hi, kel879, and welcome to allnurses!
have you been reading the care plan threads on the nursing student assistance forum? that is where they are usually posted and i will answer all care plan questions (unless someone ended up on my ignore list).
a care plan is nothing more than the written documentation of your problem solving process. the nursing process is the problem solving process that we use. you must follow the 5 steps of the nursing process in the sequence that they occur
to do the problem solving (therefore, the care plan) properly. otherwise, you end up confused and lost in the woods. these are the five steps and what activities go on in each step:
- assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
- determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
- planning (write measurable goals/outcomes and nursing interventions)
- implementation (initiate the care plan)
- evaluation (determine if goals/outcomes have been met)
now, my first question is how thorough a job did you do in your assessment of this patient because i can only find these symptoms of the patient after going through what you posted:
- decreased respirations
- pain at surgical site, right groin
- ekg shows sinus tachycardia
- edema at surgical site
there is some preliminary work and information you needed to find out before even moving on to step #2 of the nursing process here. first, know the complications of undergoing general anesthesia:
- breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
- hypotension (shock, hemorrhage)
- thrombophlebitis in the lower extremity
- elevated or depressed temperature
- any number of problems with the incision/wound (dehiscence, evisceration, infection)
- fluid and electrolyte imbalances
- urinary retention
- surgical pain
- nausea/vomiting (paralytic ileus)
or epidural anesthesia:
- rash around the epidural injection site
- nausea and vomiting from the opiates administered
- pruritis of the face and neck caused by some epidural narcotics
- respiratory depression up to 24 hours after the epidural
- cerebrospinal fluid leakage and spinal headache from accidental dural puncture
- sensory problems in the lower extremities
you would have assessed for any signs and symptoms of those problems in your patient. this partcular surgery has these specific complications connected with it (page 166, nurse's 5-minute clinical consult: treatments
- hernial recurrence
- chronic neuralgia from damage to nearby nerves
- injury to abdominal structures or the intestines
- spermatic cord injury (not a concern in a female patient)
- bowel or bladder injury
so, post-op assessment (a nursing intervention) would include assessing for signs and symptoms of these things. most of them, you seemed to pick up on as your list of nursing diagnoses indicates. i do not know whether or not you have a list of patient symptoms before you moved on to determine your nursing diagnoses. you should not have even started your outcomes and nursing interventions yet until you did your nursing diagnoses.
i see no information about the incision, how it looks, about the sutures or clips, whether there is any drainage, or if there is a dressing. was the repair done laparoscopically or by open incision? an incision usually warrants a nursing diagnosis of impaired tissue integrity
and the nursing interventions for it include the wound monitoring and wound care. i mention this because i was a med/surg nurse for many years and this was normally one of the first nursing diagnoses to go on our care plans
of surgical patients and i was a little surprised to see it missing from your list of nursing diagnoses.
your construction of all the diagnostic statements is not correct and you do not have them listed in a proper priority of need.
the 3-part nursing diagnosis statement has this structural format:
p - e - s
s = symptoms
problem - etiology(ies) - symptoms\
these are, in nanda language
nursing diagnosis - related factor(s) - defining characteristic(s)
in a care plan they look like this:
problem [related to]etiology(ies)[as evidenced by]symptom(s)
nursing diagnosis [related to] related factor(s) [as evidenced by] defining characteristic(s)
the related factor
is the underlying cause of the problem or the cause
of the signs and symptoms that the patient is having. to help you determine a related factor it is often helpful to know the pathophysiology of the medical disease process going on in the patient. to help you in determining a related factor you can ask yourself "is this the cause of the problem (meaning the nursing diagnosis)", or "is this what is causing the symptoms". remember this important rule
: you cannot list any medical diagnosis as a related factor
. you have to state a medical condition in some other scientific terms. as an example, we don't say a patient is "dehydrated" since that is a medical diagnosis, but we can say "fluid deficit". they essentially mean the same thing--the difference is in the phrasing of the words.
