surgical care plan help

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Specializes in assisted living.

Hi!

I am just looking for help picking my top dx for my patient. She has a lot of things going on so I can't decide!; long story short: She had a cholecystectomy and parastomal hernia repair. In the past she had a sacral tumor removed that left her w/ decreased function, circulation, and feeling to the LE and also in the abdomen (so she has a colostomy and urostomy) She is obese. She is in a lot of pain and has nausea. Her bowel function has not returned yet so she is not taking in much but is on IV fluids. She is on 2L of O2 because of low sats. So here are some of my dx...I feel like I can come up with a million for her! I will leave off my r/t and AEB just to shorten things up...

Nausea

Acute Pain

Decreased GI motility

Impaired Nutrition (due to low intake) or (due to high intake -obesity)

Decreased tissue perfusion (to LE from blood vessel damage)

Risk for Impaired tissue perfusion r/t blood clots

Impaired Gas exchange (she is on O2)

Risk for Infection (pneumonia or r/t incision)

Impaired Skin Integrity (incision)

Altered Elimination (colostomy/urostomy)

My instructors in the past wanted us to use ABCs and Maslows first...but this instructor said to use Pain and Nutrition/Hydration r/t to low intake as my first two. which does make sense since they are big issues right now... so now I just need the third. What would be more important, decreased GI motility or impaired skin integrity? both current problems but would her lack of bowel function be considered more normal at this point since she just had surgery? And then there is her risk for blood clots. She already has SCDs on and is taking lovenox. Any thoughts on what would be the best 3rd dx to use? I am just not sure what is most important here. I thought that blood clots would be high on the ABC scale, but it is just a risk at this point. ABC's for breathing...she is on O2 but her sats have been 95% + and I foresee her being weaned off shortly.

Thanks!!

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Specializes in ER trauma, ICU - trauma, neuro surgical.

Good job with getting all those ND's! I would agree to use ABC's and Maslows to prioritize. The "at risk for" can be argued. It's something that hasn't happened, but if they do happened, it can be life-threatening. I would say the altered elimination and impaired skin integrity is lower on the scale. Skin integrity would be higher if it was r/t to decub ulcers but the incision isn't a big deal. I would probably go with impaired gas exchange. The blood vessel damage factor is chronic, and the "at risk for's" are more of a potential issue....not current. She definitely has impaired gas exchange, even if her sats are fine. Plus, it is common for surgical pts to get post-op atelectasis. Even simple abd surgery can cause lots of resp complications. If she did have a blood clot, that would be my first choice. Hope this helps!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Hi!

I am just looking for help picking my top dx for my patient. She has a lot of things going on so I can't decide!; long story short: She had a cholecystectomy and parastomal hernia repair. In the past she had a sacral tumor removed that left her w/ decreased function, circulation, and feeling to the LE and also in the abdomen (so she has a colostomy and urostomy) She is obese. She is in a lot of pain and has nausea. Her bowel function has not returned yet so she is not taking in much but is on IV fluids. She is on 2L of O2 because of low sats. So here are some of my dx...I feel like I can come up with a million for her! I will leave off my r/t and AEB just to shorten things up...

Nausea

Acute Pain

Decreased GI motility

Impaired Nutrition (due to low intake) or (due to high intake -obesity)

Decreased tissue perfusion (to LE from blood vessel damage)

Risk for Impaired tissue perfusion r/t blood clots

Impaired Gas exchange (she is on O2)

Risk for Infection (pneumonia or r/t incision)

Impaired Skin Integrity (incision)

Altered Elimination (colostomy/urostomy)

My instructors in the past wanted us to use ABCs and Maslows first...but this instructor said to use Pain and Nutrition/Hydration r/t to low intake as my first two. which does make sense since they are big issues right now... so now I just need the third. What would be more important, decreased GI motility or impaired skin integrity? both current problems but would her lack of bowel function be considered more normal at this point since she just had surgery? And then there is her risk for blood clots. She already has SCDs on and is taking lovenox. Any thoughts on what would be the best 3rd dx to use? I am just not sure what is most important here. I thought that blood clots would be high on the ABC scale, but it is just a risk at this point. ABC's for breathing...she is on O2 but her sats have been 95% + and I foresee her being weaned off shortly.

Thanks!!

Ok....here is my take......

Her current problem is that she has had a cholecystectomy and a parastomal hernia repair. So this is the priority of THIS present admission. So........

This patient has acute pain for the present surgery......if you had a big surgery pain relief would be a big priority. As a nurse you want her to have pain relief so she will ambulate/move and cough/deep breath to prevent pneumonia and blood clot formation as well as facilitate the stimulation of peristalsis, wake up the bowels which will decrease her nausea and increase her intake. So there is a lot riding on this patients pain relief to shorten her hospital stay and decrease the chance of compilations.

Personally......I would think she has Delayed Surgical recovery AEB all the factors listed above......

NANDA-I Definition:

Extension of the number of postoperative days required to initiate and perform activities that maintain life, health, and well-being

Defining Characteristics: Difficulty in moving about; evidence of interrupted healing of surgical area (e.g., red, indurated draining, immobilized); fatigue; loss of appetite with nausea; loss of appetite without nausea perception that more time is needed to recover; postpones resumption of work/employment activities; requires help to complete self-care; report of discomfort; report of pain

Related Factors (r/t)

Extensive surgical procedure; obesity; pain; postoperative surgical site infection; preoperative expectations; prolonged surgical procedure

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