Question

Case Scenario: Your unit received Mrs. C as admission from post-anesthesia care unit (PACU) Mrs. C is 82-yrs old and underwent Right Colectomy (Right-Sided Colon Resection) to remove a non-malignant tumor. Vitals were stable in PACU. Mrs. C has “PIV in Right AC” (peripheral IV catheter in right arm), indwelling urinary catheter, naso-gastric tube (NGT) and “O2 per NC at 4L/min” (oxygen through nasal cannula going at 4 liters). Mrs. C received Morphine Sulfate 5 mg through IV push in the PACU and has a PCA (patient-controlled analgesia) Morphine Sulfate 1 mg every 10 min. You assess level of consciousness and note Mrs. C is slow to respond to your questions

3.) Name 2 priority nursing diagnoses for Mrs. C (include 1 “actual” diagnosis and 1 “risk for” diagnosis)

4.) Plan 3 nursing interventions that relate to your nursing diagnoses. Set 1 goal with 2 expected outcomes for Mrs. C at time of discharge.

Answer 1

FROM THE QUESTION:

A PATIENT 82 YEARS OLD UNDERGONE RIGHT COLECTOMY TO REMOVE A NON- MALIGNANT TUMOR.

PERIPHERAL IV CATHETER IN RIGHT ARM

INDWELLING URINARY CATHETER IN SITU.

NASO-GASTRIC TUBE

OXYGEN THROUGH NASAL CANNULA 4L/min

inj.MORPHINE SULPHATE 5 mg IV PUSH RECIEVED BY THE PATIENT

(PATIENT CONTROLLED ANALGESIA) inj. MORPHINE SULPHATE 1mg EVERY 10 MIN

LEVEL OF CONSCIOUSNESS- SLUGGISH TO RESPOND

PRIORITY NURSING DIAGNOSIS

1. RISK OF INEFFECTIVE AIRWAY CLEARANCE RELATED TO DEPRESSED RESPIRATORY FUNCTION,PAIN,AND BED REST .

2. ACUTE PAIN RELATED TO SURGICAL INCISION

INTERVENTIONS

• GOAL : RELIEVING PAIN

MOST PATIENTS EXPERIANCE SOME PAIN AFTER A SURGICAL PROCEDURE . MANY FACTORS INFLUENCE THE PAIN EXPERIANCE .THE DEGREE AND SEVERITY OF POST OPERATIVE PAIN AND THE PATIENT'S TOLERANCE FOR PAIN DEPEND ON THE INCISION SITE, THE NATURE OF THE SURGICAL TRAUMA ,THE TYPE OF ANESTHETIC AGENT ,AND HOW THE AGENT WAS ADMINISTERED.

OPIOID ANALGESIC

OPIOID ANALGESICS ARE COMMONLY PRESCRIBED FOR PAIN AND IMMEDIATE POSTOPERATIVE RESTLESSNESS.A PREVENTIVE APPROCH ,RATHER THAN AN " AS NEEDED " (PRN) APPROACH , IS MORE EFFECTIVE IN RELIEVING PAIN.WITH A PREVENTIVE APPROACH , THE MEDICATION IS ADMINISTERED AT PRESCRIBED INTERVELS   RATHER THAN WHEN THE PAIN BECOMES SEVERE OR UNBEARABLE.

PATIENT - CONTROLLED ANALGESIA

GIVEN THE NEGATIVE IMPACT OF PAIN ON RECOVERY, NURSES NEED TO THINK "PAIN PREVENTION" RATHER THAN SPORADIC PAIN CONTROL AND SHOULD ENCOURAGE THE USE OF PCA.THE AMOUNT OF MEDICATION DELIVERED BY THE IV OR EPIDURAL ROUTE AND THE TIME SPAN DURING WHICH THE OPIOID MEDICATION IS RELEASED ARE CONTROLLED BY THE PCA DEVICE.SELF ADMINISTRATION PROMOTES PATIENT PARTICIPATION IN CARE, ELIMINATES DELAYED ADMINISTRATION OF ANALGESICS,AND MAINTAIN A THERAPEUTIC DRUG LEVEL.

EPIDURAL INFUSIONS AND INTRAPLEURAL ANESTHETIC

EPIDURAL INFUSIONS PROVIDE BETTER POSTOPERATIVE ANALGESIA COMPARED WITH PARENTERAL OPIOIDS.  

3. DECREASED CARDIAC OUTPUT RELATED TO SHOCK OR HEMORRHAGE

4. RISK FOR ACTIVITY INTOLERANCE RELATED TO GENERALIZED  WEAKNESS SECONDARY TO SURGERY

INTERVENTIONS

GOAL: ABILITY TO PERFORM SELF- CARE ACTIVITIES

1. HELPS THE PATIENT MOVE GRADUALLY FROM THE LYING POSITION TO THE SITTING POSITION BY RAISING THE HEAD OF THE BED AND ENCOURAGES THE PATIENT TO SPLINT THE INCISION WHEN APPLICABLE .
2. POSITION THE PATIENT COMPLETELY UPRIGHT ( SITTING) AND TURNED SO THAT BOTH LEGS ARE HANGING OVER THE EDGE OF THE BED.
3. HELPS THE PATIENT STAND BESIDE THE BED.

BED EXERCISES INCLUDE

• ARM EXERCISES
• HAND AND FINGER EXERCISES
• FOOT EXERCISES
• LEG FLEXION AND LEG LIFTING EXERCISES
• ABDOMINAL AND GLUTEAL CONTRACTION EXERCISES

5. IMPAIRED SKIN INTEGRITY RELATED TO SURGICAL INCISION AND DRAINS

6. INEFFECTIVE THERMOREGULATION RELATED TO SURGICAL ENVIRONMENT AND ANESTHETIC AGENTS.

7. RISK FOR IMBALANCED NUTRITION ,LESS THAN BODY REQUIRMENTS RELATED TO DECREASED INTAKE AND INCREASED NEED FOR NUTRIENTS SECONDARY TO SURGERY.

8. RISK FOR CONSTIPATION RELATED TO EFFECTS OF MEDICATION ,SURGERY, DIETARY CHANGE ,AND IMMOBILITY.

9. RISK FOR URINARY RETENTION RELATED TO ANESTHETIC AGENTS.

10. RISK FOR INJURY RELATED TO SURGICAL PROCEDURE / POSITIONING OR ANESTHETIC AGENTS.

11. ANXIETY RELATED TO SURGICAL PROCEDURE

12. RISK FOR INEFFECTIVE MANAGEMENT OF THERAPEUTIC REGIMEN RELATED TO WOUND CARE ,DIETARY RESTRICTION, ACTIVITY RECOMMENDATION ,MEDICATIONS ,FOLLOW -UP CARE OR SIGNS AND SYMPTOMS OF COMPLICATION.

FROM ABOVE NURSING DIAGNOSIS WE CAN TAKE TWO OF THEM MARKED GREEN