NIAGARA COUNTY COMMUNITY COLLEGE

THEORETICAL CARE PLAN DATE:
NUR STUDENT NAME: MEDICAL DIAGNOSIS: Acute Abdominal Pain SURGICAL PROCEDURE & DATE: Hartman Procedure

PATIENT'S INITIALS: AGE: 57/M ROOM #: ERICKSON'S DEVELOPMENTAL STAGE: VII generativity vs stagnation

|A. Brief Description of Pathophysiology Including Signs & Symptoms: Hartman procedure-The Hartman procedure was developed by Dr. Henry Albert Hartmann in 1921 and involves the surgical resection of the |
|rectosigmoid colon, closure of the rectum, and creation of a colostomy. It was initially created to improve the mortality rate of patients who had colonic adenocarcinomas but is now indicated for |
|several pathologies including complicated and severe diverticulitis, rectosigmoid cancer, and in cases where a colon resection is needed but a primary anastomosis cannot be safely done. There are few |
|contraindications to the procedure and is often the procedure of choice when other complicated procedures cannot be performed. Patients with hypotension, renal failure, diabetes, malnutrition, immune |
|compromise, and ascites can have unfavorable performance to the procedure. |
|The important labs for this patient are the CBC(WBC,H&H, and diff), CMP, ABG if intubated still, lactic acid if still septic/possibly septic, if still on TPN (glucose, calcium, magnesium, phosphate, |
|LFT’s, albumin) |
|TPN-Total Parenteral nutrition (TPN) is the administration of all the bodies’ nutritional requirements directly into the blood stream. It is used in patients who cannot get their nutrition through their|
|GI tract for a number of reasons, from colon CA to obstructions in the bowel. It is typically a mix of water, energy, amino acids, fatty acids, vitamins, and minerals. The exact mixture is dependent on|
|the patient and the disorder present however the standard solutions are approximately 25% dextrose. Most of the calories supplied come in the form of carbohydrates. Weight, CBC, electrolytes, BUN, and |
|creatinine, LFT’s, and albumin should be monitored while the patient is on TPN. While a patient is on TPN, glucose abnormalities are common. Hepatic dysfunction, electrolyte imbalances can also occur |
|while patient is receiving treatment. |

|B. Theoretical Need with Rationale |C. Theoretical Nursing Approach |D. Scientific Rationale for Approach |
|I. Oxygen r/t: |1. Assess VS q4h/per MD order. Note quality, pulse pressure, and rate.|1. Clinical assessment is important. Note any changes from baseline |
| |Document/report any abnormalities esp. the BP/pulse. |further intervention may need to take place with changes of |
|Surgical Procedure/Mechanical Ventilation: | |rate/rhythms/patterns/quality of BP/pulse/resp rate/temp. increases or |
| | |decreases in BP could indicate hyper/hypovolemia |
|• Age |2. Assess skin color and temp. Centrally and peripherally at least q4h.|2. Cyanosis and pallor skin is an indication of dec. tissue perfusion |
|• SE of medications | |to the extremities. Color should return in < 3 sec. temp regulation is |
|• Hospitalization | |difficult with aging pts but also can be an indication of circulation |
|• F&E imbalances |3. assess skin temp q4h |and neurological problems |
|• Pain | |3. Stimulation to the sympathetic system causes skin to feel cool and |
|• Poss. Anemia |4. assess fatigue PRN if extubated |clammy. |
|• Poss. Changes in LOC | |4. Muscle fatigue result of failing pump and decreased oxygen perfusion|
|• Poss. Impaired Gas Exchange |5. assess peripheral pulses q4h |to tissues. |
|• Decreased Mobility | |5. Decreased CO has widespread manifestations because not enough blood |
| | |reaches all the tissues and organs evident by diminished peripheral |
|Developmental considerations: |6. Assess chest q4h and prn using IPPA - I – inspect: look for |pulses. |
| |retraction or deformities that could interfere with breathing a:p |6. Establishing a baseline on the patient is very important - making |
|• Blood vessels begin to thicken and lose elasticity |diameter P- palpate: ID areas of tenderness, excursion and tactile |sure lungs are clear. Any changes can be an indication something else |
|• Efficiency of heart may drop. Thorax shortens gradual |fremitus P- percuss: note changes in resonance A- auscultation: note |is wrong. Risk for atelectasis post-op. changes in chest symmetry may |
