my instructor stressed that i need to include items such as monitoring for s/s of dvt, his turning schedule, post-op teaching, incentive spirometer, etc.
your instructor is absolutely correct and that is why, in my first post, i brought up the issue almost immediately that he needs to be monitored for the side effects of general anesthesia and that some of them need to be made a part of your care plan. that is what your instructor was hinting at. respiration complications are a big one. i'm guessing you have never had surgery. i've had 13.i just can't seem to focus on one diagnosis.
i can tell you quite a lot about what major anesthesia does to the respiratory track. they put an et (endotracheal tube) down the patient's throat and then proceed to paralyze the person so the muscles relax and the surgeon can work. while paralyzed, the anesthesiologist places the patient on a ventilator and makes sure the patient keeps breathing. these are not like normal breaths because the patient is so relaxed. secretions begin to build up in the alveoli. fluid depletion occurs during surgery because the person has already been npo for some hours, the body is incised into and fluid escapes through the open body areas into the atmosphere. iv fluids will be given, but replacement doesn't catch up for many hours. when the patient is awakened and recovering from anesthesia, the lungs are being asked to come back to full use again after a period of sluggishness and dehydration. sputum, particularly dried sputum caught up in the alveoli, is a sticky mess and it takes a lot of effort to get it moved out. so much so that it takes up to 3 days, let me repeat that, 3 days, for that sticky sputum stuck in the alveoli of the lungs to get hydrated and moving. if it doesn't, bacteria come along and find a home in it and the patient gets a full-blown case of pneumonia. by deep breathing and coughing, even if the cough is dry and nonproductive, the patient is inflating the most distal alveoli and un-sticking the sputum which is stuck down there and gluing those air sacks shut. every deep breath works at loosening that sticky gunk. my most productive coughing was almost always done on day 3 or 4 after my surgeries and the sputum was always thick, sticky, nasty tasting stuff. and i've had surgeries on my legs, back, neck and abdomen. if you don't have a respiratory diagnosis, where are you going to put your nursing interventions for the deep breathing and coughing and the lung assessments?
turning and moving have to do with respiration and circulation. prevention of a dvt is dependent on maintaining circulation in the lower extremities. people are stationary during surgery. they are drowsy when recovering from anesthesia and not moving normally. even during our normal sleep we make movements, but not when we are drugged up with anesthetics. and, the operative limb isn't going to be doing much independent movement because it hurts and is swollen from the inflammatory response that kicked in because of tissue trauma.
i gave you the weblinks about hip replacements so you could see information in there about what needs to be taught to the patient after surgery and about their recovery.
when you are going to write a care plan, you need to sit down, assemble all the data that you collected and go through a rational process to sort it out--the nursing process as i started to demonstrate it for you. in time you will become familiar with the different nursing diagnoses. many of them are used commonly and over and over again. these two websites list the most commonly used ones and you can also get the nanda information about them:
if you have your own copy of taber's cyclopedic medical dictionary
you will find all the diagnoses listed in the appendix along with the nanda taxonomy information (definition, related factors and defining characteristics) as well as a cross reference with some medical diagnoses.
diagnosing is a skill. it is mastered with experience over time. you will learn to work with nursing diagnoses the same way medical students learn to work with medical diagnoses--on a case by case basis and reading about them when they come up against a case.
this is what i would diagnose for this patient. i think i covered everything. they are prioritized by maslow. "risk for" diagnoses (anticipated problems) are never sequenced before actual problems. if i missed something, you can fill it in. my cats are pawing at my leg for breakfast at the moment. the next step is to take each diagnosis and bring in goals and nursing interventions (this is treatment)--that is step #3 planning (write measurable goals/outcomes and nursing interventions
of the nursing process, the meat of your care plan (problem solving).
i am struggling to match assessment data, and interventions with nanda.
