V.

NURSING MANAGEMENT
PRE-OPERATIVE NURSING CARE PLANS
Problem # 1: Acute Pain
Assessment Nursing Diagnosis Scientific explanation Objectives Nursing Interventions Rationale Expected Outcome

S= O=Patient manifested:

Acute pain related to bowel distension secondary to disease condition

Lim ited movements Bo dy malaise Gu arding behavior

faci al grimaces cryi irrit ng

ability

The presence of a tumor creates an obstruction in the colon and because of this mechanical obstruction or fecal impaction, there is an impairment of flow in the intestinal contents of the GI. This would activate the secretory cell activity, releasing fluid and air which would then collect to the proximal site of the obstruction. As a

Short term: After 4 hours of nursing interventions, the patients pain will be minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10. Long Term: After 3 days of nursing interventions, the patient will be relieved from pain and will have vital signs within

Establish rapport Assess the patients condition

To gain patients trust To obtain baseline data and to plan for the appropriate care Alteration in Vital signs is evident in the presence of pain To obtain information about the pain that the patient is manifesting

Assess vital signs.

Short term: The pain shall have been minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10. Long Term: The patient shall have been relieved from pain and will have vital signs within normal limits.

Assess patients degree of pain every time she verbalizes pain

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incr eased vital signs especially BP

movement Q- sharp R- mid abdomen

P-

result, fluid and air accumulation occurs and thus distension occurs. This distension would then cause pressure and irritation of the nerve endings within the intestinal mucosa

normal limits.

Reposition patient Provide quiet environment

Serves as a comfort measure To decrease environment stimulus and promote rest To alleviate feeling of pain To lessen pain

Provide comfort measures Advise the patient to deep breathing exercises. Encourage patient to do diversional activities such as watching TV or talking to a family members Administer analgesics as prescribed

S- pain scale of 6/10 T-every time movement is elicited patient may manifest:

To lessen pain by allowing the patient to focus on other things

spiration

per sig

ns and symptoms of inflammation

Provides pharmacologic treatment to lessen patients pain

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at surgical site moaning, shouting, sighing

Problem # 2: Mild Anxiety

Assessment Nursing Diagnosis Scientific explanation Objectives Nursing Interventions Rationale Expected Outcome

S= O=Patient manifested: Restlessness Irritability Increased perspiration Anorexia Insomnia

Anxiety related to threat of death and possible complications after surgery

patient may manifest:

spiration

per

Fear of the unknown is the most prevalent causes of preoperative anxiety. The patient experienced a vagua uneasy feeling of discomfort or dread accompanied by an autonomic response. A feeling of apprehension caused by anticipation of danger in surgery.

Short term: After 4 hours of nursing interventions, the patients pain will use resources and support system effectively. Long Term: After 4 days of nursing interventions, the patient will appear relaxed and report anxiety is reduced to a manageable level.

Assess patients general condition

To know the patients condition and provide necessary actions and interventions. To obtain baseline data

Short term: The patients pain shall have used resources and support system effectively. Long Term: The patient shall have appeared relaxed and reported anxiety is reduced to a manageable level.

Monitor and record vital signs Observe the patients behaviour indicative of level of anxiety. Identify the patients coping skills and review coping

This can be a clue to the patients anxiety level To determine those that might be helpful in current

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sig ns and symptoms of inflammation at surgical site moaning, shouting, sighing

It enables the client to take measures to deal with the threat.

skills in the past. Establish a therapeutic relationship, conveying empathy and unconditional positive regard. Acknowledge anxiety or fear.

circumstances

To assist patient to identify feelings and begin to deal with problems.

Do not deny or reassure patient that everything will be alright Helps patient to identify what is reality based

Provide accurate information about the situation Provide comfort measures such as providing calm/quiet environment, soft music and back rub.

