Your patient is a 52-year-old male with a history of smoking and alcohol abuse. He presents to the ED with complaints of “my skin looks yellow, my stomach hurts, and I feel nauseous”. He is taken to CT and a tumor near the pancreas is observed. It appears to be blocking the common bile duct. Develop a plan of care for the patient. Use the attached concept map.
NUR2790_Module 10_Concept Map_v2.docx
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NUR2790_Module10_ConceptMap_v2.docx
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Student’s Name Rasmussen NPR Concept Plan Date
Nursing Interventions
Possible Nursing Diagnosis
Clinical Manifestations
Subjective:
Objective:
Medical Diagnosis
Patient Data/Risk Factors
Possible Medications
Patient Education
Diagnostic Data
Pathophysiology
Medical Interventions
____________________________
Nursing Interventions:
Assess vital signs and monitor for any signs of distress or complications.
Provide pain management using prescribed medications and non-pharmacological techniques.
Monitor and manage the patient’s fluid and electrolyte balance.
Administer antiemetic medications as prescribed to alleviate nausea and vomiting.
Collaborate with the healthcare team to prepare the patient for further diagnostic tests or procedures.
Assist with positioning and comfort measures to promote patient’s well-being.
Encourage and assist the patient with activities of daily living as tolerated.
Possible Nursing Diagnosis:
Acute Pain related to the tumor near the pancreas and blockage of the common bile duct.
Imbalanced Nutrition: Less Than Body Requirements related to impaired digestion and absorption caused by the tumor.
Risk for Deficient Fluid Volume related to vomiting, nausea, and obstruction of the common bile duct.
Anxiety related to the diagnosis and treatment plan.
Clinical Manifestations:
Subjective:
Complaints of skin appearing yellow.
Stomach pain.
Nausea.
Objective:
Jaundice (yellowing of the skin and eyes).
Abdominal tenderness or pain.
Nausea and vomiting.
Weight loss.
Medical Diagnosis:
Tumor near the pancreas causing blockage of the common bile duct.
Patient Data/Risk Factors:
52-year-old male.
History of smoking and alcohol abuse.
Possible Medications:
Pain medications (e.g., opioids, nonsteroidal anti-inflammatory drugs).
Antiemetic medications (e.g., ondansetron, metoclopramide).
Patient Education:
Educate the patient about the diagnosis, treatment plan, and prognosis.
Provide information about the importance of smoking cessation and alcohol abstinence.
Explain the purpose, dosage, and possible side effects of prescribed medications.
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Provide emotional support and resources for coping with anxiety and stress.
Diagnostic Data:
CT scan showing a tumor near the pancreas and blockage of the common bile duct.
Pathophysiology:
The patient’s history of smoking and alcohol abuse puts him at risk for developing pancreatic cancer. The tumor near the pancreas is blocking the common bile duct, leading to the backup of bile in the liver and resulting in jaundice. The obstruction can also cause abdominal pain, nausea, and vomiting. The impaired functioning of the pancreas can lead to difficulties in digestion and absorption of nutrients, resulting in weight loss and imbalanced nutrition.
Medical Interventions:
Consultation with a gastroenterologist for further evaluation and management of the pancreatic tumor.
Possible surgical intervention, such as a pancreaticoduodenectomy (Whipple procedure) or endoscopic stent placement to relieve the obstruction.
Chemotherapy or radiation therapy may be considered as part of the treatment plan, depending on the stage and extent of the tumor.
Ongoing monitoring of the patient’s condition and response to treatment.
