Need help with my cafre plan....

pharmgirl · Jun 28, 2009

Go to rncentral.com, thats where I usually can find most intervention along with goals. I'm sure Daytonite will be here shortly also to give you a hand, she is the care plan queen LOL.

Daytonite, BSN, RN · Jun 28, 2009

your diagnostic statement is not complete.

problem (nursing diagnosis):

risk for bleeding

etiology (cause, in this case the risk factor):

what is it that puts her in danger of starting to bleed? you need to be very clear about what is putting her at risk here.

then, the nursing diagnostic statement is risk for bleeding r/t ______. nursing interventions for any "risk for" diagnosis will be:

strategies to prevent the problem (bleeding) from happening in the first place
removing the risk factor, if possible
monitoring for the specific signs and symptoms of this problem (hemorrhaging and from exactly where)
reporting any of these symptoms if they do occur to the doctor or other concerned professional

so, i am not real clear as to what is going on here. did this patient already have a hysterectomy and you are now worried about postoperative hemorrhage? read this page on the surgical procedure of hysterectomy:

http://www.surgeryencyclopedia.com/fi-la/hysterectomy.html - hysterectomy
http://emedicine.medscape.com/article/267273-overview - hysterectomy

the complications of a hysterectomy include: internal bleeding, blood clots, damage to other organs such as the bladder, and post-op infection. for internal bleeding (hemorrhage) your interventions will be things to prevent postoperative hemorrhage (not that there will be many that i can think of because it would probably be physician error and then we would all be charting really closely because there is going to be a lawsuit if she dies), monitoring for the signs and symptoms of postoperative hemorrhage and reporting any signs and symptoms of postoperative hemorrhage to the doctor.

i was trying to find information on the cause of postop bleeding in hysterectomy patients and this is all i could find. http://en.wikipedia.org/wiki/hysterectomy states: "the open technique carries increased risk of hemorrhage due to the large blood supply in the pelvic region, as well as an increased risk of infection from the need to move intestines and bladder in order to reach the reproductive organs and to search for collateral damage from endometriosis or cancer. however, an open hysterectomy provides the most effective way to ensure complete removal of the reproductive system as well as providing a wide opening for visual inspection of the abdominal cavity." again, if it happens, it is probably because the surgeon missed tying off a small artery and the fix is to discover it, go back in surgically and tie it off. the nursing part in this will be to discover the signs and symptoms of internal bleeding and report them asap. so, your diagnosis would be risk for bleeding r/t surgical removal of the uterus.

problem (nursing diagnosis):

risk for bleeding

etiology (cause, in this case the risk factor):

surgical removal of the uterus(the thing causing the risk for any bleeding that might happen)

symptoms of internal hemorrhage are:

saturation of one perineal pad every 2 - 4 hours
falling blood pressure
shock
- weak, rapid, irregular pulse
- pallor
- cold, moist skin

interventions:

(mostly assessment and monitoring):
- note the amount of any drainage on the incisional dressing; if the drainage increases, note the time and amount
- monitor number of perineal pads saturated and in what length of time
- measure vital signs q4h (or more frequently if necessary)
- monitor lab reports for decreasing hemoglobin and hematocrit levels
- maintain a patent iv access
- notify the physician if the patient's vital signs change and pulse becomes tachycardic, b/p falls significantly and skin becomes cool and pale.

you might also want to read http://www.merck.com/mmpe/sec18/ch248/ch248a.html - uterine fibroids (leiomyomas; myomas; fibromyomas)

SD2LB · Jun 29, 2009

oh sorry...i wasnt clear...she just had the hysterectomy ...so this is post op care....i also was going to do ineffective coping but she didnt show problems or grief about her hysterectomy...

Daytonite, BSN, RN · Jun 29, 2009

A nursing diagnosis is merely a label for a nursing problem. There has to first be evidence (signs and symptoms) of Ineffective Coping if the patient has that before you can put that label on her and use it. The definition of Ineffective Coping is the inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources (page 254, NANDA International Nursing Diagnoses: Definitions and Classifications 2009-2011). People who do not cope well do not recognize threats against them, know how to relieve their tension, are poor solvers of their own problems, and often have low confidence in themselves. The defining characteristics (one or more need to be present) are:

abuse of chemical agents
change in usual communication patterns
decreased use of social support
destructive behavior toward others
destructive behavior toward self
fatigue
high illness rate
inability to meet basic needs
inability to meet role expectations
inadequate problem solving
lack of goal directed behavior/resolution of problem, including inability to attend to and difficulty organizing information
poor concentration
risk taking
sleep disturbance
use of forms of coping that impede adaptive behavior
verbalization of inability to ask for help
verbalization of inability to cope

I had a hysterectomy, was thrilled about it and never shed a tear. Not everyone is going to grieve (Nursing Diagnosis: Grieving) over the loss of a body part that was defective and painful and a problem that is now resolved.

Post operative patients have a common care element. That is that they have all had and are recovering from the effects of either general or a local anesthesia. Patients who have had general anesthesia are subject to these complications and must be monitored for them:

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
constipation
surgical pain
nausea/vomiting (paralytic ileus)

That is why post op patients are given incentive spirometers and continually encouraged to deep breathe and cough (Risk for Ineffective Airway Clearance). If there is an incision, there is a break in the skin and tissue (Impaired Tissue Integrity). And, of course, there is often surgical pain (Acute Pain).