To limit degree of stress. Helpful in reducing level of anxiety by relieving tension

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Problem # 3: Risk for Fluid Volume Deficit

Assessment S- O- patient manifested: Vomiting Abdominal distension Patient may manifest: Dehydration Hypotension Hypovolemic shock Nursing Diagnosis Risk for fluid volume deficit related to vomiting decreased intestinal reabsorption of fluid and decreased intestinal secretions secondary to disease condition Scientific explanation Normally, the bowel secretes 7-8 L of electrolyte-rich fluid, and most of the fluid is absorbed. When the bowel is obstructed by a tumor, this fluid is partially retained within the bowel and partially eliminated by vomiting causing severe reduction in circulating blood volume which may result in hypotension, hypovolemic shock and diminished real and cerebral blood flow. Objectives Short term: After 5 hours of nursing interventions, patient will be relieved from vomiting. Long term: After 3 days of NPI the patient will maintain volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, moist mucous membranes, good skin turgor, and prompt capillary Nursing Interventions Assessed patients overall status Monitor and record vital signs Monitor intake and output Rationale To obtained baseline data for future references To obtain baseline data To ensure accurate picture of fluid status. To assess the quality of bowel sounds. A lack of bowel sounds indicates peritoneal irritation Expected Outcome Short term: The patient shall have been relieved from vomiting. Long term: The patient shall have been maintained a volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, moist mucous membranes, good skin turgor, and prompt capillary refill. 75

Auscultate bowel sounds

refill.

Observe for signs of dehydration

To make necessary interventions.

Establish individual needs/replace ment schedule Provide supplemental fluids as indicated Provide small frequent feedings Administer anti-emetic medications as ordered.

To correct the deficit

To prevent peaks and valleys in fluid level To maintain the nutritional needs of the patient To reduce patients vomiting episodes.

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INTRA OPERATIVE NURSING CARE PLANS

Problem # 1: Risk for Infection
Assessment Nursing Diagnosis Risk for infection Scientific explanation Surgery is performed using aseptic technique and in a manner to prevent cross contamination. During the operation, a surgical incision must be made. Breaks in the integument, the bodys first line of defense, and/or the mucous membranes allow invasion by pathogens. If the patients immune system cannot combat the invading organism adequately, an infection occurs. Open wounds, traumatic or surgical, can be sites for infection during and Objectives Nursing Interventions Implements aseptic technique. Classifies surgical wound. Assesses susceptibility for infection. Performs skin preparations. Monitors for signs and symptoms of infection. Rationale Expected Outcome Short term: The patients surgery shall have been performed using aseptic technique and in a manner to prevent cross contamination. Long Term: The patient shall have been free of signs and symptoms of infection.

S=

O=patient may manifest:

sig

ns and symptoms of inflammation at surgical site increase in vital sign signs and symptoms of shock

Short term: After 4 hours of nursing interventions, the patients surgery is performed using aseptic technique and in a manner to prevent cross contamination. Long Term: After 5 hours of nursing interventions, the patient will be free of signs and symptoms of infection.

To maintain a sterile field during the operation To know to the preventive measures to be taken To be able to administer prophylactic treatment Ensures that lessening of risk for infection To enable proper and early management of signs and

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after an invasive procedure. Minimizes the length of invasive procedure planning care. Administers prescribed prophylactic treatments. Administers care to wound sites.

symptoms To lessen occurrence or possibility of trauma and infection To provide pharmacological management for infection To minimize exposure of wounds to microorganisms

Problem # 2: Risk for Impaired Skin Integrity Related to Positioning, Immobilization, Pressure or Shearing Forces
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Assessment

Nursing Diagnosis

Scientific explanation

Objectives

Nursing Interventions

Rationale

Expected Outcome

S=

O=patient may manifest:

si gns and symptoms of inflammation at surgical site increase in vital sign Pressure sores Redness or blemishes

Risk for impaired skin integrity related to positioning, immobilization, pressure, and/or shearing forces

Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for altered skin integrity. Advanced age; the normal loss of elasticity; inadequate nutrition; potentiate the effects of pressure and hasten the development of skin breakdown. Improper positioning and surgical management during the operation can predispose the occurrence of

Short term: After 4 hours of nursing interventions, the patients skin remains smooth, intact, nonreddened, nonirritated, and free of bruising, other than surgical incision. Long Term: After 5 hours of nursing interventions, the patient will be free of signs and symptoms of physical injury.