|loss of lung elasticity, breathing capacity reduces |any adventitious lung sounds |indicate improper placement of ET tube or development of barotrauma |
|• chest wall muscles gradually lose strength, reducing |7. Assess LOC q4h –alert and oriented X3. Also note memory, vocabulary,|7. Proper orientation to person, place, and time indicates good |
|respiratory efficiency |awareness to current events and proper speech patterns. (If extubated) |perfusion to the brain. Decrease in oxygen could cause confusion, |
|Vitals: |if still intubated Glasgow coma scale can also be used. |restlessness, and memory loss for the pt. slight changes could indicate|
| | |a larger problem such as an increase or decrease in blood sugar. |
|BP 90/60-120/80 |8. monitor SpO2 levels q4h |8. Normal SpO2 level is >95%. Decrease in SpO2 level may be an |
|HR 60-100 | |indication that supplemental O2 may be needed for adequate tissue |
|Resp. 12-20 | |perfusion |
|Temp. 97.6-99.6 |9. Monitor ABGs/vent settings per MD order. TV 750 – SIMV|9. Controls or settings are adjusted according to pts |
|SpO2 >95% |RATE 14 – FIO2 50% - PEEP 5 |primary disease and results of diagnostic testing to maintain |
| | |parameters within appropriate limits. Adjustments to settings may be |
|Lab values: | |required depending on pts response and trends in gas exchange |
|WBC 5000-10000 | |parameters |
|RBC 4.2-5.4 F 4.6-6.2 M |10. Resp mechanics, vent weaning per resp. extubated if |10. couching pt to take slower, deeper breaths; practice |
|HGB 12-14 F 13-16 M |ready per MD order. Assist pt in “taking control” of breathing if |abdominal or pursed-lip breathing; assume position for comfort; and use|
|HCT 37-47% F 40-54% M |weaning is attempted |relaxation techniques can be helpful in maximizing resp function |
|GLUCOSE 70-110 | |11. Patients on vents can experience hyperventilation, |
|BUN 10-20 |11. Observe overall breathing pattern. Note RR, distinguish |hypoventilation, or dyspnea and attempt to correct deficiency by over |
|K+ 3.5-5.0 |between spontaneous resp and vent breaths q4hrs |breathing. |
|Na 135-145 | |12. Resp rates vent depending on problem. Rapid resp |
|Cl 90-105 |12. count pts resp 1 full min and compare with desired vent|can produce resp alk and prevent desired volume being delivered by |
|ACT: 70-120 sec |set rate q4hrs |vent. |
|PT: 11-15 sec | |13. TE: low molecular weight heparin with antithrombotic properties. |
|PTT: 25-35 sec |13. Administer enoxaparin per MD order (pg. 540) antithrombotic |Does affect TT and aPTT up to 1.8 times to control value. |
|PT/INR: 0.9-1.2 |SE: fever, pain, inflammation at injection site. Peripheral edema, |Antithrombotic properties are due to its antifactor Xa and antithrombin|
|D-Dimer: 95% insures proper blood oxygen levels; they are within |
| | |normal range to demonstrate the effectiveness of lungs in adequate |
|Surgical Procedure/Altered Tissue Integrity: | |tissue perfusion. |
| |3. Monitor laboratory studies; serum osmolarity, Hgb/Hct, BUN/Cr as |3. Imbalances can impair mentation. If fluid replacement is necessary |
|• Decreased physical mobility |indicated. |and occurs too quickly, water intoxication can occur-sodium |
|• Age | |concentration falls, water enters brain cells, and confusion, |
|• SE of medications | |disorientation, or coma may develop. |
|• Hospitalization |4. Obtain specimens for culture and sensitivities as indicated |4. Identifies organisms & appropriate antibiotic therapy if necessary.|
|• HRF infection | |5. Pupil reactions are regulated by the oculomotor (III) cranial nerve |
| |5. Evaluate pupils (note size, shape, equality, and light reactivity q |and are useful in determining if the brainstem is intact. Pupil size |
|Developmental considerations: |4 hr. |and equality is determined by balance between parasympathetic and |
| | |sympathetic enervation. Response to light reflects combined function of|
|• Sensory – eyes begin to change gradually at age 40 | |the optic (III) and oculomotor (III) cranial nerves. |
|• Auditory nerve and bones of inner ear gradually change.| |6. Aids in ventilating all lung areas and mobilizing secretions. |
