I am in my 1st semester of nursing and on my 1st week of clinicals I had a post-op pt with an elective total hip replacement the prior day. He was 80 and had no additional health concerns over than high BP. His Hgb, Hct, WBC were low, and his BP was running 90/52 (normally takes hypertensive meds/BP dropped post surgery). He received 1 unit of blood while I was there. Surgeon's rpt indicated less than 200cc blood loss. His incision looks good - no swelling, dressing was clean, dry, entact - drain was removed prior to my shift starting. He was not ambulated following surgery d/t low BP, and was not ambulated the next day d/t the same. PT did ROM exercises with him.
I am completely lost about a Nursing Dx. I thought about Risk for Infection or Impaired Skin Integrity d/t surgical incision but I have used these Dx's already. My clinical instructor will not let us use the same Dx's back-to-back (even if it fits).
WOW great information I will print this!! THANK YOU
Okay so it is
Acute pain r/t hip surgery aeb patient states pain 5 out of 10 on movement
Constipation r/t depressant affects of narcotic analgesic, decreased activity, decreased intake of food and fluids aeb patient is on vicodin, lost his appetite and on a bed rest. (Should I also include vomiting here? when I read the adverse effects of vicodin, it states there constipation, vomiting?)
Imbalanced nutrition: less than body requirements r/t nausea, loss of nutrients associated with vomiting and feeling of fullness aeb hyperactive bowel sounds, inadequate food intake (he intake only 20%) , poor muscle tone
Muskuloskeletal impairment r/t total hip surgery, acute pain aeb patient states pain 5 out of 10 on muscle movement.
Sensory problem? I wasnt able to check his balance, but his right pupil didnt constrict when checked with a pen light. Also, he doesn't have any hearing problems. He wears glasses but he doesnt know his prescriptions. He also said that he has been having problems with his eyes especially the right one so I encourage him to see an ophthalmologist. He was able to use the walker from bed to toilet with minimal assistance.
What do you think?? I used sparks and taylor nursing diagnosis reference manual and my assessment, hey you want to know my interventation that I did for this patient?
My interventions for him includes:
1. To assess his respiratory and encourage the use of incentive spirometer and deep breathing
a. Reason: after surgery, patients have a high risk of respiratory ailment due to the tube inserted during surgery/anesthesia, lung collapse
2. To check his vital signs, temp, BP, Pulse ox
a. Reason: essential for every post op patients, to make sure he is recovering well
3. To check his wound/skin
a. Reason: To make sure that it is healing well, intact, and has no signs of complications
4. To check for pain
a. Reason: it is important to the patient so he can function well
5. To make sure he eats/eliminate, encourage him to eat crackers and drink sprite to determine whether he will vomit again or not
a. Reason: patient lost his appetite because of vomiting 10/27/09, fluid imbalance might happen or dehydration
6. To ambulate him or at least move him
a. Will promote better healing for him and inhibit muscle wasting, prevent pressure ulcers
i. Patient can use the crutch, walker properly.
ii. Patient was seen by a PT.
7. To check his neurological status
a. To make sure patient is not confused or in any mental condition because of anesthesia/medications, or pain.
8. To provide therapeutic communication
a. To talk to patient and encourage the patient to open up if he has any concern, also talk to the patient’s wife so they will feel secure that someone is caring for them
9. To always provide safety
a. Patient had a hip surgery, he is susceptible to fall therefore bed should be in the lowest position every time I leave, side rails should be up, call light should be with in reach, make sure I wash my hands or pump in then wash out.
10. To check his lab values/medication
a. To better understand his complication and be able to see any apparent value change that might worsen his condition
11. To educate the patient about the use of deep breathing, incentive spirometer, proper body mechanics (how to sleep on his side: make sure he puts pillows in between legs and doesn’t cross his legs), teach about hospital materials (eg. The use of the table)
a. This promotes well being for the patient and his wife.
