Writing a nursing goal,HELP

Daytonite, BSN, RN · Feb 14, 2009

we are nurses and we treat the patient for their nursing problems. a billroth ii is a surgical treatment done by a physician to correct a medical problem which you do not mention. the billroth ii is actually a gastrojejunostomy which is an excision (removal) of most of the lower part of the stomach and duodenum and the surgical connection of the remaining portion of the stomach to the jejunum. it is very similar to the gastric bypass surgeries that are done electively for weight loss except that in this patient's case i suspect there is a more serious reason for this surgery. i hope you were able to go through her chart to find out why this surgery was performed. i'm guessing that this patient either had cancer or peptic ulcer disease that had damaged the stomach and duodenum pretty badly. the subclavian iv with tpn, more medical treatment, is how she is getting her food. the doctors will want her npo for some time while the surgical area heals and if they do allow her to begin oral feeding there will be some issues that will need to be addressed. anytime the tissues of the body are cut into surgically and manipulated by the surgeons, the body responds by evoking the inflammatory response (cardinal signs: redness, heat, swelling and pain).

before any care plan can be started, assessment and data collection must be done. a doctor never diagnoses anyone with a medical disease or medical condition until he takes a history, does a physical exam and sometimes does some testing. we proceed in the same manner. goals don't get determined until a bit later. a care plan is nothing more than a written summary of the patient's nursing problems and strategies that attempt to solve those problems. we employ the nursing process as a tool to help us organize and problem solve. the first step in doing this is assessment. assessment consists of:

a health history (review of systems) - this information will be in the patient's chart and you can ask the patient as well
performing a physical exam - a head-to-toe assessment works great
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - this is what we nurses do exclusive to our profession
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - this is why i say there is an underlying medical reason for the surgery and the billroth ii is just the surgical treatment. it will help your understanding of what is going on to read about this patient's disease and this procedure.
- http://www.medcyclopaedia.com/library/topics/volume_iv_1/b/billroth_ii_procedure.aspx
- http://www.surgeryencyclopedia.com/fi-la/gastroduodenostomy.html - see the section entitled "risks". these are the side effects of this surgery (both the billroth i and ii). vitamin replacement will be life long now for this patient, particular iron and calcium.
- this is your basic surgical patient. all surgical patients who have undergone general anesthesia must be monitored for the following complications:
  - breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
  - hypotension (shock, hemorrhage)
  - thrombophlebitis in the lower extremity
  - elevated or depressed temperature
  - any number of problems with the incision/wound (dehiscence, evisceration, infection)
  - fluid and electrolyte imbalances
  - urinary retention
  - constipation
  - surgical pain
  - nausea/vomiting (paralytic ileus)
[*]reviewing the signs, symptoms and side effects of the medications they are taking

you need to sit down and make a list of everything you can remember about this patient. nursing diagnoses, like medical diagnoses, are based upon symptoms. symptoms are those things you found when you assessed the patient--abnormal data (tubes, incisions, moaning, pain). nursing interventions target and treat those things.

and then, goals are what you predict will happen when your interventions are carried out as you ordered. until i see what your diagnoses and interventions are, i can't help you with any goals. i can give you a link to a thread that shows you how goals and interventions are interlinked to each other: https://allnurses.com/nursing-student-assistance/help-choosing-nursing-369473.html - see post #13

hopeshell · Feb 15, 2009

The patient (male)was admitted because of a GI bleed. Three units of blood were given. A Ct scan showed a tumor in the stomach and an aortic aneurysm. This is the reason the patient had a billirothII. He has a NG tube and a JP drain.The day after surgery labs showed the patient still has low RBC(3.24), HCT(32.2), HGB(10.1), LYMPH (5.6)along with a elevated WBC(10.8) and Neutro(86.7). We are given a patient and are told to audit their chart and write and fill in 80% of a process tool before we even see the patient. We are not allowed to make a nursing diagnosis at this level so we have not covered them in class. Our instructor wants us to write 2 goals pertaining to nutrition, activity exercise,sleep rest, elimination, cognitive perceptual, and health perception health management. She wants us to pick 2 of what we think the top priority is going to be for this patient and they must be specific. After we write gaols we write interventions and a rationale for the interventions. What is hard about this is I dont get to do an assessment on the patient and collect subjective data before writing a goal and after I do get to do the assessment and such I find that my goals needs to be changed. I just try to the best with what I have to work with. So far my clinical experience has been in a nursing home, this only my second week at the hospital and my first week my patient was from the nursing home and I already had taken care of them. That is why I feel out of my league a little right now.

I am really concerned about the status of this patients nutrution because of his labs which are still low but likely is expected after hemorhage and surgery.I feel like one of my goals should do with nutrition but how do I as a nurse treat this patients nutritional needs when he is npo w/ng tube and recieving tpn. I am also concerned about infection post surgery but the only info I got from the chart about the incision was medial abdominal incision with a Jackson Pratt drain. I also feel like I should address pain but the chart said the patient has a pain level of 0 but is on a pca pump and we were told that we cannot use any meds in our goals or treatments.

Daytonite, BSN, RN · Feb 15, 2009

assessment can be done just from getting information from the patient's chart. if you look at what i posted about assessment above the only things you will need to add to that are actually going in and doing a physical exam on him and observing him doing adls. goals can be figured out based on what you know from assessment. this is a post-op patient. patients who have had general anesthesia must have their breathing and circulation (abcs) watched like a hawk.

i would place attention on his respiratory situation. he needs to keep his lungs moving. he just had major surgery on his abdomen and if he doesn't cough and deep breathe he is going to get pneumonia--big time. he needs to splint his abdomen and deep breathe and cough at least q2h. see https://allnurses.com/nursing-student-assistance/help-choosing-nursing-369473.html for respiratory interventions and coughing and deep breathing exercises.

secondly, i would be concerned about his blood volume and fluid situation. hct(32.2), hgb(10.1) is still low. you can call it a fluid deficit (blood is a fluid and blood loss is a loss of the mineral, iron). it affects the oxygen carrying capacity of the blood which has all kinds of ramifications. people get dehydrated in surgery. their peristalsis shuts down when the intestines are manipulated in surgery, so ileus is another real potential complication. fluid third spaces in these bowels where there is no peristaltic activity and it is considered lost fluid that can never be regained (risk for deficient fluid volume) even though the patient is receiving iv fluids. it is why he is npo. i would be monitoring his i&o, watching his ivs to make sure they are infusing at the correct rates and monitoring his chemistries and labs.

these are just working by maslow's hierarchy of needs: oxygen, water and food.