|Loss of hearing from high pitched sounds | |Prevents stasis of secretions and infection risk. Lowers risk of tissue|
|• Skin – decreases in size and the number of sweat glands|6. Reposition q 2 hrs. |breakdown. |
|• Skin wrinkles, tissue sags, and pouches under eyes form| |7. Although fever, chills, and diaphoresis are common with infectious |
|because epidermis flattens and thins with age | |process, fever with flushed, dry skin may reflect dehydration. Patients|
|• Skin is thinner and dryer |7. Monitor temperature, skin color, and moisture q 4h. |may be normothermic or hypothermic because of peripheral vasodilation. |
|• Progressive loss of melanin from hair bulb causes gray | |8. Surgical patients are high risk for infection especially bowel |
|hair in most adults by age 50. | |cases. Break in skin – tissue – muscle – GI tract. IVs, Foley cath and |
| | |vent leaves the patent vulnerable to infections |
|Values: |8. Observe for signs of infection and inflammation-fever, flushed | |
| |appearance, wound drainage, purulent sputum, and cloudy urine as | |
|WBC 5,000-10,000 |appropriate. – abdominal wound REEDA – colostomy site: watch for signs | |
|Temp 97.6-99.6 |of hypoxia to tissue – ostomy should be bright red at this point and | |
| |bleeds to the touch – pale can mean decrease tissue perfusion. – vent | |
| |any changes in sputum could mean resp infection. – Watch for any |9. Reduces risk of cross-contamination |
| |abnormal drainage from anus: closure could be infected. |10. TPN can raise blood glucose - high glucose in the blood creates an|
| |9. HT and promote good hand hygiene AAT. |excellent medium for bacterial growth/break in skin barrier |
| |10. Maintain aseptic technique for IV insertion procedure, |11. Reduces risk of oral and gum disease. |
| |administration of medications, and providing site care. Rotate IV sites| |
| |as indicated PRN |12. Assure medications are being administered to the correct patient |
| |11. Encourage and assist with oral hygiene q shift if extubated. In |and that medications and dosages are correct. |
| |intubated – oral hygiene q hr. |13. Position changes reduce pressure and irritation of tissues. |
| |12. Assess patients name x2 and check meds x3 before administration of |Adequate care reduces risk of skin breakdown and infection. |
| |medications AAT. |14. Assure patency of IV access. Necessary for medication |
| |13. Encourage frequent position changes (change position slowly) and |administration and emergency situations. |
| |provide meticulous skin care q shift. |15. Indicator of complication. Site should be free from infiltration, |
| |14. Flush saline lock per hospital policy: note any signs of |phlebitis, redness, edema, & pain AAT. |
| |infiltration/phlebitis/redness. |16. cuff must be properly inflated to ensure adequate ventilation and |
| |15. Assess saline lock site q shift. |delivery or desired TV and to decrease the risk of aspiration |
| | |17. Kinks in tubing prevent adequate volume delivery and increase |
| |16. Inflate tracheal tube cuff properly, use minimal leak and occlusive|airway pressure. Condensation in tubing prevents proper gas |
| |technique. Check cuff inflation every 6 to 8 hrs./whenever cuff is |distribution and predisposes to bacterial growth |
| |de/re-inflate |18. Vents have a series of visual and audible alarms, such as oxygen, |
| |17. check tubing for obstruction, such as kinking or accumulation of |low volume/apnea, high pressure, and inspiratory/expiratory ratio. |
| |water q4hrs/PRN |Turning off/failure to reset alarms places pt at risk for unobserved |
| | |vent failure/resp distress/failure. |
| |18. Check vent alarms for proper functioning. Do not turn off alarms, |19. provides/restores adequate ventilation when pt or equipment |
| |even for suctioning. Q shift |problems require pt to temp be removed from vent |
| | |20. Broad-spectrum carbapenem antibiotic that inhibits the cell wall |
| | |synthesis or gram-positive and gram-negative bacteria by its strong |
| |19. keep resuscitation bag at bedside and vent manually when indicated |affinity for penicillin-binding proteins of the bacterial cell wall. |
| |20. Administer ertapenem sodium per MD order (pg. 565) antibiotic | |
| |SE: phlebitis/thrombosis in inj. site. Fatigue, fever, leg pain, death,| |
| |chest pain. Increased AST/ALT. | |
