Gluc Labs only as

Labs only as indicated Result Normal Result Normal

indicated
CO2mg/dl
Cre
K+
70-110
136 Normal 2.9 Low
NA 135-145 Albumin 3.5-5gm/dl
4.2 Normal 6.1 Low
K 3.5-5.0 Total Protein 6.4-8.3 gm/dl
102 Normal 14.0 Normal
Cl 98-106 Hgb 12-18m/dl
26 Normal 43.2 Normal
CO2 Hct 37-52m/dl
8.9 Normal 9-10.5mg/dl 150 Normal 150-400 M/mm
Calcium Platelets
1.3-2.1mEq/L 11-12.5 sec
Mag PT
30-40 sec
Phos PTT
7L Low
BUN 10-30L D. Bilirubin 0.1-0.3 mg/dl
0.89 Normal 1.0 Normal
Creatinine T. Bilirubin 0.3-1 mg/dl
10.8 Normal
WBC
205 High 22% Normal
Glucose 80-100 Lymphocytes 20-40%
Alk. Phos. 116 Normal 9% Normal
3-120 units/l Monocytes 2-8%
Mg+
Ca++
Phos ALT 4-36 units/L 1% Normal
Eosinophils 1-4%
9-10.5mg/dl
1.3-2.1mEq/L
3-4.5mg/dl AST 0-35 units/dl
Amylase 0.5%
5-10M/mm 3
150-400 M/mm
HCT
3
60-120 units/dl Basophils 0.5-1%
Lipase 87 Normal 89.8 Normal
M 42-52% 0-160 units/L MCV 80-95 m3
F 37-47%
CPK 32.4 Normal
30-170 units/L MCHC 32-36 gm/dl
PTT
PT
11-12.5 sec.
30-40 sec. Troponin <0.02 Normal 29.1 Normal
<0.03 ng/mL MHC 27-31 pg
BNP
<100 pg/mL MPV 7.4-10.4 fL
INR
LDH
100-190 units/L Sed. Rate 15 mm/hr
1.0-2.0

Cholesterol <200 mg/dl D-Dimer <250-600 ng/mL

HDL >45 mg/dl
Bleeding Time 1-9 minutes
LDL 60-180 mg/dl

Triglycerides 35-160 mg/dl Digoxin level 15-25 ng/mL

Abnormal Labs: Please document abnormal labs here. Add more lines if needed.

Date Test/Finding Result Reason out of Norm

xxxx Albumin 2.9 Acute stress from surgery may cause a decrease in albumin levels.

xxxx Total protein 6.1 Acute stress from surgery may cause a decrease in total protein levels.
Can also be expected with use of clopidogrel.
xxxx BUN 7L Changes in protein levels may affect the BUN level. Since the albumin
and total protein level is low, it may decrease the BUN. In addition, the
use of metoprolol may decrease BUN levels.
xxxx Capillary blood 205 Acute stress response caused by hormone release such as epinephrine.
glucose
Pathophysiology
Treatments
Usually results from Cholecystitis. Gallstones result from an imbalance in bile
salts, cholesterol, calcium. The stones migrate to the common bile duct causing an -Pain control
obstruction and stasis of bile. -Control of infection
-Maintenance of fluid and electrolyte
imbalance
-ERCP-clearing of stones from the
billiary duct
-Mechanical lithotripsy
-Oral drugs to dissolve the stones
-Cholecystectomy
Risk Factors
High fat diets, estrogen therapy,
certain ethnic backgrounds,
advanced age, female gender,
pregnancy, genetics, and bariatric
surgery.

Medical
Diagnosis
Cholelithiasis
Ineffective airway clearance r/t Retained
secretions
AEB: diminished breath sounds.

Risk for infection r/t Inadequate primary

defenses

Risk for falls r/t :Postoperative condition

and antihypertensive medication

Nursing diagnosis
 System Finding System Finding
BP 120/60 Abdominal Soft/distended
Contour/Firmness
Pulses (Bilaterally Normal, equal, match Bowel Sounds X 4 BS noted in 2/4 quadrants
when applicable) the apical pulse Quadrants
Rhythm Regular rhythm GI Last BM 11/12/10-early AM

Apical Rate 88 at rest Bowel Program None

Cardiovascular
Radial 88 at rest Dentition Adequate

Capillary Refill <3 seconds Amount 200 cc 1st void after foley
d/c
Heart Sounds S1, S1 and S2 present Continent or Continent
Urinary
S2,S3,S4, Rub Incontinent
Murmur None noted Bladder Program None

Respiratory Rate 18 Skin Integrity Intact/Warm

Rhythm Regular Hydration/Turgor Elastic

Effort Nonlabored Lesions/Scars/Wounds Abd incision from

(Location and choleolectomy
Descriptions)
Pulse Oximetry 99% Edema None noted
(Location/Amount)
 Breath Sounds Diminished/Clear Mobility/Strength Mobility limited due to
sugery
LUL Diminished/Clear M/S Assistive Devices None

