I am having a hard time coming up with a short nursing care summary for my patient with diverticulitis. She is post op today, colostomy in lower left quadrant, did not respond to antibiotics, she has had a segmental resection of sigmoid colon, abscess drain, peristomal hernia, and small bowel resection. She had surgery to take down colostomy and repair peristomal hernia. I don't even know where to start. Do I use post op nursing care or do I jump right in to all the other problems, this is just a summary that I need to come up with, the care plan I will do after I meet her. Any help would be much appreciated. Other history: asthma, 5 vessel bypass, MI, DM 2, CAD, CKD, past cervical fusion, and depression.
May 21, '12
What is your role? Will you be providing long term care or short term, hospital stay care? Long term, every one of her co-morbidities will affect her outcomes. However, you can't bombard her with too much information. Start simply, post-op care & recovery first. If you're caring for her while she's in hospital, add to your summary whatever your role is in getting home care/post-hospital care set up. If you'll be caring for her longer term, can you say in your summary that you will focus first on post-op care and then add in subsequent cares and education as appropriate? Good luck!