| |NI: baseline C&S prior to therapy. Monitor LFTs and kidney function | |
| |Labs: AST, ALT, CBC, alkaline phosphates, platelet count, routine blood|21. TE: Gastric acid pump inhibitor that belongs to a class of |
| |chemistry during prolong therapy |antisecretory compounds. Gastric acid secretion is decreased by |
| |21. Administer pantoprazole sodium per MD order (pg. 1148) antiulcer |inhibiting the H+, K+-ATPase enzyme system responsible for acid |
| |SE: Diarrhea, flatulence, abdominal pain, headache, insomnia, rash |production |
| |NI: monitor for and immediately report S&S of angioedema or a sever | |
| |skin reaction | |
| |Labs: urea breath test 4-6 weeks after completion of therapy | |
| |22. Administer midazolam hydrochloride per MD order (pg. 996) |22. short-acting benzodiazepine that intensifies activity of GABA a |
| |anesthetic; antianxiety; sedative-hypnotic |major inhibitory neurotransmitter of the brain, interfering with its |
| |SE: retrograde amnesia, headache, euphoria, hypotension, N/V. weakness,|reuptake and promoting its accumulation at neuronal synapses. Calms the|
| |coughing, laryngospasm, resp arrest |pt, relaxes skeletal muscles, and in high doses produces sleep |
| |NI: assess for extravasation at injection site. Monitor for resp | |
| |distress, hypotension. Other S/S watch for: confusion. Sedation. | |
| |overdose | |
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| | |1. symptoms are indicative of depletion of muscle energy and can reduce|
| |1. observe/monitor for generalized muscle wasting and loss of |resp function |
| |subcutaneous fat q shift |2. significant/recent weight loss and poor nutritional intake provides |
| |2. weigh per MD order |clues regarding catabolism, muscle glycogen stores, and ventilator |
| | |drive sensitivity |
| | |3. Appetite is usually poor. After extubated/post-op pt may be started |
| |3. Document oral intake when resumed. Per MD order |with ice chips/clears and progress from there |
| | |4. prevents dehydration that can be exacerbated by increased insensible|
|III. Nutrition r/t: |4. administer fluids per MD order |losses (vent) and reduce risk of constipation/fluid volume from |
| | |surgery/bleeding |
|NPO Status/Decreased Ability to Process/Digest Nutrients:| |5. post-op/TPN feeds BS may be hypoactive. Vent pts are at risk for abd|
| |5. Assess GI function using IAPP q 4 hrs |distention/trapped air. |
|• SE of medications | |6. provides adequate nutrients to meet individual needs when oral |
|• Hospitalization |6. administer TPN with additives per MD order |intake is insufficient/not appropriate |
|• Disease process | |7. provides info about adequacy of nutritional support or need for |
|• dietary restrictions |7. monitor lab studies: prealbumin, serum transferrin, BUN/Cr and |change |
|• decreased mobility |glucose if ordered per MD |8. Based on individually estimated caloric and protein requirements. A |
|• age |8. Administer TPN solutions at prescribed rate via infusion control |consistent rate and nutrient administration ensures proper utilization |
| |device as needed. Adjust rate to deliver prescribed hourly intake. Do |with fewer side effects, such as hyperglycemia or dumping syndrome. |
|developmental considerations: |not increase rate to “catch up” if infusion slows. |9. metabolic complications of nutritional support often result from |
| |9. be familiar with electrolyte content of solution PRN |lack of appreciation of changes that can occur because of feeding – |
|• weight gain common – BMR slows down | |hyperglycemia, HHNC, and electrolyte imbalance |
|• may begin to notice a gradual loss of taste sensation | |10. effectiveness of IV vitamins diminishes and solution degrades after|
|• decreased caloric needs 1600-2200cal/day |10. observe appropriate “hang” time per agency policy – change |24 hrs |
|• fluid needs 30cc/kg/day |bag/tubing q 24hrs. |11. high glucose content of solution may lead to pancreatic fatigue, |
| |11. accucheck FSBS per agency policy |requiring supplemental insulin to prevent hyperglycemia complications. |
|Labs: | |12. TE: recombinant insulin analog that is more rapidly absorbed than |
|HDL- >60 | |human insulin, with more rapid onset and shorter duration than regular |
|LDL-