Identifies physical alterations that may affect procedurespecific positioning. Positions the patient.

To determine extent of adjustment when performing positioning To ensure that the patient is comfortable and position is appropriate for the procedure To avoid trauma from external forces in the environment

Short term: The patients skin shall have remained smooth, intact, non-reddened, non-irritated, and free of bruising, other than surgical incision. Long Term: The patient shall have been free of signs and symptoms of physical injury.

Implements protective measures to prevent skin or tissue injury due to thermal, chemical, or mechanical sources.

To observe 79

disruption of skin integrity thus management must be done to minimize such.

Evaluates for signs and symptoms of injury to skin and tissue. Evaluates for signs and symptoms of injury as a result of positioning.

for any alterations in skin integrity To provide prompt management of identified signs and symptoms

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Problem #3: Risk for Hypothermia

Assessment Nursing Diagnosis Risk for hypothermia Scientific explanation Hypothermia occurs when the bodys core temperature falls below its normal level of 98.6F to 95F or colder. It is the opposite of fever, when the bodys temperature is above normal. The operating room must be kept in a certain temperature to reduce the growth of microorganisms and prevent the build up of moisture. With that, the room is maintained in a cool temperature. This in turn predisposes the Objectives Nursing Interventions Implements thermoregulati on measures. Monitors body temperature. Evaluates response to thermoregulati on. Perform insulation measures like warming blankets, socks, head covering and other apparel Rationale Expected Outcome Short term: The patients core body temperature shall have remained within expected range. Long Term: The patient shall have been at or returned to normothermia at the conclusion of the immediate postoperative period.

S= O=patient may manifest:

hills

C old clammy skin D ecrease in vital signs

Short term: After 4 hours of nursing interventions, the patients core body temperature will remain within expected range. Long Term: After 5 hours of nursing interventions, the patient will be at or return to normothermia at the conclusion of the immediate postoperative period.

To prevent a decrease in body temperature To monitor patients core temperature To perform appropriate measures and management Increases in ambient temperature are used to keep the peripheral tissue closer to target temperatures

C yanotic nail beds Tr emors

H ypotension R apid and weak pulse

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patient in to experiencing hypothermia because of his/her environment. Hypothermia is dangerous because it affects the body's core the brain, heart, lungs, and other vital organs. accidents. Severe hypothermia causes loss of consciousness and may result in death.

Warming of IV fluids as ordered

Significantly reduces the impact of vasodilation and redistribution hypothermia

POST OPERATIVE NURSING CARE PLANS

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Problem # 1: Acute Pain R/T Disrupted Skin Integrity, Damaged Tissues and Nerves
Assessment Nursing Diagnosis Scientific explanation Objectives Nursing Interventions Rationale Expected Outcome

S= kumikirot ung tahi ko sa tiyan. as verbalized by the pt. O=Patient manifested:

Acute pain r/t disrupted skin integrity, damaged tissues and nerves

cial grimaces

fa

ying

cr irr

itability

in creased vital signs especially BP

movement Q- sharp R- mid

P-

Pain is an expected outcome postoperatively. And because pain is intensified with movement increase in discomfort is exhibited. Due to the presence of a surgical incision, continuity in the integrity of the skin is interrupted. The abundance of nerve endings in the skin makes it very sensitive to pain stimuli. Trauma such as cuts and incisions in invasive procedures post

Short term: After 4 hours of nursing interventions, the patients pain will be minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10. Long Term: After 3 days of nursing interventions, the patient will be relieved from pain and will have vital signs within normal limits.

