Question

Patient Introduction

Location: Surgical Unit 0800

Report from night nurse:

Situation: Mr. Hayes is a 43-year-old white male who underwent a laparoscopic abdominal perineal resection with a permanent sigmoid colostomy 3 days ago for rectal cancer.

Background: Mr. Hayes experienced weight loss, increasing fatigue, and narrowing stools with blood, which led to the diagnosis of rectal adenocarcinoma and the recent surgery.

Assessment: Vital signs have been stable with a saturation of 94%–97%. Pain level is currently 1 after pain medication was administered an hour ago. The colostomy appliance is an open-ended pouch attached to a skin barrier. The stoma is red and moist with liquid, brown stool output. The three small abdominal incisions are open to air. There is a clean pad covering the perineal incision. Mr. Hayes has been up and ambulating and is taking full liquids.

Recommendation: It is time for Mr. Hayes's morning assessment. Assess his colostomy, and empty the pouch, if necessary. He can advance to a regular diet as tolerated. Start providing patient education to prepare him for discharge in 2–3 days.

1. Discuss at least 3 (three) nursing interventions with rationale that are implemented to decrease the chances of Mr. Hayes acquiring postoperative Pneumonia.

1.

2.

3.

2. Discuss at least 3 (three) nursing interventions with rationale that are implemented to decrease the chances of Mr. Hayes acquiring a postoperative thrombus formation.

List a different PRIORITY Education nursing diagnosis from the one above (R/T and AEB MUST be there) for Mr. Hayes?

1. Write a GOAL with measurable criteria for the above nursing diagnosis.

2. List three (3) PRIORITY nursing interventions each with rationale for the above Education related Nursing Diagnosis.

Answer 1

Answer to 1Q

1..Auscultate breath sounds. Listen for gurgling, wheezing,crowing or silence after extubation

Rationale:Lack of breath sounds is indicative of obstruction by mucus or tongue and can be corrected by positioning or suctioning.Diminished breath sounds suggest atlectasis. Wheezing indicates bronchospasm whereas crowing or silence reflects partial to total laryngospasm

2.Observe respiratory rate and depth, chest expansion, use of accessory muscles, retraction or flaring of nostrils, skin color and note airflow

Rationale:Ascertains effectiveness of respirations immediately so that corrective measures can be initiated

3.Position client appropriately, depending on respiratory effort and type of surgery

Rationale:Head elevation and left lateral sim's position prevents aspirations or secretions of vomitus, enhances ventilation to lower lobes and relieves pressure on diaphram

Answer to 2Q

1. Evaluate circulatory and neurological studies of extremiites both sensory and motor.Inspect legs from groin to foot for skin color,temperature changes as well as edema. Note symmetry of calves; measure and record calf circumference. Report proximal progression of inflammatory process and travelling pain

Rationale: Symptoms help to distinguish between thrombophlebitis and venous thromboembolism(VTE). . Redness, heat, tenderness and localized edema are characteristic of superficial involvement. Unilateral edema is the most significant finding of VTE. Calf vein involvement is associated with absence of edema;femoral vein involvement is associated with mild to moderate edema; ileofemoral vein is characterized by severe edema

2.Evaluate for presnece of Homan's sign(pain in the calf of the leg upon dorsiflexion of the foot with legs extended

Rationale: Is easily applied at point of care and is an assessment that clinicians often perform

3.Initiate passive or active exercise while in bed; for eg: flex, extend and rotate feet periodically. Assist with gradual resumption of ambulation as soon as client is out of bed

Rationale:These measures are designed to increase venous return from lower extremities and reduce venous stasis as well as improve general muscle tone and strength

Answer for 3Q

Deficient kowledge regarding condition, prognosis, self-care and discharge needs related to lack of exposure;recall, information misinterpretation and unfamiliarity with information sources as evidenced by inaccurate follow-through of instruction(ostomy care), inappropriate hostile behaviours(Hostile,agitated and apathic)

Goal

Client will

verbalize understanding of condition, disease process, prognosis and potential complications

Correctly perform necessary procedures and explains reasons for action

Interventions

1.Evaluate client's physical, emotional and cognitive capabilities

Rationale: These factors affect client's ability to master tasks and willingness to assume responsibilty for ostomy care

2.Include written and picture(Photo,video, internet) learning resources

Rationale:Provide references for providing support,equipment and additional information after discharge to support client efforts for independence in self-care

3.Instruct client in stoma care. Allot time for return demonstrations and provide positive feedbacks for efforts

RationalePromotes positive management and reduces risk of improper ostomy care and development of complications