LLL Diminished/Clear Immobilization Devices None

(Traction/Cast/Fixators)
RUL Diminished/Clear Temperature 36.3 Degrees C

RML Diminished/Clear LOC A&OX4

RLL Diminished/Clear Speech Clear

Cough Present, Vision Adequate/No corrective

nonproductive/sputum lenses used
in bronchus Neurologic
Secretions/Sputu None produced Hearing Adequate/No hearing aid
m used
Amount/Appearan
ce
Mucous Pink/dry Sleep Pattern Adequate
Membrane Color
O2 administration None GCS 15

Pain Control Effectiveness of

Location Duration Cause/Description
Scale Method/Management Relief
RUQ Flank Pain Intermitt Increases with activity 4 Pain medication 3 When PAIN
ent reevaluated

Medication page
 Medication: Pharmacotherapeutic Normal Amt. Dr. Route Why is Patient receiving Life threatening and Nursing responsibilities
Trade and Classification Dosage ordered and Time medication? most common
Generic names & Drug Action Range reactions to
monitor/observe
platelet aggregation 75mg Oral To prevent blood clots. GI BLEEDING, Assess patient for symptoms
300mg
clopidogrel inhibitors initially then QAM BLEEDING, of stroke, peripheral vascular
Plavix NEUTROPENIA, disease, or MI periodically
75mg daily THROMBOTIC during therapy.
THROMBOCYTO Monitor patient for signs of
PENIC thrombotic thrombocytic
PURPURA. purpura (thrombocytopenia,
microangiopathic hemolytic
anemia, neurologic findings,
renal dysfunction, fever). May
rarely occur, even after short
exposure (<2 wk). Requires
prompt treatment.
Monitor bleeding time during
therapy. Prolonged bleeding
time, which is time- and
dose-dependent, is expected.
Monitor CBC with differential
and platelet count periodically
during therapy. Neutropenia
and thrombocytopenia may
rarely occur.
May cause ↑ serum bilirubin,
hepatic enzymes, total
cholesterol, nonprotein
nitrogen (NPN), and uric acid
concentrations.
Antidiabetics, 100unit TID-with Hormone replacement HYPOGLYCEMIA. Assess for symptoms of
Insulin aspart HIGH-
hormone 1unit/kg/day /ml inj meals to treat diabetes. ALLERGIC hypoglycemia (anxiety;
NovoLOG 10 ml Patient’s blood sugar REACTIONS restlessness; tingling in
LOW0.5unit
was high after surgery, INCLUDING hands, feet, lips, or tongue;
/kg/day so they are treating him ANAPHYLAXIS. chills; cold sweats; confusion;
aggressively. (Rapid cool, pale skin; difficulty in
acting) concentration; drowsiness;
nightmares or trouble
sleeping; excessive hunger;
headache; irritability; nausea;
nervousness; tachycardia;
 tremor; weakness; unsteady
gait)and hyperglycemia
(confusion, drowsiness;
flushed, dry skin; fruit-like
breath odor; rapid, deep
breathing, polyuria; loss of
appetite; nausea; vomiting;
unusual thirst) during
therapy.
Monitor body weight
periodically. Changes in
weight may necessitate
changes in insulin dose.
Monitor blood glucose every
6 hr during therapy, more
frequently in ketoacidosis and
times of stress.
Overdose is manifested by
symptoms of hypoglycemia.
Mild hypoglycemia may be
treated by ingestion of oral
glucose. Severe
hypoglycemia is a life-
threatening emergency;
treatment consists of IV
glucose, glucagon, or
epinephrine.
4 Subcuta Hormone replacement HYPOGLYCEMIA. Assess patient periodically
IV- 0.1
insulin antidiabetics, unit/kg/hr units/0. neous, to treat diabetes. ALLERGIC for symptoms of
NovoLIN hormones as a 04ml TID Patient’s blood sugar REACTIONS hypoglycemia (anxiety;
continuous was high after surgery, INCLUDING restlessness; tingling in
infusion.
Subcu: 0.5– so they are treating him ANAPHYLAXIS. hands, feet, lips, or tongue;
1 aggressively. (Short chills; cold sweats; confusion;
unit/kg/day
in divided
acting) cool, pale skin; difficulty in
doses. concentration; drowsiness;
Adolescent nightmares or trouble
s during
rapid sleeping; excessive hunger;
growth— headache; irritability; nausea;
0.8–1.2 nervousness; tachycardia;
unit/kg/day
in divided tremor; weakness; unsteady
doses. gait).
 beta-blocker 5mg/5 Slow IV Used to treat BRADYCARDIA, Monitor blood pressure,
HIGH
metoprolol antihypertensive 200mg/day ml push Q hypertension/ lower CHF, ECG, and pulse frequently
Lopressor 12 hours blood pressure. Pt. PULMONARY during dose adjustment and
has a history of EDEMA, periodically during therapy.
LOW hypertension. hypotension, Monitor frequency of
25mg/day fatigue, weakness, prescription refills to
Or
IV:
erectile determine compliance.
5mg dysfunction. Monitor vital signs and ECG
every 5–15 min during and
for several hours after
parenteral administration. If
heart rate <40 bpm,
especially if cardiac output is
also decreased, administer
atropine 0.25–0.5 mg IV.
Monitor intake and output
ratios and daily weights.
Assess routinely for signs
and symptoms of CHF
(dyspnea, rales/crackles,
weight gain, peripheral
edema, jugular venous
distention).
Angina: Assess frequency
and characteristics of anginal
attacks periodically during
therapy.
Lab Test Considerations:
May cause ↑ BUN, serum
lipoprotein, potassium,
triglyceride, and uric acid
levels.
May cause ↑ ANA titers.
May cause ↑ in blood glucose
levels.
May cause ↑ serum alkaline
phosphatase, LDH, AST, and
ALT levels.
HIGH
 LOW