Establish rapport Assess the patients condition

To gain patients trust To obtain baseline data and to plan for the appropriate care Alteration in Vital signs is evident in the presence of pain To obtain information about the pain that the patient is manifesting Serves as a comfort measure

Assess vital signs.

Short term: The pain shall have been minimized as evidenced by an absence of facial grimaces and restlessness and a decrease in pain from 6/10 to 2/10. Long Term: The patient shall have been relieved from pain and will have vital signs within normal limits.

Assess patients degree of pain every time she verbalizes pain Reposition patient

Provide quiet

To decrease 83

abdomen Spain scale of 6/10 T-every time movement is elicited patient may manifest:

erspiration

p si

operatively, the release of nociceptors that transmit pain stimuli and there is the release of chemicals such as histamine, bradykinin and prostaglandin that contributes to the experience of pain.

environment

environment stimulus and promote rest To alleviate feeling of pain

Provide comfort measures Advise the patient to deep breathing exercises. Encourage patient to do diversional activities such as watching TV or talking to a family members Administer analgesics as prescribed

To lessen pain

gns and symptoms of inflammation at surgical site moaning, shouting, sighing

To lessen pain by allowing the patient to focus on other things

Provides pharmacologi c treatment to lessen patients pain

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Problem # 2: Risk for Spread of Infection r/t Inadequate Primary Defenses (Broken Skin, Traumatized Tissue)
Nursing Diagnosis Scientific Explanation Expected Outcome

Assessment

Planning

Intervention

Rationale

S=

O= Pt. may manifest: with wound dressing

Risk for spread of infection r/t inadequate primary defenses (broken skin, traumatized tissue)

May manifest:

dr ainage in the surgical site.

In creased WBC count

There are normal flora residing in our skin and these microorganisms are opportunistic in nature. As a result of the disruption in the skin integrity, these microorganisms may cause an increased risk to infection due to the break in the continuity of the skin, the bodys first line of defense. This disruption serves as a portal of entry for microorganisms.

Short Term: After 4 hours of nursing interventions, the client will be free from infection. Long Term: After 3 days of nursing interventions, the patient shall get rid or there shall be a total elimination of risk for infection.

Observe aseptic techniques when handling the patient.

To prevent the spread of microorganis ms, proper washing is a first line of defense against nosocomial infection. It may predispose the occurrence of infection since the hands are also carrier of microorganis ms. Prevent environmental contamination of fresh

Short Term: The risk for infection shall have been minimized Long Term: The patient shall have no infection AEB WBC within normal range

Instruct patient to avoid touching wound with bare hands.

Provide sterile dressing

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soiled dressing

wounds Encourage patient to increase fluid intake To prevent possible recurrence of infection

dness of affected area

re

esence of pus at the surgical incision

pr

Administer antibiotics as ordered

To provide pharmacologi cal treatment

welling of affected area

skin is warm to touch at the affected area

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Problem # 3: Risk for Aspiration Related to Impaired Swallowing Due to Previous Placement of Nasogastric Tubing
Nursing Diagnosis Scientific explanation Nursing Interventions Assessed patients overall status Noted amount and rate of food and fluid intake from all sources Expected Outcome Short term: The patient will demonstrate techniques to prevent aspiration such as sitting upright and eating slowly. Long term: The patient will be free from aspiration.

Assessment

Objectives

Rationale

S- Minsan, nahihirapan akong lumunok

O- patient manifested: coughing after drinking shortness of breath and easy fatigability when eating needs assistance when drinking

Risk for aspiration related to impaired swallowing due to previous placement of nasogastric tubing

To prevent aspiration and gas distension, a NGT is placed. When this tube is inserted and removed, the tubing leads to trauma of the esophagus, making it difficult for the patient to swallow properly. Aspiration happens when food, liquid, or any material blocks or enters the air passages, leading

Short term: After 4 hours of NPI the patient will demonstrate techniques to prevent aspiration such as sitting upright and eating slowly. Long term: After 3 days of NPI the patient will be free from aspiration.

