Problem
Female patient admitted for laparoscopy cholecystectomy on 2/12/19 complicated by bile injury. She come to ED for severe epigastric pain (UQ). Pt denies fever but complain of chill. X-Ray shown extensive fluid collections in the upper abdomen. PERRLA. VS. T 97.9, P 112, R, 16, BP 103/69, O2 98%. Labs: WBC: 18.2 H, RBC: 3.48 L, Hgb 8.9 L, Plt count 624 H, RDW, 29.9 H, Neut 16.1 H, Lymph 0.9 L, Baso 0.2 H.
I. What is the pathophysiology of the primary problem? What primary health related concepts does this primary problem represent?
Problem: Pathophysiology of Problem in OWN Words:
Primary Concept:
II. What is the worst possible/most likely complication(s) to anticipate based on the primary problem of your patient? Worst Possible/Most
Likely Complication to Anticipate:
-Nursing Interventions to PREVENT this Complication:
-Assessments to Identify Problem EARLY:
-Nursing Interventions to Rescue:
III. What data did you collect from the medical record and patient that is RELEVANT to the nurse?
RELEVANT Data:
Clinical Significance:
IV. Likely Problems: Additional Clinical Data Needed:
V. Rank the assumptions/concerns (likely problems) by urgency. Which problem is most serious? Why?
Assumptions/Concerns:
Most Likely/Serious Problem:
Rationale:
VI. Based on the most likely/serious problem, what is the nursing priority and PRIORITY interventions to advance the plan of care?
Nursing PRIORITY:
PRIORITY Nursing Interventions:
Rationale:
Expected Outcome.