Specializes in med/surg, telemetry, IV therapy, mgmt.
maflores84 said:
WOW! great information I will print this!! thank you
okay so it is
acute pain r/t hip surgery aeb patient states pain 5 out of 10 on movement
constipation r/t depressant affects of narcotic analgesic, decreased activity, decreased intake of food and fluids aeb patient is on vicodin, lt his osappetite and on a bed rest. (should I also include vomiting here? when I read the adverse effects of vicodin, it states there constipation, vomiting?)
imbalanced nutrition: less than body requirements r/t nausea, loss of nutrients associated with vomiting and feeling of fullness aeb hyperactive bowel sounds, inadequate food intake (he intake only 20%) , poor muscle tone
muskuloskeletal impairment r/t total hip surgery, acute pain aeb patient states pain 5 out of 10 on muscle movement.
sensory problem? I wasnt able to check his balance, but his right pupil didnt constrict when checked with a pen light. also, he doesn't have any hearing problems. he wears glasses but he doesnt know his prescriptions. he also said that he has been having problems with his eyes especially the right one so I encourage him to see an ophthalmologist. he was able to use the walker from bed to toilet with minimal assistance.
what do you think?? I used sparks and taylor nursing diagnosis reference manual and my assessment, hey you want to know my interventation that I did for this patient?
my interventions for him includes:
1. to assess his respiratory and encourage the use of incentive spirometer and deep breathing
a. reason: after surgery, patients have a high risk of respiratory ailment due to the tube inserted during surgery/anesthesia, lung collapse
2. to check his vital signs, temp, bp, pulse ox
a. reason: essential for every post op patients, to make sure he is recovering well
3. to check his wound/skin
a. reason: to make sure that it is healing well, intact, and has no signs of complications
4. to check for pain
a. reason: it is important to the patient so he can function well
5. to make sure he eats/eliminate, encourage him to eat crackers and drink sprite to determine whether he will vomit again or not
a. reason: patient lost his appetite because of vomiting 10/27/09, fluid imbalance might happen or dehydration
6. to ambulate him or at least move him
a. will promote better healing for him and inhibit muscle wasting, prevent pressure ulcers
I. patient can use the crutch, walker properly.
ii. patient was seen by a pt.
7. to check his neurological status
a. to make sure patient is not confused or in any mental condition because of anesthesia/medications, or pain.
8. to provide therapeutic communication
a. to talk to patient and encourage the patient to open up if he has any concern, also talk to the patient's wife so they will feel secure that someone is caring for them
9. to always provide safety
a. patient had a hip surgery, he is susceptible to fall therefore bed should be in the lowest position every time I leave, side rails should be up, call light should be with in reach, make sure I wash my hands or pump in then wash out.
10. to check his lab values/medication
a. to better understand his complication and be able to see any apparent value change that might worsen his condition
11. to educate the patient about the use of deep breathing, incentive spirometer, proper body mechanics (how to sleep on his side: make sure he puts pillows in between legs and doesn't cross his legs), teach about hospital materials (eg. the use of the table)
a. this promotes well being for the patient and his wife.
thankyou daytonite
please read the information I gave you on the construction of a nursing diagnostic statement because it seems like you still aren't understanding it. your sparks and taylor nursing diagnosis reference manual should have information in the beginning of it on the construction of a care plan. you need to read it.
constipation r/t depressant affects of narcotic analgesic, decreased activity, decreased intake of food and fluids aeb patient is on vicodin, lt his osappetite and on a bed rest. (should I also include vomiting here? when I read the adverse effects of vicodin, it states there constipation, vomiting?)
problem:
constipation.
definition
: decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry, stool.
etiology (cause):
are OK
symptoms
(the evidence proving that the problem, constipation, exists):
patient is on vicodin -
being on vicodin is part of the etiology (r/t) of this problem (your
depressant affects of narcotic analgesic
). you are just stating more specifically what narcotic is being used. being on vicodin is
not
being constipated because it is
not
evidence of any decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry, stool.
lt his osappetite
- can't read or understand what you are saying here
on a bed rest
- laying in bed is
not
being constipated because it is
not
evidence of any decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry, stool.
check your sparks and taylor nursing diagnosis reference manual for the defining characteristics of constipation so that you get these symptoms right.
imbalanced nutrition: less than body requirements r/t nausea, loss of nutrients associated with vomiting and feeling of fullness aeb hyperactive bowel sounds, inadequate food intake (he intake only 20%) , poor muscle tone
problem:
imbalanced nutrition: less than body requirements.
