Assessment
Other than my patient's history of smoking, she has no significant medical history. She was admitted for an emergency surgery today and had a right colectomy due to cancer. She reports pain of 5/10; T 98.6; BP 110/68; RR 14; and O2 93%. She has a capillary refill of fewer than three seconds, is alert and oriented, and can move all four extremities. Lab values are all normal and patient education on her NG tube, O2, JP drain, and Penrose drain have all started.
Nursing Diagnosis #1
Critical agony r/t colectomy operation earlier today a/e/b verbal pain complaints
NOC: Pain control
NIC: Guided imagery, distraction techniques, pain medication, medication management
Expected Outcomes
According to Mehta et al. (2014) the patient should:
Describing non-pharmacological techniques, which can be applied to support achievement of the comfort-function objective
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Inform punctually team members about intensity level of the pain that is steadily greater than the side effects occurrence, as well as the goal of comfort-function
Planning and Implementation
Establishing if patient is having discomfort during the consultation session and documenting it.
Assess agony intensity as well as discuss what reduces the pain level – try to stay away from narcotics
Evaluation
My patient’s pain after 2 hours in the PACU is now verbalized as a 2/10. My patient has discussed non-pharmacological techniques to relieve her pain and calls when she needs help as well as pain medication (Columbus et al., 2018).
Nursing Diagnosis #2
The risk for aspiration and inadequate nutrition r/t intolerance to tube feeding
NOC: Proper nutritional intake
NIC: Educate on how to use the NG tube, how much to put it in and when
Expected Outcomes
According to Hulshof, Boucherie, Hans, and Hurink (2013) the patient should:
Self-monitoring intake of food, as well as maintaining a diet journal
Maintaining patient’s respiratory tract as well as clearing the tract
Swallowing as well as digesting NG feeder minus desire
Planning and Implementation
Monitoring rate, depth, as well as effort of the respiratory system by noting any signs and symptoms of aspirations including foul-odor sputum, wheezing, and hoarseness, foul-smelling sputum, and fever (Ladwig , 2014).
Frequent auscultation of lung sounds, prior as well as afterward feeding by noting any new wheezing as well as crackles onset.
Track bowel movements and keep a log
Evaluation
On my patients first day of recovery, she is educated on how to use her NG tube, how to keep a record as well as how to monitor for signs of aspiration (Columbus et al., 2018). My patient's husband will be educated, as well.
Nursing Diagnosis #3
Impaired skin integrity risk, right physical rigidity
NOC: Prevent integrity of skin surface
NIC: Turn patient every 2 hours in bed, ambulate patient when ready
Expected Outcomes
According to Ladwig (2014) the patient should:
Properly clean and dress the wound using aseptic techniques
Be able to report any adverse findings to the doctor
Exhibit a better injury prevention understanding
Detail measures to care for the incision
Planning and Implementation
I would develop a care plan that includes the following interventions during the patient’s post-operative recovery (Mehta et al., 2014):
Using aseptic techniques during dressing change
Effectively monitoring pulse and temperature every four hours to evaluate for any elevations
Assessing wound every eight hours for odor and purulent drainage. Furthermore, assessing the wound edges for redness, approximation, inflammation, and edema over anticipated inflammatory reaction.
Teaching the patient aseptic technique use while assessing the wound as well as performing the dressing change.
Teaching the patient wound infection symptoms and signs, as well as when to report findings to the doctor.
Conveying an empathetic understanding of the patient's incisional as well as wound pain
Evaluation
Upon discharging the patient, she will have a well-approximated incision devoid of infection indications. The nurse will be confident that the patient can appropriately assess the incision, and with minimal support can operate the NG tube, drain the Penrose/JP, as well as properly clean and dress the wound using aseptic techniques (Ladwig, 2014). Furthermore, monitor infection signs and symptoms, along with when to report any adverse findings to the doctor.
References
Columbus, A.B., Morris, M.A., Lilley, E.J., & et al. (2018). Critical differences between elective and emergency surgery: identifying domains for quality improvement in emergency general surgery. Surgery , 163 (4), 832-838. Retrieved from https://doi.org/10.1016/j.surg.2017.11.017
Hulshof, P. J., Boucherie, R. J., Hans, E.W., & Hurink, J. L. (2013). Tactical resource allocation and elective patient admission planning in care processes . Health Care Management Science , 16 (2), 152-166. Retrieved from https://doi.org/10.1007/s10729-012-9219-6
Ladwig, G. (2014). Guide to Nursing Diagnosis, (4th ed.). Maryland Heights, Missouri: Mosby Inc.
Mehta, Y., Gupta, A., Todi, S., & et al. (2014). Guidelines for Prevention of Hospital Acquired Infections. Indian Journal of Critical Care Medicine, 18(3): 149-163. doi: 10.4103/0972-5229.128705
