Question

Patient Introduction

Location: Surgical Unit 0800

Report from night shift charge nurse:

Situation: Sara Lin is an 18-year-old female patient who had an emergency appendectomy. It is day 2 postoperative, and Sara is expected to be discharged late this afternoon. We have discontinued her IV antibiotics after her morning dose. She will be getting oral meds today.

Background: Sara presented in the ED 2 days ago with a 2-day history of nausea, vomiting, and increasing pain. She was taken to surgery that day and had an open appendectomy for a ruptured appendix. She has been stable since arriving to the unit. Her parents have been here with her most of the time and are very helpful and supportive.

Assessment: Sara is alert and oriented, appropriate for age. She needs to be reminded to use her incentive spirometer. Abdomen is soft, tender to touch. Bowel sounds active. She has progressed to regular diet, and she's eating small amounts. No nausea reported since postoperative day 1. The abdominal dressing was changed by the surgery team early this a.m. The incision is closed with staples; the edges are well-approximate and only slightly reddened with minimal serosanguinous drainage. Her sequential compression devices were discontinued, and her Jackson-Pratt drain was pulled this morning. A small amount of bleeding was present; no further bleeding is noted. This morning, she had her first small soft brown stool since surgery.

Recommendation: You will have to transition Sara to oral antibiotics and pain medication. She last had pain medication 4 hours ago. You will need to provide discharge patient education on incision care, pain medication and antibiotics, signs of postoperative infection, activity restrictions, and surgical follow-up.

1.Assessment- 2 subjective data, 2 Objective data

2. 1 Nursing diagnosis

3. 2 long term goals, 2 short term goals

4. evaluation of goals, 3 evaluation of intervention

Answer 1

Assessment

Subjective data

1. Pain in the incision area.

2. Anxiety

Objective data

1. Pain scale 6/10

2. Patient is restless

Nursing diagnosis

1. Risk of infection related to incision/ suture in the right lower abdominal area.

Long term goal

1. Within the time of hospitalization the client will identify interventions to prevent or reduce risk of infection by taking prescribed antibiotics timely. And immediately informing the doctor if there is fever, persisting pain and discharge from the wound.

2.At the end of hospitalization the client will participate in prevention measures and treatment program by not doing extensive movement after going home.

Short term goal

1. To make the client identify intervention to prevent or reduce infection.

2. The client will display timely healing of the wound at the incisional site.

​​​​​​Goal evaluation

Assessing the the risk of infection.

Assessing hand hygiene of the caregiver and the client.

Administration administration of correct medication regimen.

Emphasize taking of medication timely and acknowledging patient by non pharmacological measures for decreasing pain.

Keep wound area clean and emphasize on early ambulation

Instruct client in unfamiliar activity and provide alternate ways of doing familiar activity

Instruct client for follow up if any abnormality such as persistent pain, fever, discharge from wound is noted.

Evaluation of interventions

1. The client will identify intervention to prevent or reduce risk of infection at the wounded area by initiating change of dressing at the the wound site and verbalizing benefits of handwash

2. Client will verbalize the decrease of pain after timely taking of prescribed medication also the client will verbalize non pharmacological measures of decreasing pain by diversion through TV and mass media

3. At the end the client will display timely healing of skin lesions/wound without complication by mmanifesting dry wound and intact suture also the client will participate in preventive measures and treatment program by participating in passive range of motion exercises.

4. The client verbalize signs and symptom of infections like fever discharge and pain that should be taken care of and follow-up should be made if these signs persist.

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