the defining characteristics
are always the signs and symptoms that come from that list you created from your assessment activities. these will be anything from the same signs and symptoms that doctors use to statements made by patients that indicate something wrong to adl evaluations that were not normal.
let me go through the nursing diagnoses you listed one by one after listing them in priority order for you (some instructors want acute pain listed as a top priority; i do not list it that way. maslow includes comfort near the bottom of the physiological needs. you must, however, list acute pain in the priority that your instructors want it listed.):
ineffective breathing pattern r/t decreased depth of respirations associated w/depressant effect of anesthesia
"decreased depth of respirations" is a symptom. it is an abnormal data item you would have picked up during your assessment of the patient. symptoms do not belong in the "r/t" part of the diagnostic statement. etiologies, or causes, of the problem are the only thing that belong there. the related factors, or r/ts, that nanda lists for this particular diagnosis are (page 26, nanda-i nursing diagnoses: definitions & classification 2007-2008):
- body position
- chest wall deformity
- cognitive impairment
- hypoventilation syndrome
- musculoskeletal impairment
- neurological immaturity
- neuromuscular dysfunction
- perception impairment
- respiratory muscle fatigue
- spinal cord injury
in this particular case of a post-op patient it would be ok to simply say "depressant effects of anesthesia" because it is true. so this diagnostic statement should be re-written to say: ineffective breathing pattern r/t depressant effects of anesthesia. if you want to make it a 3-part diagnostic statement, then it would become: ineffective breathing pattern r/t depressant effects of anesthesia aeb decreased depth of respirations.
impaired physical mobility r/t pain at surgical site
actually, nothing wrong here. i, personally, would shorten the r/t part to "surgical pain".
acute pain r/t surgical procedure
nothing wrong here either. i, personally, would change the wording of the r/t part to "surgical intervention"
risk for urinary retention r/t possible edema at surgical site
now, think about this. the r/t part of the diagnostic statement is supposed to be the best underlying cause that you can come up with short of a medical diagnosis that is responsible for the urinary retention. what would actually be causing the urinary retention? the urine not being able to get out of the bladder because. . .the ureters are being squeezed shut, or occluded. yes, the edema is causing it, but it is actually occluded ureters that are the problem. there can be swelling without occluded ureters. so, this should be changed to: risk for urinary retention r/t occlusion of ureters or risk for urinary retention r/t ureteral occlusion.
risk for infection r/t invasive procedures
the reason you are struggling with outcome criteria is, i suspect, because you are not following the steps of the nursing process. nursing diagnoses, goals/outcomes, and nursing interventions are all
based upon the list of signs and symptoms that you develop in the early stage of step #2 of the nursing process which comes after you have done your thorough assessment of the patient. that list is the real foundation
of your care plan, or problem solving.
in formulating outcomes you are linking them to the nursing interventions
you are going to be ordering for your patient's symptoms (nanda calls them defining characteristics, in case you are using a nursing diagnosis reference) and sometimes linking them to underlying etiologies
of the diagnosis. everything in the care plan has to be one big related circle where everything connects back to each other with symptoms
at the heart of it all. so, your outcomes will be the anticipated or expected results you want to see after your nursing interventions have been put into action. sometimes, then, your outcomes will be an improvement of symptoms, or even a total clearing up and disappearance of a symptom. make sense? just about everything in the care plan hangs on that list of symptoms that you come up with after your assessment of the patient.
there is a post on the actual mechanics of how to compose outcome/goal statements here: http://allnurses.com/forums/2509305-post157.html
hope that gets you on track. you will have to take care of many, many patients and write many, many care plans before this stuff starts to sink in and start to get easier and make more sense. but keep at it. as hospital rns we are required by federal law to have a written care plan in every patient chart, so this is partly why you are having to do these. the assessment and nursing intervention parts are also helping you to learn about the various medical conditions patients have which will help you make decisions about their care.