Nursing Interventions and assessments for this pt?

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I'm a 2nd semester nursing student, starting med surg. clinical tomorrow. The pt I was given had colon carcinoma & had a laproscopic surgery a week ago to remove the tumor. There will be an incision in the perineal and abdominal area.

My biggest problem is applying what I learn in class into clinical. Other than changing the dressing, taking vitals, and monitoring I&O's. What else could be done? I understand the basic stuff - inspirex, SCD'S, TED'S etc..

labs show low RBC, Hgb & HCT count which is attributed to the surgery. calcium levels are low - which could be due to vitamin D deficiency (don't have enough info to say this) and BUN levels are a bit elevated. Given this, what interventions can be done?

I also have trouble giving and reporting off to the cover nurse. I never know what to say or what important info should be given. In my first semester, we were told to say "oh we gave the pt a bed bath and changed their bed.." but they're not interested in that.. If someone could give me an example that would help. Thanks in advance!

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Structured reports are best - start with name, age, dx, surgery, other PMH. Talk about recent VS, talk about surgery recovery, status of wound/incision , Bowels ---- very important, pain assessment (!!!) including used pain scale. Beside the usual basic care you also want to see if the pat is ambulating, tolerating nutrition/fluids prescribed diet. Other considerations for a patient with cancer are what is the plan of tx going forward - anything known already? How is the pat coping with dx ?

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Specializes in Medical-Surgical/Float Pool/Stepdown.

Familiarize yourself with SBAR. It's nice that your instructor is having you do a handoff report but in this stage of your game you really don't know what you don't know...even more so than when being a new grad that just passed NCLEX!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

SBAR: Situation, Background, Assessment and Recommendation.....The Joint Commissions gold standard for handoff report and physician communication. Many facilities also focus their documentation using this tool.

  • SITUATION: What is the situation? Why are you calling the physician? What is happening at the present time? What is the acute change? Explain in the fewest words, exactly what the situation is.
  • BACKGROUND: What is the background information? What are the vital signs and pertinent history? Explain how the situation came to be? What were the circumstances leading up to this situation?
  • ASSESSMENT: What is your assessment of the problem? What do you think the problem is?
  • RECOMMENDATION: What should we do to correct the problem/address the situation? What action/response do you propose?

SBAR can be applied to almost all forms of communication between healthcare providers and thus provides a standard framework to transfer important information. SBAR helps students organize their thoughts prior to calling physicians, during handoff to another healthcare provider, and when transferring patients to other organizations or levels of care. SBAR communication technique for shift change report:

  • SITUATION: Patient's/Resident's name, room number, age, diagnosis, chief complaint, medications and allergies.
  • BACKGROUND: Medical history.
  • ASSESSMENT: Observations, such as VS, pain assessment, bowel sounds, lung sounds, current IV lines.
  • RECOMMENDATION: Patient's/Resident's care plan.

Communication and Documentation
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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I'm a 2nd semester nursing student, starting med surg. clinical tomorrow. The pt I was given had colon carcinoma & had a laproscopic surgery a week ago to remove the tumor. There will be an incision in the perineal and abdominal area.

My biggest problem is applying what I learn in class into clinical. Other than changing the dressing, taking vitals, and monitoring I&O's. What else could be done? I understand the basic stuff - inspirex, SCD'S, TED'S etc..

labs show low RBC, Hgb & HCT count which is attributed to the surgery. calcium levels are low - which could be due to vitamin D deficiency (don't have enough info to say this) and BUN levels are a bit elevated. Given this, what interventions can be done?

Think what is important for any surgical patient. If the surgery was laproscopic, and I hate to sound obtuse, why is there two suture lines? (There will be an incision in the perineal and abdominal area. ) If there is suture lines what would be important for you to be aware of? What would you check for?

Now why else is the calcium low? Could that be related to the low H&H? https://labtestsonline.org/understanding/analytes/cbc

Think about your patient....look up the disease and procedures.....then develop your plan of care.....now you know what you need to watch for while you care for your patient.

((HUGS)) trust me it does get easier........eventually

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thanks everyone for the help!

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Specializes in kids.
Think what is important for any surgical patient. If the surgery was laproscopic, and I hate to sound obtuse, why is there two suture lines? (There will be an incision in the perineal and abdominal area. ) If there is suture lines what would be important for you to be aware of? What would you check for?

Now why else is the calcium low? Could that be related to the low H&H? https://labtestsonline.org/understanding/analytes/cbc

Think about your patient....look up the disease and procedures.....then develop your plan of care.....now you know what you need to watch for while you care for your patient.

((HUGS)) trust me it does get easier........eventually

Good to see you back on the boards Esme!

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