NURSING Care Plan

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NURSING Care Plan

NURSING Care Plan

Video Transcript:

KARI (on phone): This is Kari the nurse from the Emergency Department. I’m calling to give you a transfer report on Ms. Janet Lieberman. Janet is a 36-year-old woman who came because she felt weak and dizzy. She has a history of Crohn’s disease with intermittent gastritis and six months ago she had surgery and an ileostomy. Traces of serosanguineous effluent were present in her ostomy bag upon arrival. Her Blood type is A-. She is typed and cross-matched for two units of packed RBCs, so please administer as soon as they are available. She started on Infliximab IV six months ago and the last dose was given seven weeks ago. Her vital signs were temperature 98.8, pulse 114, respiration 22, blood pressure 100/60, and oxygen saturation 95%. Her hemoglobin is seven milligrams per deciliter and her hematocrit is 21%. She has an IV of 0.9% sodium chloride 1000- milliliters infusing at 150-milliliters per hour, and has 700-milliliters remaining in the bag. We started an IV while she was in ED. Her skin has been pale, warm, and dry to the touch. She voided 500-milliliters at 1500 in the ED. A hemoccult of her stool was sent to the lab. Esther: Were the coagulation tests within normal range? KARI: Yes, her pro time is 12.2, her PT is 21 seconds, and her INR is 0.7. Esther: Okay, thanks for the report. KARI: You’re welcome. I’ll bring her up to your unit in a few minutes. Esther: Thanks. KARI: Hi Esther, this is Janet Lieberman. Esther: Hi Ms. Lieberman, my name’s Esther. I’ll be taking care of you this evening. KARI: I gave you a transfer report a couple minutes ago. Ms. Lieberman needs the two units of packed RBCs as soon as possible. Esther: Okay. Ms. Lieberman, I need to take a quick look at your ostomy bag. MS. LIEBERMAN: Sure, okay. Esther: Thank you. Do you have any family here? MS. LIEBERMAN: No, I came alone to the emergency room today, but I have a sister who’s on her way to the hospital. KARI: Do you have any questions before I leave? Esther: No, thanks for the report. I can take it from here. KARI: I am going back to the Emergency Department now. Esther’s going to be taking care of you. I hope you feel better soon. MS. LIEBERMAN: Thanks so much for taking such good care of me. Esther: Ms. Lieberman, I need to ask you some questions. MS. LIEBERMAN: Okay, what else do you need to know? Esther: I need to review your abdominal status. Are you having abdominal pain? MS. LIEBERMAN: Oh yes, it’s very sore and crampy. Esther: On a scale of 0 to 10, with 0 being no pain, and 10 being unbearable, how do you rate your pain now? MS. LIEBERMAN: I would say a 6. Esther: When did the pain begin? MS. LIEBERMAN: Uh, after I got up this morning. Esther: Can I ask you where the pain is? MS. LIEBERMAN: Yes, it’s here in the top of my stomach. Esther: Okay, Have you noticed anything that brings on the pain or makes it worse? MS. LIEBERMAN: I’m pretty sure stress makes it worse. Esther: Okay. MS. LIEBERMAN: When I get stressed I don’t eat healthy foods and then I get headaches and take Ibuprofen. Esther: Okay, when you’re feeling a little bit better I’d like to review some ways to manage your stress. For now, I need to take a listen to your bowel sounds. MS.

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