Client: Maelynn Ramsey – 51 year old

Client: Maelynn Ramsey – 51 year old female diagnosed with small bowel obstruction Goals of Care- R1 Allergies:Penicillin – causes hives Past Medical History – History of T6 spinal injury 1 year ago from a snowmobile accident resulting in loss of sensation and movement to her lower extremities and loss of sensation to her bowel and bladder. She self-catheterizes 4-6 times daily for urinary control. The client was admitted at 0500 today from Emergency where a nasogastric tube was inserted. On arrival to the unit, she was connected to Low Intermittent Suction and drained 800mL brown liquid. Admission vital signs were T – 37.1, Pulse 51 regular and strong, BP 140/95, Resp 23 – shallow and regular, and O2 saturations 95% on room air. IV insitu in right hand and infusing Ringers Lactate at 100 mL/hr. Medications: Metronidazole 500mg IV TID, Cefuroxime 500mg IV TID, Temazepam 15mg PO Bedtime, Baclofen 20mg PO QID, Tylenol 325-650 mg PO/PR Q4H PRN, Morphine 5-10mg IV Q4H PRN, Gravol 25-50mg IV Q6H PRN, Ondansetron 4mg IV Q8H PRN, Pantoprazole 40mg IV Daily Appropriate Nursing care plan: Identify the priority nursing diagnosis. A SMART goal for the DX Identify three interventions to address this priority diagnosis o Include an intervention to address 1. Nursing care, 2. Medication Administration, & 3. Education needed o Identify the evaluation criteria that will be used to assess effectiveness of care o Identify the rationale for the priority dx, interventions, evaluation criteria, etc. SCIENCE HEALTH SCIENCE NURSING XHLT 1510

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