A Nursing Care Plan Presented to the Nursing Department

of San Pedro College

In Partial Fulfillment of the Requirements in NCM-212 RLE

IMMUNOLOGY/CANCER ROTATION

Submitted to:
MR. ADAM BAROTE, RN
Clinical Instructor

Submitted by:
XYRELCREIZ JULLIAN E. PLOYA, ST.N
BSN-3Q - GROUP 2

November 27, 2023

 NURSING CARE PLAN

Name: M. J. A Age: 5 Y.O Ward: St. Mary’s Room/Bed#: 250

Attending Physician: Dr. Quitain Sex: M Diagnosis: Chief Complaint: LBM

Date Impl
Patient em
And Cues Need Nursing Diagnosis Nursing Intervention Evaluation
Outcome enta
Time
tion

N Subjective: N Dysfunctional gastric Within 2 hours • Assess lab values. 1 November 18,
O “sir sige siyag kalibang U motility related to of holistic R: The nurse can 2023 @ 5am
V og suka, unya butod T disease process as nursing care, monitor for
E iyang tiyan.” As R evidenced by diarrhea the patient will abnormalities in “GOAL
M verbalized by the I and vomiting. report nutritional lab values PARTIALLY
B patient’s mother. T decreased such as albumin and MET”
E I severity or electrolyte levels such
R O Rationale: elimination of as potassium and
N Paralytic ileus, or diarrhea and sodium. After 2 hours of
Objective: A adynamic ileus, involves vomiting, meticulous
1 Vital Signs: L functional motor prevent further • Assess VS, and the 2 nursing care, the
8 BP: 110/80 paralysis in the digestive dehydration, extent of nausea, patient somehow
RR: 26 M tract due to and electrolyte vomiting, food and manifested a
CR: 110 E neuromuscular failure, imbalances. fluid intake. decreased
2 Temp: 36.8 T affecting the myenteric R: To provide severity in
0 A (Auerbach’s) and baseline data, and diarrhea and
2 o (+) abdominal B submucous (Meissner’s) determine is fluid and vomiting.
3 distention O plexus. This condition nutrient
 o (+) cold clammy L results in a functional supplementation is
extremities I obstruction, primarily required. The patient
o (+) pale C affecting the small verbalized “yes”
conjunctiva intestine, with potential • Auscultate the 3 upon asking the
o (+) lethargic - involvement of the colon client’s abdominal question if he
o (+) grimace face and stomach. The area. feels a little
o (+) diarrhea P consequence is the R: Auscultation may better.
o (+) vomiting A accumulation of fluid and demonstrate
o (-) cyanosis T gas, leading to bowel increased bowel “medyo ok na
o NPO status T distension, vomiting, sounds in obstruction iyang pamnisar
o Attached with E decreased bowel or absent bowel gamay sir
Percutaneous R sounds, and absolute sounds in the ileus. A kumpara ganina”
Endoscopic N constipation. Causes succession splash as reinforced by
Gastrostomy include abdominal detected by listening the mother.
Tube via Foley surgery, inflammatory over the epigastrium
Catheter conditions, infections, while shifting the
medications like opioids, abdomen side to side
Serum Electrolytes: electrolyte imbalances, suggests
(L) Sodium – 129.0 neurological disorders, gastroparesis or
(L) Potassium – 3.4 and serious illnesses. gastric outlet Xyrelcreiz
Potassium depletion obstruction. Jullian E. Ploya,
(H) WBC: 15.2 further complicates the St.n
(H) Neutrophil: 79.7 situation, causing • Meticulously 4
weakness and smooth monitor intake and
muscle paresis, output.
potentially adding a state R: intestinal ileus can
of adynamic ileus to an cause the patient to
existing obstructive experience vomiting,
lesion. This combination which can
results in progressive worsen malnutrition a
dehydration, electrolyte nd electrolyte
imbalance, and systemic abnormalities. It’s
toxicity due to the important to record all
migration of toxins and intake and output
bacterial translocation. sources accurately.
To address these issues,
intervention focuses on • Assess current 5
correcting fluid and nutritional status
electrolyte deficits and diet.
through parenteral R: Assessment allows
administration, along the nurses and health
with measures such as care providers to collect
nasogastric more information and
decompression to perform a nutrition-
"defunction" the small focused physical
bowel. Oral fluids and examination to
food are withheld until distinguish if there is a
bowel sounds return or nutrition issue, identify
flatus is passed. the problem, and
Identifying and determine the severity.
addressing the
underlying cause of the • Maintain NPO status 6
ileus is crucial. as ordered.
Conservative treatment R: Patients will generally
often succeeds, with the be NPO at first to rest the
possibility of restored bowel. This reduces
contractility, especially if hyperactivity in the bowel
and decreases vomiting
electrolyte and fluid which will limit the loss of
balance can be restored. fluids and nutrients,
therefore decreasing
further malnutrition.
Bibliography:
Weledji E. P. (2020). • Weigh daily. 7
Perspectives on R: Daily weight can help
paralytic ileus. Acute evaluate the patient for
medicine & malnutrition. It also
surgery, 7(1), e573. provides information on
https://doi.org/10.1002/a how effective the ongoing
ms2.573 treatment is while the
patient is in the hospital.

• Resume diet as
tolerated.
R: Once the patient is no
8
longer NPO and is
cleared to eat, follow the
doctors order regarding
enteral feeding. Starting
with 8 hours of interval of
feeding with small
amounts until close
intervals with (increased
amount) gives the small
intestine a chance to
readjust and absorb what
is being introduced.

• Administer 9
prescribed
medications.
R: Prescribed
medications can help to
treat ileus with vomiting
and diarrhea.
Antiemetics can help to
reduce nausea and
vomiting, while
antidiarrheals can help to
firm up stools. Prokinetic
agents, such as
metoclopramide, can
stimulate bowel motility
and help resolve ileus.
Additionally, antibiotics
may be prescribed if the
ileus is caused by an
infection.

• Administer fluid and

electrolytes as 10
ordered.
 R: To replace fluid and
electrolyte loss.

REFERENCES:

Beach EC, De Jesus O. Ileus. [Updated 2023 Aug 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 J Retrieved
from: https://www.ncbi.nlm.nih.gov/books/NBK558937/

Cleveland Clinic. (October 8, 2021). Paralytic ileus. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/21853-paralytic-ileus

Wayne, G. (2023, October 12). Nausea & vomiting nursing care plan and management. Nurseslabs. https://nurseslabs.com/nausea/