Preop NANDAS need help!

Antikigirl, ASN, RN · Sep 14, 2006

Okay first thing...what is going on with this patient?

Lets look first at some basics. First, pain is going to be a large hurdle at first...so pain is a good one and really should be addressed!

Also, since the surgery/post op/recovery is going to be dealing with lots of narcotic medications...I would thrown in something about elimination either risk or actual and retaining urine post surgery or if there are any complications.

Mobility may also be a factor r/t pain, activity tolerance, narcotic medications, fluid/electrolye imbalances from fluid loss, depression/anxiety and more.

Skin intergrity too...you have a wound now, and if they aren't moving like they should or being turned if they are unable...you have yourself a risk or actual.

Now to the emotional. Many women get a bout of feeling less of a woman because of this, and/or feel saddened with the reality that they can never have children again. This will hit altered sexual health, self esteme, family dynamic changes. Not to mention emotional changes caused by hormone imbalances big time!

Knowledge deficit is one I frequently find in almost all patients. Does the patient understand pain control and how to use it once home? Does the patient know about the effects of hormones after a surgically induced menopause? Does the family know what this all means and that mommy may be feeling painful for a while and can't do as much as she did for a while, and may not be the most patient person in the world..LOL! Lots to go on there!

Now with all of these, I suggest finding the actual probelm or a pretty high risk dependant on your assessment of the patient and work your way backwards. What did you see to trigger this careplan (that is your AEB), What is it you plan to do for the patient to reduce the risk/actual symptoms (that is your implementations). What would be the ACHIEVEABLE outcome given the amount of time you have with the patient or at home (your goals and evaluation of goals included). Why is this happening (your related to but do NOT use MD terminology...spell it all out if necessary...this is a skill to learn :) ). Finally..what NANDA does this one fit into (Bingo your DX!).

Hope that is helpful!

Daytonite, BSN, RN · Sep 14, 2006

I'm a little puzzled by what you mean by "something different". If what you mean is something that is going to make your careplan unique to that patient rather than a "rubber stamped" pre-op patient care plan, then what you have to do is go through this patient's assessment data. That means reviewing all the written information in the chart including the doctor's H&P, History and Review of Systems. Look for a medical disease or condition or some other problem in life that the patient might have that may have an impact on the performance of her ADLs either before or after surgery that will require intervention or pre-op teaching and care plan it.