Careplan goal help?!!!

[mg08]

Hello all nurses, students, and everyone!

So i have my OR rotation tomorrow and i am having trouble coming up with a realistic goal for my NDX, i was wondering if anyone could help! I actually dont even know if my NDX is a decent one...so if there are better dx im all ears. So the surgery is a total shoulder arthroplasty, my dx is risk for bleeding. I feel like just saying "pt. will maintain minimal blood loss, or pt. will maintain stable vital signs" are just unrealistic in this situation...

Any help is greatly appreciated!!!!

[DayDreamin ER CRNP]

What would the #1 priority be for a post op patient?

[link51411]

thats not a nursing Dx from what i understand. I would go along the lines of risk for infection r/t surgery. but if you wanted to focus on blood loss I would say risk for altered tissue perfusion t r/t active bleeding in surgery. as for goal give a specific number. say something like pt wont lose more than 500ml of blood and maintain tissue perfusion. always give a goal that can be measured.

[mg08]

I actually used risk for infection, and impaired skin integrity, and risk for impaired tissue perfusion for this patient already. My instructor is having us come up with 4 ndx, which is why im having so much trouble with finding another realistic one. Im just thinking as long as i have something half way realistic sounding it should work...right...??? Thanks for the help though!!!! It helps alot!

[Nurse Kyles, BSN, RN]

What about Anxiety r/t change in health status/hospital environment or fear of the unknown. or Risk for imbalanced Fluid Volume:risk factor: surgery

Not sure if any of those will help. Or perhaps it is too late.

[vmoh18]

Those are all good dx, but I would think along the lines of ABC. Your first priority post-op is to prevent respiratory problems. I would add one r/t to that.

[itsmejuli]

Did you use "impaired mobility"?

[pippylockstocking]

Since this is an OR rotation, you'd probably want to stick more with things that apply to a pre-op patient, rather an a post-op. But could use post-op if you plan to see the patient in recovery, and on the med-surg floor.

Some that come to mind:

Risk for bleeding as you already mentioned

Risk for infection

Pain

Anxiety

Knowledge defecit

Impaired Mobility

Not necessarily in that order though :))

The two goals that you mentioned seem fine to me.

[MissJulie]

Risk for ineffective breathing pattern: risk factors: pain, location of incision, effects of anesthesia or narcotics.

Remember A-B-C :)

[mg08]

Thanks everyone!! You all helped so much! The OR was so cool, after the day was done, i think i had a ton of ndx that came to mind, ones that i just wasnt thinking about since i didnt know what all would happen before, and most of them were ones you all came up with, so thanks again!!!!