definition
: intake of nutrients insufficient to meet metabolic needs
etiology (why this is happening):
nausea
loss of nutrients associated with vomiting
- I would just shorten this to "vomiting"
feeling of fullness
symptoms:
hyperactive bowel sounds
inadequate food intake (he intake only 20%)
- for how long a period of time?
poor muscle tone
- poor muscle tone of what muscle?
muskuloskeletal impairment r/t total hip surgery, acute pain aeb patient states pain 5 out of 10 on muscle movement.
problem:
muskuloskeletal impairment
.
not a nanda diagnosis so I have no idea what the definition of this problem is, but it sounds like you are meaning it to be either
acute pain
or
impaired physical mobility
.
sensory problem? I wasnt able to check his balance, but his right pupil didnt constrict when checked with a pen light. also, he doesn't have any hearing problems. he wears glasses but he doesnt know his prescriptions. he also said that he has been having problems with his eyes especially the right one so I encourage him to see an ophthalmologist. he was able to use the walker from bed to toilet with minimal assistance.
I would have asked him to talk more about his vision problem.
disturbed sensory perception, visual r/t brain surgery aeb difficulty with vision in right eye.
msAnneRN11
27 Posts
WOW great information I will print this!! THANK YOU
Okay so it is
Acute pain r/t hip surgery aeb patient states pain 5 out of 10 on movement
Constipation r/t depressant affects of narcotic analgesic, decreased activity, decreased intake of food and fluids aeb patient is on vicodin, lost his appetite and on a bed rest. (Should I also include vomiting here? when I read the adverse effects of vicodin, it states there constipation, vomiting?)
Imbalanced nutrition: less than body requirements r/t nausea, loss of nutrients associated with vomiting and feeling of fullness aeb hyperactive bowel sounds, inadequate food intake (he intake only 20%) , poor muscle tone
Muskuloskeletal impairment r/t total hip surgery, acute pain aeb patient states pain 5 out of 10 on muscle movement.
Sensory problem? I wasnt able to check his balance, but his right pupil didnt constrict when checked with a pen light. Also, he doesn't have any hearing problems. He wears glasses but he doesnt know his prescriptions. He also said that he has been having problems with his eyes especially the right one so I encourage him to see an ophthalmologist. He was able to use the walker from bed to toilet with minimal assistance.
What do you think?? I used sparks and taylor nursing diagnosis reference manual and my assessment, hey you want to know my interventation that I did for this patient?
My interventions for him includes:
1. To assess his respiratory and encourage the use of incentive spirometer and deep breathing
a. Reason: after surgery, patients have a high risk of respiratory ailment due to the tube inserted during surgery/anesthesia, lung collapse
2. To check his vital signs, temp, BP, Pulse ox
a. Reason: essential for every post op patients, to make sure he is recovering well
3. To check his wound/skin
a. Reason: To make sure that it is healing well, intact, and has no signs of complications
4. To check for pain
a. Reason: it is important to the patient so he can function well
5. To make sure he eats/eliminate, encourage him to eat crackers and drink sprite to determine whether he will vomit again or not
a. Reason: patient lost his appetite because of vomiting 10/27/09, fluid imbalance might happen or dehydration
6. To ambulate him or at least move him
a. Will promote better healing for him and inhibit muscle wasting, prevent pressure ulcers
i. Patient can use the crutch, walker properly.
ii. Patient was seen by a PT.
7. To check his neurological status
a. To make sure patient is not confused or in any mental condition because of anesthesia/medications, or pain.
8. To provide therapeutic communication
a. To talk to patient and encourage the patient to open up if he has any concern, also talk to the patient’s wife so they will feel secure that someone is caring for them
9. To always provide safety
a. Patient had a hip surgery, he is susceptible to fall therefore bed should be in the lowest position every time I leave, side rails should be up, call light should be with in reach, make sure I wash my hands or pump in then wash out.
10. To check his lab values/medication
a. To better understand his complication and be able to see any apparent value change that might worsen his condition
11. To educate the patient about the use of deep breathing, incentive spirometer, proper body mechanics (how to sleep on his side: make sure he puts pillows in between legs and doesn’t cross his legs), teach about hospital materials (eg. The use of the table)
a. This promotes well being for the patient and his wife.
THANKYOU DAYTONITE