Transcript
ASSESSMENT
O: -Dressing on surgical site -Pale
DIAGNOSIS
PLANNING
INTERVENTION
Risk for infection related to incision/suture in the right lower abdominal area.
Short Term Goal: At the end of the shift, the client will identify interventions to prevent or reduce risk of infection.
1. Note risk factors for occurrence of infection (e.g., skin/tissue wounds)
Long Term Goal: Within hospitalization, the client will achieve timely wound healing; be free of purulent drainage.
2. Stress proper hand hygiene by all caregivers between therapies and clients. 3. Assess and document skin conditions, noting inflammation and drainage. 4. Cleanse incision site per facility control with appropriate solution. 5. Administer or monitor medication regimen. 6. Emphasize necessity of taking antibiotics as directed.
RATIONALE
EXPECTED EXPECTED OUTCOME
To assess At the end of the shift causative/contributing the client will identify factors. interventions to prevent or reduce risk of A first-line defense infection like initiating against healthcare change of dressing on associated infections. surgical site and verbalizing the importance of daily hand washing.
To reduce potential for catheter-related blood-stream infections. To determine effectiveness effectiveness of therapy/presence therapy/presence of side effects.
Within hospitalization the client will achieve timely wound healing as marked by absence of secretions in the dressing and verbalizing of the healing wound.
ASSESSMENT ASSESSMEN T
S: -Pain scale of 7/10 O: -Dressing on surgical site -Pale -Facial grimacing
DIAGNOSIS
Acute pain related to presence of surgical incision as manifested by facial grimacing.
PLANNING
INTERVENTIO N
RATIONALE
Short Term Goal: At the end of the shift, the client will report pain is relieved and controlled.
1. Note clients age/developmental level and condition affecting ability to report pain parameters.
To assess etiology/precipitating contributing factors.
Long Term Goal: Within hospitalization, the client will verbalize nonpharmacologic methods that provide relief.
2. Note location of surgical procedures.
Influence the amount of post operative pain experienced. To help determine possibility of underlying condition. To rule out worsening of underlying condition/development of complication.
3. Assess for referred pain, as appropriate. 4. Obtain client’s assessment of pain to include location, characteristics, quality, intensity, etc.
5. Instruct an use of relaxation techniques (e.g., focused breathing) and diversional activities. 6. Administer analgesics as indicated to maximum dosage, as needed.
To distract attention and reduce tention.
To maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal.
EXPECTED OUTCOME
At the end of the shift the client will report pain is relived and controlled by verbalizing that his pain scale from 7/10 becomes 2/10 after taking medication. Within hospitalization the client will verbalize nonpharmacologic methods that provide relief like use of diversional activities such as TV, radio and socialization with others.
ASSESSMENT
O: -With surgical incision at right lower abdominal area
DIAGNOSIS
Impaired skin integrity related to destruction of skin/tissue layers.
PLANNING
Short Term Goal: At the end of the shift, the client will display timely healing of skin lesions/wounds without complication Long Term Goal: After hospitalization, the client will participate in prevention measures and treatment program.
INTERVENTION
1. Determine nutritional status potential for delayed healing exacerbated by malnutrition.
RATIONALE
EXPECTED OUTCOME
To assess At the end of the shift causative/contributing the client will display factors. timely healing of skin lesions/wounds lesions/wounds without complication by manifesting intact 2. Evaluate client with To identify risk for sutures and dry wound impaired cognition, injury/safety dressing. need/use of restraints, requirements. long term immobility. After hospitalization, the client will 3. Periodically remeasure To monitor progress participate in wound and observe for of wound healing. prevention measures complications. and treatment program like participating in in 4. Keep area clean/dry, passive range of motion carefully dress wounds, exercises. To assess body’s support incision. natural process of repair. 5. Encourage early Promotes circulation ambulation/mobilization. and reduces risks associated with immobility. 6. Assist the client/SO(s) Enhances in understanding and ff. commitment commitment to plan, medical regimen and optimizing outcomes. daily maintenance.
ASSESSMENT
O: -With surgical incision at right lower abdominal area
DIAGNOSIS
Activity intolerance related to presence of surgical incision as manifested by limited mobility.
PLANNING
Short Term Goal: At the end of the shift, the client will verbalize understanding of potential loss of ability in relation to existing condition. Long Term Goal: After hospitalization, the client will participate in conditioning and rehabilitation program to enhance ability to perform.
INTERVENTION
1. Note presence of medical diagnosis/ regimens.
2. Determine current activity level/physical level/physical condition with observation, exercise tolerance testing.
RATIONALE
This may have potential for interfering with client’s ability to perform at a desired level of activity. Provides baseline for comparison and opportunity to track changes.
3. Implement physical therapy exercise with client and team members.
Coordination of program enhances likelihood of success.
4. Instruct client in unfamiliar activities and alternate ways of doing familiar activities.
To conserve energy and promote safety.
5. Assist client/SO(s) with planning for changes that may become necessary, such as use of supplemental oxygen.
To improve client’s ability to participate in desired activities.
EXPECTED OUTCOME
At the end of the shift the client will verbalize understanding of potential loss of ability in relation to existing condition like verbalizing habits and lifestyle that is appropriate to his condition.
After hospitalization, the client will participate in conditioning and rehabilitation program to enhance ability to perform like doing ROMEx, and relaxation techniques.
ASSESSMENT
DIAGNOSIS
O: -With surgical incision at right lower abdominal area -weight loss
Imbalanced nutrition: less than body requirements related to nausea and vomiting, loss of appetite and decrease peristalsis as manifested by loss of weight.
PLANNING
Short Term Goal: At the end of the shift, the client will demonstrate progressive weight gain toward goal. Long Term Goal: After hospitalization, the client will demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight.
INTERVENTION
RATIONALE
EXPECTED OUTCOME
All factors that can affect ingestion and/or digestion of nutrients. To appeal to client’s like and dislikes.
At the end of the shift the client will demonstrate progressive weight gain toward goal by verbalizing to take in nutrients to meet metabolic needs.
3. Assess weight; measure/calculate measure/calculate body fat/muscle wasting, etc.
May indicate proteinenergy malnutrition.
4. Evaluate total daily food intake, patterns and times of eating.
May have changes that could be made in client’s intake.
5. Consult dietician/nutritional team, as indicated.
To implement interdisciplinary interdisciplinary team management.
After hospitalization, the client will demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight like taking adequate food, increase in appetite and interest in food.
1. Determine client’s ability to chew, swallow and taste food.
2. Discuss eating habits, including food preferences, intolerances/aversions.
6. Administer vitamin/mineral supplements as indicated. 7. Assist client/SO(s) to learn how to blenderize food.
Supervision/home nutrition therapy.
