Formulate nursing care plan

Reference no: EM133295040

Case: 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

Formulate nursing care plan, nursing diagnosis actual, potential and wellness diagnosis

Reference no: EM133295040

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