- acute pain r/t surgical invasion aeb patient's ranking of pain at 5 on a 0 to 10 scale
- impaired physical mobility r/t musculoskelatal impairement and inflammation of ___ hip aeb ["impaired gait" is not specific enough. what can't he do? can he get in and out of bed by himself or does he need assistance? say that. does he need one or two people to transfer to a chair? say that.] see these websites that list the defining characteristics (symptoms) of this diagnosis just below the title:
- deficient knowledge, self-care and discharge needs r/t lack of information aeb [evidence you have that patient didn't know specific information about what would be needed at home to help with his recovery]
- risk for ineffective airway clearance r/t effect of anesthesia and narcotics
- risk for constipation r/t decreased activity
- risk for vascular injury r/t altered peripheraltissue perfusion and immobility [this is a diagnosis i would use to monitor for a dvt]
- risk for infection r/t surgical invasion [this is a diagnosis i would use to monitor the wound and specifically to monitor for signs and symptoms of a wound infection]
- risk for falls r/t age, receiving postop narcotic analgesics, hypotensive state and blood loss
you need to keep all three of these things clear in your mind.
is information. assessment is an activity where you are specifically looking for evidence--clues--of nursing problems. it's a hunt. you never know what you are going to find. you may have an idea because you know what the person's medical diagnoses are, but because we ask about their adls we could find anything that is out of the norm. that's why you learn about normal anatomy and physiology and what normal adls are. if something is abnormal it is a symptom, a defining characteristic (this is nanda language), evidence (as in aeb-as evidenced
by), proof that something isn't right. think of yourself, nursing student surviving, as a detective with your antenna up and always on the alert for clues, clues and more clues--that is your mission. you can't have problems without clues and patients would not be in the hospital if they didn't need nursing help. these clues will not always be as simple as something that has gone wrong with their anatomy and physiology. they could be weird behavior, not acting right in society or not accomplishing simple (or more complex) adls.
a nanda, as you are using it, is a nursing diagnosis, or nursing problem identification. the nursing diagnosis is actually just a shortened label that stands in place of a much longer definition. this is why you want to see a nursing diagnosis reference so you understand exactly what you are calling something such as acute pain (unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months--
page 354, nanda international nursing diagnoses: definitions and classifications 2009-2011)
or impaired physical mobility (limitation in independent, purposeful physical movement of the body or of one or more extremities
--page 124, nanda international nursing diagnoses: definitions and classifications 2009-2011
). a care plan is a compiled list
of the patient's nursing problems.
interventions are the strategies you will employ to do something about the nursing problems. you can't perform any interventions (strategies) until (1) you identify the problem and (2) the evidence that supports the existence of the problem. one of the analogies i use is taking a car to a mechanic. if your car is making a knocking sound in the rear end, you take it to a mechanic and the mechanic opens the hood of your car and starts pulling stuff out, does that make sense? are you going to pay the bill when the knocking sound is still there as you start to drive the car away? what did he do wrong? he didn't assess
the situation. how could he apply interventions that pertained to the right problem, the knocking sound in the rear end? what i am saying is that you can't start coming up with interventions until you know what you need to target. in care planning you are also being asked to name (nursing diagnosis) the problem that goes with the evidence. that is why you need to follow the steps of the nursing process which helps keep you on the logical road in doing that. interventions actually target the abnormal data that got collected back during assessment. those abnormal things are really what we would like to correct and many times there are things within our scope of nursing practice that we can do for them.
example: acute pain r/t surgical invasion aeb patient's ranking of pain at 5 on a 0 to 10 scale
- goal: patient will be comfortable
- assess and document patient's level and intensity of pain using the 0 to 10 rating scale with 0 being no pain and 10 being the worst possible pain
- assess and document where the pain is located and what, if anything, makes it worse or better
- observe and document any of the following physical responses: frequent changing of body position, moaning, sighing, grimacing, crying, restlessness, dyspnea, tachycardia, diaphoresis, pallor
- give pain medication as ordered
- provide emotional support by spending time talking to the patient and reassuring them that measures are being taken to relieve their pain
- reposition the patient
- give a back massage
- use short, simple relaxation exercises to distract the patient's attention
- dim the lights in the room and keep noise down
- play soft, soothing music
- have the patient perform slow deep breathing and concentrate on feeling weightless with each breath
- reassess and evaluate the patient's response to each method employed. ask the patient which techniques work better for them.
- monitor for side effects of narcotic therapy: respiratory depression, constipation, nausea/vomiting
- teach the patient about prescriptions they will be going home with including the dosage, how they should be taken and any side effects