Updated: May 1
I'm new to this website and new to nursing too. We have care plan discussions every week within my course; however, I am having trouble with this week's care plan. So any insight from the experts would be great:)
Here is the case study info:
The patient is a 50-year-old male who has undergone a laparotomy and subsequent hemicolectomy of the ascending colon for cancer under general anesthesia.
- mild HT treated with diet and exercise
-diet controlled TYPE 2 DIABETES
-smokes 30 cigarettes a day (33 years)
- weight 130 kg.
- nil known allergies
- CBP - raised white cells, Hb 110
-LFT - normal
- UEC - raised urea, normal creatinine
- C-reactive protein - raised
- BGL - 7mmol
- CXR - Clear
- AXR - loops of gas in the small bowel
-Married, and his wife is in a wheelchair
-three teenage children
-sole income earner for the family
-routine post-op observations
-NGT on 4/24 aspirations and free drainage (aspiration to be replaced with N/saline)
-anti-emetics for nausea and vomiting PRN, IV metoclopramide, 10mg 8/24 PRN
-IVT - 3 liters over 24 hours alternating compound sodium lactate with N/saline
- O2 via nasal specs @ 2L/min
- IV antibiotics:
- IV metronidazole 500mg/100ml TDS
- IV gentamycin 240 mg daily
- IV cephazolin 1g TDS
- S/C morphine 2.5 - 5mg 2/24
- paracetamol 1g 6/24 PR
-wound drain (haemo vac)
-rest in bed for 24 hours, then mobilize as tolerated
On return to the ward
- T 38
- BP 140/80
- PR 108
- RR 26
- Sa02 95%
Now the discussion will focus on the diagnoses and interventions in the first 48 hours after surgery - looking at each of the body's systems (I.e., respiratory, cardiovascular, neurological, renal, gastrointestinal, metabolic, immune, integumentary).
If anyone has any input, it would be much appreciated.
Some of my choices would be activity intolerance, acute pain, the potential for ineffective airway clearance/breathing pattern related to most patients' desire to t/c/db use due to pain, the risk for infection, knowledge deficit, and altered family process.
RNTutor, BSN, RN
What ideas have you come up with for nursing dx/interventions?
I would suggest looking at a nursing dx for post-op. One of the top dx might be an Ineffective Breathing Pattern, maybe r/t pain AEB increased RR. After any abdominal surgery, the pain from the surgical site often leads to shallow breathing. So it is essential to maintain adequate pain control and teach the importance of deep breathing (to reduce the risk of respiratory complications) and proper technique (such as splinting the surgical site with a pillow).
That's one idea. If you post others you have, I'd happily look them over for you.
In which of the body systems should pain management be discussed?
Central nervous system.
DolceVita, ADN, BSN, RN
Welcome to AllNurses.
As you are new, you should know that it is bad form to post a homework assignment, having not shown any effort to answer it yourself. What is good condition is to make a real effort to do it yourself. Post what you got and ask someone to review it.
Sorry if this is snippy. It rubs my rhubarb when people work so hard to finish assignments, and others post case studies, say they don't get it, and get them answered on all nurses. It is no better than copying someone else's work.
I'm with you DolceVita. You won't get by with people doing your work for you in real life. I rarely consult AllNurses unless I've exhausted my resources at home and my brain. This is what lead me to this post -- trying to find my one final diagnosis for a hemicolectomy, LOL.
Archana Shrestha, BSN, RN
We must go according to the nursing process first. Assessing the patient is vital. I usually follow Maslow's hierarchy approach for assessing my patient. The possible nursing diagnosis and the intervention can be as follow:
1. Ineffective Breathing pattern :
Interventions; Auscultate breath sounds, monitor respiratory rate, Vital signs monitoring, Encourage incentive spirometry
2. Acute pain:
Interventions: Vitals signs monitoring, Assessing pain score, Positioning the patient, encouraging relaxation techniques, Administer medications
3. Fluid volume deficit:
Interventions: measure and record I&O, Assess urinary output and NGT- Drain, Inspect Dressing and drainage devices, monitor skin temperature, monitor labs(Hct, Hb, electrolytes), administer parenteral fluids, blood products, administer antiemetics as PRN,
4. Altered sensory/ Thought process :
Interventions: assess sensation or movement of extremities; observe for delusions, hallucinations, and depression; Reorient patient continuously; speak in a standard clear voice and normal tone; use padding and restrains as necessary; secure IV lines and drains also check for patency
5. Knowledge deficient:
Interventions: avoidance of environmental risks, demonstrate dressings or wound care, schedule rest period, review the importance of a nutritious diet
6. Fear and anxiety:
Interventions: provide postoperative education, prevent unnecessary body exposure, give simple, concise direction and explanation, review environmental concerns, control external stimuli, administer medication as needed
7. Risk of Infection:
Interventions: examine skins for breakdown, review lab reports, verify sterility, administer antibiotics as indicated, dress as indicated
These are the common nursing diagnoses in your scenario, but there can be more.
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