Here is the case. A 48 years old woman who just had abdominal surgery. And she is having an IV infusion of 5% dextrose running at 500mL in 6hours. The IV stopped running and her infusion site is swelling and pallor. She is also complaining about the IV is hurting her. She is feeling pain, discomfort and general malaise. She has hypertension and intermittent episodes of gout in her past health history. Here are her vital signs.
BP 148/62, Pulse:62, Temperature:36.5, Respiratory rate:26, SpO2 % in room air.
What are the significance and importance in this case?What should the care plan be? like an actual problem and potential problem? Impaired tissue integrity?
Online teaching has limited my study nowadays. May anyone please give me some help?
Specializes in Endoscopy/Gastroenterology, General Surgery.
7 hours ago, Wuzzie said:
You can, and should order it on-line. Do you have access to Amazon?
Open your text book and read about abdominal surgeries.
Try "Nursing Care Plans: Diagnoses, Interventions, and Outcomes by Meg Gulanick PhD APRN FAAN (Author), Judith L. Myers RN MSN (Author)". I have heard good things about this book from people using it to write care plans. It's one of the best NANDA books published.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
Here's what jumped out at me: how likely would she be having general malaise from an infiltrated IV? What is the main location for her pain? Just her IV site? Also the pulse ox number is missing from her VS.
Specializes in Endoscopy/Gastroenterology, General Surgery.
30 minutes ago, TriciaJ said:
Here's what jumped out at me: how likely would she be having general malaise from an infiltrated IV? What is the main location for her pain? Just her IV site? Also the pulse ox number is missing from her VS.
SpO2 is 100% based on his/her other duplicated posting. I remember because he/she was also wondering if having 100% SpO2 is normal.
Do you know the answer to that? This can be one of your nursing dx
Here are all the nursing diagnoses I have noticed. Thank you for your help!
Acute pain is related to the initial postoperative period of the abdominal surgery, secondary to IV infiltration and the past health history of Intermittent episodes of gout, as evidenced by a chief complaint of pain, tachypnea, and reported that the IV is hurting the patient.
Ineffective airway clearance is related to the administration of anesthetic and analgesics during the abdominal surgery as evidenced by tachypnea.
Impaired tissue integrity is related to the leakage of IV fluid into surrounding tissue due to IV infiltration as evidenced by swelling and pollar around the infusion site.
Risk for infection is related to the surgical site and tissue damage because of IV infiltration.
I am wondering should I also put hypertension as one diagnosis or just ignore it as I think it should be normal with a past health history?
There are other nursing diagnoses that might occur, should I also mention them, like the disturbed sleeping pattern because of pain, and disturbed body image? Since the case given doesn't give any evidence, I can't see them as an actual problem. And I have taken a look at the functional health pattern, they cannot put with "risk for".
Specializes in Endoscopy/Gastroenterology, General Surgery.
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NG KIU HO
Ineffective airway clearance is related to the administration of anesthetic and analgesics during the abdominal surgery as evidenced by tachypnea.
Think again why the patient will have ineffective airway clearance. It has nothing to do with the anesthetic. When patient has a wound in their abdomen, and especially in post-op day 1-2, he/she is usually bed resting...what would the breathing pattern like? Shallow or deep?
Think again why the patient will have ineffective airway clearance. It has nothing to do with the anesthetic. When patient has a wound in their abdomen, and he/she is usually bed resting...what would the breathing pattern like? Shallow or deep?
should it be shallow in supine?
Also here is another one.
Activity intolerance is related to the pain from the surgery site and infusion site, and the prolonged bed rest needed during the initial postoperative period of the abdominal surgery as evidenced by a chief complaint of general malaise and discomfort.
Think again why the patient will have ineffective airway clearance. It has nothing to do with the anesthetic. When patient has a wound in their abdomen, and he/she is usually bed resting...what would the breathing pattern like? Shallow or deep?
But I have just read some researches and they mentioned that mucus form and retain with the effect of anesthetic and analgesics. And those drugs will also depress the action of cilia on the lining of the respiratory tract, so as to reduce the effectiveness of mucus removal.
If it is nothing to do with anesthetic, will "ineffective breathing pattern" be more appropriate?
I can’t properly quote on my old iPad (will answer some of your questions tomorrow) but just wanted to say you’re doing a great job. You’re really thinking more clearly and obviously working hard. I’m super proud that you took my tough love words and really applied yourself instead of just disappearing. Being able to take criticism and using it to steer your growth is a great attribute. Keep up the good work! ??
Specializes in Endoscopy/Gastroenterology, General Surgery.
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NG KIU HO
they mentioned that mucus form and retain with the effect of anesthetic and analgesics. And those drugs will also depress the action of cilia on the lining of the respiratory tract, so as to reduce the effectiveness of mucus removal.
This is true (and I am glad you did you research), which is why its important to teach our post-op patients deep breathing and coughing technique (this can be one of the interventions) but if the abdominal pain is not managed properly, the patient will less likely to practice DB&C. And we all know if too much mucus sitting in the lungs of a patient with wounds who is not breathing effectively, It can turn into ....? You are on the right track...remember...we look at the patient as a whole, dont focus on just one thing.
This is true (and I am glad you did you research), which is why its important to teach our post-op patients deep breathing and coughing technique (this can be one of the interventions) but if the abdominal pain is not managed properly, the patient will less likely to practice DB&C. And we all know if too much mucus sitting in the lungs of a patient with wounds who is not breathing effectively, It can turn into ....? You are on the right track...remember...we look at the patient as a whole, dont focus on just one thing.
So positioning is also a related factor of ineffective airway clearance. Thx for your guide!
Also, I am going to add one more ND for hypertension.
Decreased cardiac output is related to the hx of hypertension (also wound pain?) as evidenced by BP 148/60.
But I saw some information pages mention that hypotension is also a sign of decreased cardiac output. Therefore, I am confused about this.
Specializes in Endoscopy/Gastroenterology, General Surgery.
17 hours ago, NG KIU HO said:
So positioning is also a related factor of ineffective airway clearance. Thx for your guide!
Of course it can, imagine a patient who can sit up on his/her own and breathe normally versus a patient who guard/shield his/her abdominal wound and unwilling to breathe normally because of the pain
17 hours ago, NG KIU HO said:
Also, I am going to add one more ND for hypertension.
Decreased cardiac output is related to the hx of hypertension (also wound pain?) as evidenced by BP 148/60.
Ummm...I personally don't think it can decrease cardiac output. Other commenters can correct me If I am wrong.
I talked about your case study with my colleague...she also wants you to be focus on
On 3/17/2020 at 4:57 PM, NG KIU HO said:
Risk for infection is related to the surgical site and tissue damage because of IV infiltration.
What can risk of infection lead to? There could be serious complication to that; even though the given vital signs are not very suggesting it, but one of the vital signs did meet the criteria.
On the other hand, I want you to know that; for any type of surgery, and especially for abdominal surgery, the patient is first placed on clear fluid diet, and then NPO before the surgery. So mentioning I & O is critical. In this case, the vital didn't show that the patient is dehydrated (VS will be hypotension and tachycardia) but I want to keep in mind that other patients can have fluid deficit; especially after surgery because we expect moderate amount of blood loss from any type of surgery.
Rosalie Blythe, BSN, RN
57 Posts
Try "Nursing Care Plans: Diagnoses, Interventions, and Outcomes by Meg Gulanick PhD APRN FAAN (Author), Judith L. Myers RN MSN (Author)". I have heard good things about this book from people using it to write care plans. It's one of the best NANDA books published.