Nursing Care Plan 334

Nursing Diagnosis Statement (include subjective and objective data): Delayed surgical recovery r/t extensive surgical procedure, pain, obesity,
postoperative surgical site infection AEB, perception that more time is needed to recover, report of pain, loss of appetite with nausea, evidence of interrupted healing of
surgical area (dehisedx2, abcess).
Subjective: pt reports pain at surgical site, not interested in food, states usually has poor wound healing
Objective: dehiscence x2, abscess, need for wound vac, delayed healing
SMART GOALS
INTERVENTIONS(specific, individualized) and patient centered)
Consider the following categories for interventions
Assess/Monitor:(5)
1. Perform pain assessment
Short term goal:
2. Determine age, developmental level, and general state of health
Pt will have a pain score of 6 or
less by end of shift
3. Assess circulation and sensation in surgical area.
4. Determine nutritional status and current intake
5. Note lifestyle factors: obesity, cigarette smoking,
sedentary lifestyle.
Long term goal: Pt will be able to
Administer/Treat: (5)
state 5 reasons for poor wound
6. Practice and instruct clients and caregivers in proper hand hygiene and aseptic
healing related to her lifestyle
technique for incisional care.
before discharge.
7. Provide optimal nutrition with adequate protein.
8. Employ non pharmacological healing measures as indicated.
9. Inspect incisions or wounds routinely, describing changes as necessary
Giddens Concepts
10. Administer antibiotics as appropriate, and medications to manage
2 Functional ability
postoperative discomforts, as well as other concurrent or underlying conditions.
6 Adherence
11. Change wound dressing as ordered per wound nurse.
13 Nutrition
14 Elimination
Education/teaching: (5)
22 Infection
12. Instruct client and caregiver in routine inspection of wound and report
24 Tissue Integrity
changes in wound indicative of failure to heal.
26 Pain
13. Refer to physical or occupational therapist, wound care specialist, as
indicated, discuss what services they will provide.
14. Identify community resources, suggest resources to utilize and what services
they provide.
15. Refer for counseling or support, discuss importance of mental health therapy.
16. Discuss the possibility of alternative placement, explain why it may be
necessary and what benefits it will provide.

RATIONALE FOR EACH INTERVENTION

(with source referenced APA)
1. To ascertain whether pain management is adequate
to meet client's needs during recovery
2. To help determine time that may be required for
client to resume ADLs and other activities or
expectation of time needed for healing.
3. To evaluate for internal bleeding that
compromises wound integrity or loss of
blood flow to area, resulting in
decreased oxygen supply to tissues, or
nerve damage, delaying healing.
4. To ascertain if nutrition is adequate to
support healing. Client may have
preexisting nutritional concerns or may
have been fasting preoperatively or
experienced nausea, vomiting, and loss
of appetite postoperatively, depending
on the surgical procedure performed
and clients reactions to medications.
5. These factors may impede recovery
time
6.To reduce incidence of contamination and infection.
7.To provide a positive nitrogen balance, which aids in
healing and contributes to general good health.
8.To promote relaxation of muscles and tissue healing as
well as improve coping and outlook for a positive healing
experience.
9. Observing the wound bed early and often can help catch
future possible complications as early as possible.
10.Client may require antibiotics perioperatively, insulin to

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support tissue repair, or management of chronic pain to
improve mobility and tissue recovery.
11. Helps prevent further infection, as well as allowing for
a good look at the wound bed.

12.To establish comparative baseline and allow for early

intervention.
13. To address exercise program and home health care
needs, and identity assistive devices to facilitate
independence in ADLs.
14. Facilitates adjustment to home setting.
15. Client may need additional help to overcome feelings of
discouragement with changes in life.
16. Brief stay with concentrated support and therapy may
speed recovery and return to home.
EVALUATION:
Were short term goals met/not met/partially met? Yes, while my patient was not able to give a pain score by the end of my shift, she was sleeping comfortably when I left.
What modifications would you make to achieve a goal that was not met or partially met? My patient was very keen on ambulation, which can be both a positive and a negative
for a diagnosis as this. If she had more pain issues, I would have encouraged her to rest more between ambulations.
Identify, initiate and evaluate at least one primary strategy in this plan of care: Continuous monitoring of the wound allows us to catch any problems hopefully before they start,
if not soon after. Since this client has had her wound dehiscence twice, as well as one abscess within the incision, she is at high risk of continued complications. This however requires
strong compliance from the nursing staff, following all of the wound care nurses exactly, and contacting wound at the first sign of possible issue.
Identify one secondary prevention strategy in the plan of care: Screening for underlying issues.
Evaluate the secondary prevention strategy: Unfortunately, many clients are stuck in their ways, and not interested in changing a lot (i.e. smoking, obesity), even in the face of
such a health change. Sometimes the best that we can do is give them the information, and hope that even a small bit of it will get through, and become something that they can
change. Lifestyle changes are not something that can quickly or even directly change the clients current health concerns, which can make it harder for clients to adhere to these
changes. Providing screenings during the admission can help identify problems or potential problems early, and hopefully change their ways before they become a habit. Doing so can
help identify diabetes, hypertension, etc as soon as possible.

Nursing Care Plan 334