Don't know where to go with process paper

  1. Question: I have to come up with a care plan for a pt admitted to the hosp. with dysphagia and a weight loss of 25 lbs over the past 2 months. On the day that I took care of him he had already undergone a transhiatal esophagastrectomy, jeujunostomy, and pleural chest tube instertion (turns out is was an esophageal tumor). So I guess my question is, do I address the dysphagia in the careplan, or his post-op needs? In one part of the paper I'm supposed to describe in detail his chief complaint (at admission it was dysphagia and weight loss), but at the time of care he was unable to verbalize whether he still was having trouble swallowing or not. Would appreciate any input!
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    About s_le2006

    Joined: May '08; Posts: 24; Likes: 25

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  3. by   Daytonite
    a care plan is nothing more than strategies that tell how you have decided to address and solve nursing problems that the patient has. you use the nursing process to determine what those problems are and the sequence you take to make some conclusions about the care. the nursing process requires you to follow a logical and rational sequence.

    so i guess my question is, do i address the dysphagia in the careplan, or his post-op needs? this depends on if he still has the dysphagia after surgery. you absolutely address his postop needs in the care plan. i doubt that the staff nurses are ignoring his post op needs. this is the primary reason he is hospitalized--to have his post op needs taken care of because he doesn't have the equipment or the training to do them by himself at home. in one part of the paper i'm supposed to describe in detail his chief complaint (at admission it was dysphagia and weight loss), but at the time of care he was unable to verbalize whether he still was having trouble swallowing or not. would appreciate any input!

    you will describe his dysphagia and weight loss in detail. this information would have been in the doctor's history and physical exam. the fact that he may or may not have either symptom now is not what that question is asking you.

    as for the actual plan of care, it will be based on the abnormal assessment data you obtained on the day you took care of him. a care plan addresses actual and potential problems--not past problems. your assessment of him was
    • he was unable to verbalize (talk)
    being more experienced i might have asked him some "yes" and "no" questions that he could have given some nonverbal answers to. you may not know if he still has his dysphagia postoperatively, but you do know that he is not able to talk and that is an assessment item you can use.

    you need to look up specific information about this surgery and what is altered so you know the anatomical changes that were made to better understand what things need to be monitored in this patient and what specific nursing care he will need. you also need to remember to address potential complications of anesthesia.

    you should also be able to find a specific post op care plan for this specific type of surgery on this website:
    • http://www.pana.org/ - generic care plans for all kinds of surgeries - to access the care plan bank, click on the "student activities" link at the left side of the home page. when the pana student resources page comes up, scroll down and click on the "care plan bank" link. these are intraoperative care plans.
    other websites you can check for information for this care plan are:
    i am posting the following information on dysphagia and weight loss. not all of it applies to your assignment, but i thought that some of it would be useful to you and all of it is informative. this patient will most likely have a bit of both problems, but it is hard to know because both are difficult to assess immediately after surgery; the dysphagia because the patient is often npo and the weight loss because it is something that is assessed over time. the pathophysiology of the dysphagia is what is eating at me. i could not find information to indicate that the dysphagia was due to the tumor itself or swelling in the throat caused by the inflammatory processes of the cancer which would subside once the tumor was removed.

    this is the information from nurse's 5-minute clinical consult: signs & symptoms pages 190-191:
    overview
    • refers to difficulty swallowing, the most common symptom of esophageal disorders
    • factors that interfere with swallowing: severe pain, obstruction, abnormal peristalsis, impaired gag reflex, and excessive, scanty or thick oral secretions
    • classified by three phases: transfer of chewed food to back of throat (phase 1), transport of food into the esophagus (phase 2), or entrance of food into stomach (phase 3)
    • increases the risk of choking and aspirating and may lead to malnutrition and dehydration
    history
    • obtain a medical and surgical history
    • ask about the onset and description of pain, if present
    • determine aggravating and alleviating factors
    • ask about recent vomiting, regurgitation, weight loss, anorexia, hoarseness, dyspnea, or cough.
    physical assessment
    • evaluate swallowing and cough reflexes.
    • if a sufficient swallow or cough reflex is present, check the gag reflex.
    • listen to the patient's speech for sign's of muscle weakness.
    • check the mouth for dry mucous membranes and thick, sticky secretions.
    • observe for tongue and facial weakness and obstructions.
    • assess for disorientation.
    causes
    • esophageal cancer
      • painless dysphagia (phases 2 and 3) with weight loss are the earliest and most common findings
      • as the cancer advances, dysphagia becomes painful and is accompanied by steady chest pain, hemoptysis, hoarseness, and sore throat.
    nursing considerations
    • stimulate salivation by talking about food, adding a lemon slice or dill pickle to food tray, and providing mouth care.
    • with decreased salivation, moisten food with liquid.
    • give an anticholinergic or antiemetic to control excess salivation, as prescribed.
    • consult with the dietician to select foods with distinct temperatures, consistencies, and textures.
    • consult a therapist to assess the patient's aspiration risk and to begin exercises to aid swallowing.
    patient teaching
    • explain measures the patient can take to reduce the risk of choking and aspiration, including food choices.
    • teach the patient about prescribed medications.
    • teach the patient about the underlying condition, diagnostic tests, and treatments.
    from pages 604-605 on weight loss:
    overview
    • occurs with decreased food intake, decreased food absorption, increased metabolic requirements, or a combination of these.
    history
    • take a diet history, noting use of diet pills and laxatives.
    • question the patient about why he isn't eating properly, if applicable.
    • ask about previous weight and if weight loss is intentional.
    • note sources of anxiety or depression.
    • ask about changes in bowel habits, nausea, vomiting, abdominal pain, excessive thirst, excessive urination, or heat intolerance.
    physical assessment
    • check height and weight.
    • take vital signs and note general appearance.
    • examine the skin for turgor and abnormal pigmentation.
    • look for signs of infection or irritation on the roof of the mouth; note hyperpigmentation of thee buccal mucosa.
    • check the eyes for exophthalmos and the neck for swelling.
    • evaluate breath sounds.
    • inspect the abdomen for wasting; palpate for masses, tenderness and enlarged liver.
    causes
    • cancer
      • weight loss occurs with findings specific to the tumor, including fatigue, pain, nausea, vomiting, anorexia, abnormal bleeding, or a palpable mass.
    nursing considerations
    • take daily calorie counts and weigh the patient weekly.
    • consult a nutritionist to determine an appropriate diet with adequate calories.
    • administer hyperalimentation or tube feedings to maintain nutrition.
    patient teaching
    • provide guidance in proper diet and keeping a food diary.
    • instruct the patient in good oral hygiene.
    • provide a referral to nutritional and psychological counseling, if appropriate.
    • discuss underlying disorder and treatment plan.

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