To obtained baseline data for future references. to monitor patients daily intake.

Placed in semi To facilitate fowlers position as movement of appropriate diaphragm, improving respiratory effort Advise the patient to maintain an upright position when eating. Encourage the client to eat food To facilitate swallowing

To allow proper breaking down of 87

and eating

to compromised breathing.

and drink more slowly

food for easy swallowing.

Problem # 4: Activity Intolerance Related to Generalized Weakness

Nursing Diagnosis Scientific explanation Nursing Interventions Expected Outcome

Assessment

Objectives

Rationale

S- Nanghihina ako lagi as verbalized by the pt.

Activity intolerance related to generalized weakness

O- patient manifested: weak posture inability to maintain balance pale slow movement

Activity intolerance is a condition of the body where there is insufficient physiological or psychological means or capability to endure or complete the required or desired daily activities. Depression can be one of the factors that may increase or contribute to general weakness and may lead to

Short term: After 4 hours of NPI the patient will be able to use and identify techniques to enhance activity

Assess pts condition

To obtained baseline data for future references. To identify more causative or precipitating factors

Long term: After 3 days of NPI the patient will demonstrate a measurable increase in activity.

Note the pts report of weakness, fatigue or difficulty accomplishing tasks Provide adequate rest periods Increase activity levels gradually Assist the pt in

Short term: The patient shall have used and identified techniques to enhance activity. Long term: The patient shall have demonstrated a measurable increase in activity.

To prevent fatigue To conserve energy To protect the pt from

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 limited range of motion discomfort decreased levels of potassium

inability of the person to participate in the activities of daily living. Tolerance to activity wil be compromised for a patient experiencing a disease condition.

doing her ADLs

injury

Promote comfort measures

To enhance ability to participate in activities To indicate the need to alter activity level To promote wellness and proper circulation To treat underlying factors

Monitor responses to the activity

Encourage pt to change position frequently

Administer medication as ordered

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Problem # 5: Anxiety Related to Lack of Knowledge about the Disease Condition

Nursing Diagnosis Scientific Explanation Expected Outcome

Assessment

Planning

Intervention

Rationale

S = Ano naba nyan ang mangyayari sakin.? as verbalized by the pt. O= Patient manifested Restlessness Appears tense High blood pressure Patient may manifest:

Anxiety related to lack of knowledge about the disease condition

Increased RR

Anxiety is a vague uneasy feeling of discomfort or dread accompanied by an autonomic response or a feeling of apprehension caused by anticipation of danger. Due to the lack of knowledge about the disease condition, the patient is not aware or is having difficulty adjusting about

Short Term: After 3 hours of Nursing Interventions the patient will be able to identify ways to reduce anxiety.

Establish rapport Assess pts condition Assess for level of anxiety

To gain clients trust and participation To obtain baseline data In order to know the manageability of anxiety and provide appropriate intervention Limited knowledge of the unknown results may cause anxiety to the patient

Short Term: The patient shall have identified ways to reduce anxiety.

Long Term: After 2 days of Nursing Interventions patient will demonstrate reduction of anxiety into manageable

Long Term: Patient shall have demonstrated reduction of anxiety into manageable levels 90

Explain to the patient, what to expect

Muscle tension

Diaphoresis

the levels manifestations of the disease. Thus the patient is afraid on what will happen to her condition as the disease progresses.

Teach the pt proper breathing exercises Instruct the patient to do diversional activities Collaborat e with other professionals

Deep breathing exercises can reduce tension To divert focus to other things Collaboration promotes the best long range plan to attain success for the health of the patient Helps to relax the patient if necessary and uncontrollable

Administer anti anxiety drugs as ordered

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