al., 2008). The outcome of these assessments should be recorded and communicated to the surgical team, particularly any obvious sign of perforation, for effective management. The nurse should also ensure that Jean remains NPO and must not administer laxative or enema as part of bowel preparation, as this may cause perforation of the appendix. No heat should be applied to the abdomen as this may increase circulation to the appendix and also cause perforation (Smeltzer et al., …show more content…
Follow up appointment allows time for further assessment to ensure the patient has recovered fully without any complications (Medicinenet, 2012). The nurse should also find out from Jean and her partner if they have private transport to take her home, if not transport should be booked early according to trust policy to avoid unnecessary delays on the day of discharge. The nurse should ensure transport is also booked for return clinic appointment if necessary. Transport should be cancelled if discharge date or out patients’ appointment is altered, to prevent a waste of
PLAN
* Prevention of fluid and electrolyte imbalance, dehydration and sepsis (IV fluids) *Jean is vomiting* (check vomitus for blood) * Fluid balance chart * The insertion of IV cannula * Remains Nil by Mouth-insertion of NG tube * Central Pulse - rate, volume & regularity * Pulse rate on admission – 98 beats/min * Peripheral pulses * Blood pressure * *Respiratory rate* * Capillary refill (teach importance of removal of nail polish/make up – circulatory assessment) * Skin colour, appearance, texture and turgor. *Jean was hot & clammy on admission- Temp 38.1* * Assessment for DVT (prophylaxis, e.g antiembolic stockings stockings) *Jean is on oral contraceptive, a risk factor …show more content…
Jean’s abdominal status should also be assessed frequently, including distension, bowel sounds, and tenderness. Increasing generalised pain, a rigid, boardlike abdomen, and abdominal distension may indicate developing peritonitis Smeltzer et al., (2008). Jean’s abdomen should also be frequently assessed for tenderness and increased generalised pain which may indicate perforation (Smeltzer et al., 2008). The outcome of these assessments should be recorded and communicated to the surgical team, particularly any obvious sign of perforation, for effective management. The nurse should also ensure that Jean remains NPO and must not administer laxative or enema as part of bowel preparation, as this may cause perforation of the appendix. No heat should be applied to the abdomen as this may increase circulation to the appendix and also cause perforation (Smeltzer et al., …show more content…
Follow up appointment allows time for further assessment to ensure the patient has recovered fully without any complications (Medicinenet, 2012). The nurse should also find out from Jean and her partner if they have private transport to take her home, if not transport should be booked early according to trust policy to avoid unnecessary delays on the day of discharge. The nurse should ensure transport is also booked for return clinic appointment if necessary. Transport should be cancelled if discharge date or out patients’ appointment is altered, to prevent a waste of