CRITICAL THINKING SUMMARY

Student: ______________Derek Sibley________________

Client Dx: _______________________Choledocholithiasis_____________ Age: 59__

Allergies: _________________nka____________________________
The MEDICAL DIAGNOSIS that brought the client to the hospital is:
RUQ pain, intercostal pain,

PATHOPHYSIOLOGY of diagnosed disease: (From text)

Hardened deposits of digestive fluids form in the callbladder and make their way
into the common bile duct, blocking juices from flowing and inflammation in the
ABD




SYMPTOMS typically seen with this diagnosis include (as identified in your text):
Fever abd inflammation
jaundice
abd pain

CLIENTS SYMPTOMS of the diagnosed disease include:
Jaundice of the eyes
RUQ pain
Distended, tender Abd



NUTRITIONAL ASSESSMENT:
Height (actual or estimated): __70 inches______ Weight (actual or estimated): 83 kg_______

Estimate Ideal Body Weight (Male: 105lb + 6 lb/inch > 5. Female: 100lb + 5lb/inch > 5): ____75
kg____

Does this client have characteristics of a well-nourished person? Yes __X_ No _____
Explain your answer.
Client has healthy BMI and looks well nourished


PSYCHOSOCIAL STAGE OF DEVELOPMENT

What is the clients developmental stage?
Middle adulthood

Has he/she met the necessary accomplishments? Yes __X__ No _____
Explain.
Pt. has wife, children, and grandchildren. He talks about the fun he has with the grandkids.


How is this illness affecting the clients ability to meet these necessary accomplishments?
Severe pain prevents completion of ADLs and ability to enjoy the fruits of his labors


NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnoses that are most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Acute pain r/t obstruction of bile flow
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
ABD pain, distended abdomen

OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Pt. report that pain mgmt. is effective in maintaining comfort level

NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:

1.Assess pt. for pain routinely and medicate accordingly

2.discuss clients fear of addiction

3.Explain that pain mgmt. approach is temporary and talk about alternative methods of pain control

#2 NURSING DIAGNOSIS (problem r/t)
Imbalanced nutrition-less than requirements r/t nausea/vomiting
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Nausea/vomiting, anorexia

OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Consume adequate nutrition

NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:

1.monitor intake and record percentage of meals eaten

2.consult nutrition specialist for pt. education

3.offer easy to eat or easy to digest foods.

COMPLICATIONS:
If this clients condition were to worsen, what would be the most likely reason and why?
Worsening abd pain and jaundice r/t bile buildup or possible infection

How would you know this is happening?
Pt. reported pain, worsening jaundice, fever

What will you do if this happens?
Check vital signs, consult dr. about situation and assume a blood draw will be ordered

PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS

MEDS/IVs/TX/DIET
(Include dose, route,
frequency)
REASON PRESCRIBED
(Drug Classification,
What is it treating?)
NURSING IMPLICATIONS
FROM TEXT
(Checking for adverse
reactions, preparation &
administration concerns)
CLIENT DATA FROM
YOUR ASSESSMENT
(What data is important to
know before & after
giving)
Atenolol 50 mg PO BID


HTN Check bp pulse
Monitor EKG
Monitor serum electrolytes
Causes bronchospasms,
hypotension, and fatigue
Clonidine 0.3 mg PO QHS


HTN Check bp, pulse
No abrupt stopping
Assess for HF
Zosyn 3.375 GmIVPB Q6


Antibiotic Hypersensitivity
Interaction with blood
thinners
ABN LFTs
Lowers WBC
Nausea
Dilaudid 1mg IVP q3


Pain control

Constipation
Dependence
CNS depression
Check BP and Pulse,
Respirations
Assess pain
Monitor for change of
consciousness

Zofran

antiemetic Blurred vision
Sob
Tachycardia
Interacts with tramadol and
antipsychotics












































Analysis of Diagnostic Tests

DIRECTIONS:

1. List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical
treatments (i.e. medications) and provide the patient values for each test. Explain why they are
pertinent for this patient.

2. List any screening diagnostic and laboratory tests that are not within normal limits. Explain why
these tests are increased or decreased in relation to your patient's medical condition.

Diagnostic/Lab Test Patient Values Analysis of Values


HCO3
20 low COPD, smoker
Calcium

8.3 low Malnutrition r/t abd pain
ALB

3.0 low Liver dysfunction r/t obstruction of
bile duct
Bili


6.2 high

ALK Phos


elevated


AST

Elevated

ALT

elevated