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 interrupted healing of surgical area (dehisedx2, abcess! "ub#ective$ 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
"hort term goal$ goal$ %t will have a pain score of & or less by end of shift
'ong term goal$ %t will be able to state reasons for poor wound healing related to her lifestyle before discharge!
)iddens *oncepts 2 Functional ability 6 Adherence 13 Nutrition 14 Elimination 22 Infection 24 Tissue Integrity 26 Pain
INTERVENTIONS(specific, individualized) and patient –centeed) !"nside t#e f"ll"$in% cate%"ies f" inteventi"ns AssessM"nit"*(+) ! %erform pain assessment 2! Determine age, developmental level, and general state of health
3! "ssess circulation circulation and sensation in su surgical rgical area! 4! #eter$ine #eter$ine nutritional nutritional status and curren currentt inta%e inta%e &! Note lifestyl lifestyle e factors: factors: obesity, obesity, cigarette cigarette s$o%ing, s$o%ing, sedentary lifestyle! AdinisteTeat* AdinisteTeat* (+) &! %ractice and instruct clients and caregivers in proper hand hygiene and aseptic techni+ue for incisional care! ! %rovide optimal nutrition with ade+uate protein! -! Employ non pharmacological healing measures as indicated! .! nspect incisions or wounds routinely, describing changes as necessary 01! Administer antibiotics as appropriate, and medications to manage postoperative discomforts, as well as other concurrent or underlying underlying conditions! 00! *hange wound dressing as ordered per wound nurse! Educati"nteac#in%* (+) 02! nstruct client and caregiver in routine inspection of wound and report changes in wound indicative of failure to heal! 0! 3efer to physical or occupational therapist, wound care specialist, as indicated, discuss what services they will provide! 04! dentify community resources, suggest resources to utili5e and what services they provide! 0! 3efer for counseling or support, discuss importance of mental health therapy! 0&! Discuss the possibility of alternative placement, explain why it may be necessary and what benefits it will provide!
RATIONALE &OR EA!' INTERVENTION ($it# s"uce efeenced AA) AA) ! 6o ascertain whether pain management is ade+uate to meet client7s needs during recovery 2! 6o help determine time that may be re+uired for client to resume AD's and other activities or expectation of time needed for healing!
3! 'o evaluate evaluate for interna internall bleeding bleeding that that co$(ro$ises wound integrity or loss of blood )ow to area, resulting in decreased oxygen su((ly to tissues, or nerve da$age, delaying healing! 4! 'o ascertain ascertain if nutrit nutrition ion is ade*uate ade*uate to to su((ort healing! Client $ay have (reexisting nutritional concerns or $ay have been fasting (reo(eratively or ex(erienced nausea, vo$iting, and loss of a((etite (osto(eratively, de(ending on the surgical (rocedure (erfor$ed and client+s reactions to $edications! &! 'hese 'hese factors factors $ay $ay i$(ede i$(ede recov recovery ery ti$e &!6o reduce incidence of contamination and infection! !6o provide provide a positive nitrogen balance, which aids in healing and contributes to general good health! -!6o promote relaxation of muscles and tissue healing as well as improve coping and outloo8 for a positive healing experience! .! 9bserving the wound bed early and often can help catch future possible complications as early as possible! 01!*lient may re+uire antibiotics perioperatively, insulin to
Nursing Care Plan 334 support tissue repair, or management of chronic pain to improve mobility and tissue recovery! 00! :elps prevent further infection, as well as allowing for a good loo8 at the wound bed!
02!6o establish comparative baseline and allow for e arly intervention! 0! 6o address exercise program and home health care needs, and identity assistive devices to facilitate independence in AD's! 04! ;acilitates ad#ustment to home setting! 0! *lient may need additional help to overcome feelings of discouragement with changes in life! 0&! Brief stay with concentrated support and therapy may speed recovery and return to home! EVAL-ATION* .ee s#"t te %"als etn"t etpatiall/ et0 nfortunately, many clients are stuc8 in their ways, and not interested in changing a lot (i!e! smo8ing, obesity, even in the fa ce of such a health change! "ometimes 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! 'ifestyle changes are not something that can +uic8ly or even directly change the client?s current health concerns, which can ma8e it harder for clients to adhere to these changes! %roviding 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
