Professional Documents
Culture Documents
9. Anxiety
A: post operation
- verbalized difficulty sleeping
- stated she was anxious.
- abd pain 9/10
Meds: PRN: 1mg Lorazapam tab
PO Q4H
8. Ineffective Breathing
Pattern
A: Abd incision pain
- abd distention
- tachycardia
- tachypnea
- dyspnea
- SOB
Tx: Turn, cough & deep
breathe Q2H
- Use IS
- Position with pillows as
needed.
- Splint abd incision by using
hands or a pillow.
- Ambulate in hallway TID
- Up in chair BID
- HOB elevated at least 30
degrees.
Meds: O2 as needed
Sheryl Sato
3. Pain
A: Abd surgical wound
- Rates pain btwn 8-9/10
Tx: Frequent position changes
- Healing Touch
Meds: 1,000mg Acetaminophen IV
Q6H
- PRN: 4mg Dilaudid tab PO Q4H
- PRN: 1-2mg Dilaudid inj. with
dressing changes.
MHx: Recurrent SBO
- Chronic Pain Syndrome
- Nephrolithiasis
4. Infection
A: WBC: 12.05
- 4+ Staph Aureus
- 4+ Strep Group B
Meds: 600mg Clindamycin IVPB
Q8H
- Topical Dakins 0.25% sol.
6. Imbalanced Nutrition:
Less Than Body
Requirements
A: post-laparoscopy
- Recent NPO status
- albumin: 3.1
- Trace of Ketones in urine
Meds: TPN: Standard
Formula @70mL/hr.
- Fat Emulsions (Intralipid)
20% 240mL 2x/wk.
Interventions
1. Assess for S&S of fluid volume
deficit (decreased skin turgor, dry
mucous membranes, thirst, sudden
weight loss of 2% or greater, postural
hypotension or low BP, weak &
thready pulse, cap refill time >3
seconds, change in mental status
and elevated BUN.
2. Assess for S&S of hypokalemia
(cardiac dysrhythmias, postural
hpotension, muscle weakness, N/V,
continued abd distention, hypoactive
or absent BS and low serum
potassium.
3. Assess for hypochloeia &
metabolic alkalosis (dizziness,
irritability, paresthesias, muscle
twitching or spasms, hypoventilation,
low serum chloride, elevated pH &
TCO2.
4. Administer Protonix (and
Ondansetron PRN)as scheduled to
prevent N/V.
5. Perform actions to reduce fever if
present (administer antypyretics,)
sponge client with tepid water,
remove excessive clothing or
bedcovers, in order to prevent
diaphoresis & subsequent loss of
fluid.
6. Measure drainage (pt had NG tube
before) & administer replacement
fluids as ordered.
7. Adminiser fluid & electrolyte
replacements (NS IV & TPN.)
8. Maintain a fluid intake of at least
2,500 mL/day, unless
contraindicated.
1. Monitor & report any postoperative
bleeding (intraabdominal,
intraluminal & incisional.)
2. Assess hydration status by
monitoring BP & HR and checking
9. Anxiety:
1. The patient uses effective coping
mechanisms.
2. The patient describes a reduction
in the level of anxiety experienced.
III. Evaluation
3. Pain:
Desired Outcome:
1. Patient reports satisfactory pain control at a level less than 3-4 on a 010 rating scale.
2. Patient uses both pharmacological & nonpharmacological pain relief
strategies.
Evaluation: Desired outcome has been NOT MET based on the following:
1. Patient consistently rates pain between 8-9 on a 0-10 rating scale.
Diet: After surgery, the diet will start first with a clear diet with sips
then advancing to half-cup to one-cup portions. Foods allowed on the
clear diet are broths, gelatin, ice pops, jice and carbonated beverages
that are clear in color. Then you will advance to the full liquid diet.
This includes all of the foods allowed in the clear liquid diet in addition
to milk, smooth yogurt, pudding, creamed soups without chunks, and
hot cereals. Since this diet is limited in calories and protein & your
bowel need to rest, you will get additional nutrients from your TPN &
lipids. Then you will advance to the low fiber diet. This temporarily
limits the amount of fiber you get to encourage diet tolerance and
bowel healing. High fiber foods such as fruits, vegetables, beans and
whole grains (whole grain bread, cereal, rice.) Select foods low in fiber
or with 3g of fiber or less. To transition back to a regular diet, your
doctor will gradually incorporate fiber-containing foods such as a
swelling, bleeding, looks larger or deeper, looks dried out or dark, there
is increased drainage (from and around the wound), if the drainage is
increasing, the drainage becomes thick, tan, yellow and if there is a
bad smell.
-
Works Cited
Gulanick, Meg & Myers, Judith L. (2011). Nursing Care Plans (7th ed). St.
Louis, Missouri: Elsevier.
Lewis, S.L. Dirkensen, S., Heitkemper, M. Bucher, L. & Camera, I. (2011).
Medical-Surgical Nursing (8th ed). St. Louis, Missouri: Elsevier.
No
Instructor comments