# 1 Nursing Diagnosis Ineffective airway clearance

Patient’s Goals (label Nursing Actions Rationale for Actions Evaluation of Patient/significant/family
them short term or long (Interventions in order Interventions educational needs
 term) of priority)
Short term-must be
measurable for the
duration of clinical
Long-term-
measurable after
clinical)
R/T: 11/18/10 0700 Breath Teach and encourage
Patient will demonstrate Auscultate breath To check prognosis of sounds normal and patient to use the
Retained effective coughing and sounds q3 hours. the implemented clear. incentive spirometer.
secretions breath sounds within 3 teachings.
days. Monitor respiratory To check the quality of
patterns including rate, respirations and to make 11/18/10 0700 Teach patient to
Patient will verbalize depth, and effort q3 sure they are not Respirations 18, regular, observe changes in
methods to enhance hours. labored. nonlabored. color, odor, character
secretion removal. and amount of sputum.
Help client deep breath To loosen and produce 11/18/10 0700 Patient
and perform controlled secretions. was helped to deep Encourage ambulation
coughing. breath and cough. A and activity as
AEB: small unmeasureable tolerated.
diminished amount of clear sputum
breath was produced.
sounds.
# 2 Nursing Diagnosis Risk for infection

Patient’s Goals (label Nursing Actions Rationale for Actions Evaluation of Educational needs
them short term or long (Interventions in order of Interventions
term) priority)
Short term-must be
measurable for the
duration of clinical
Long-term-
measurable after
clinical
R/T: Client will remain free Observe and report Redness, warmth, 11/12/10 1300 Wound Teach patient proper
Inadequate from symptoms of signs of infection such discharge, and RUQ from Cholecystectomy hand hygiene (hand
primary infection for the duration as redness, warmth, increase in body is pink with no drainage. washing and alcohol-
defenses of hospital stay. discharge, and temperature may all Incision is apprx 6 cm long based rubs).
increased body be signs of infection. and intact with staples. No
Client will demonstrate temperature q1 hour. Change in LOC may redness or odor noted. Teach patient proper
appropriate care of also be a sign. Temperature 36.3 C. wound care, and how
infection-prone site. Patient’s vitals will be Same as above-vitals to change his
taken Q4 hours may change when an Temp 36.3, RR 18 regular, dressing in a way that
(including temperature) infection is present. HR 88, SPO2 98% at rest will minimize
Q4 hours). infectious
Here is where I would transmissions.
Laboratory reports Lab reports may report lab values and if
including WBC and reflect an elevation in anything was outside of Teach patientrisk
differential, serum WBC count and serum normal range, I would factors contributing to
protein, serum albumin, albumin and total address that. surgical wound
and cultures will be protein may decrease infection (smoking
monitored and/or with an acute and higher BMI).
reported Q8 hours. infection.
Assess whether pt
knows how to read a
thermometer. If not,
teach how to.
# 3 Nursing Diagnosis At risk for falls

Patient’s Goals (label them Nursing Actions Rationale for Actions Educational needs
short term or long term) (Interventions in order of
Short term-must be priority)
measurable for the duration
of clinical
Long-term- measurable
after clinical
R/T:Postoperative Patient will remain Explain the importance of In order to prevent patient Teach patient about non-skid
condition and free of falls for the remainder using the call light to call for from getting out of bed foot wear during rehabilitation
antihypertensive of his hospital stay. help, and not getting out of without nursing personnel to prevent falls.
medication bed without assistance. present.
Patient will explain Teach patient to keep
methods to prevent Place frequently used items In order to prevent patient walkways well lit and free of
falls/injury before discharge. such as call light, and water from getting out of bed clutter .
within reach. This will be when something is out of
checked during hourly reach. The patient will be taught the
rounding. importance of a regular
therapy and exercise program
Routinely assist patient with To prevent patient from
toileting and ask patient getting out of bed to go to
during hourly rounding. the bathroom without help.