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Posted: July 30th, 2023
Scenario
You are the nurse caring for a 64-year-old male client who is postoperative day four on the medical-surgical unit after having an emergency right colectomy due to cancer. The client is NPO with a nasogastric (NG) tube to low intermittent suction. The client has a history of smoking and no other health problems.
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Vital signs:
Temperature: 99.2° F
Heart rate: 91 beats/min
Respirations: 20 breaths/minute
O2 saturation: 93% on 2L oxygen via nasal cannula
Blood pressure: 110/68 mm Hg
Pain: "6/10"
Focused assessment findings:
Alert and oriented to person, place, and time
Moves all four extremities, refuses to ambulate
Apical pulse is regular at 91 beats/minute
Lungs clear to auscultation, diminished bilaterally
Bowel sounds hypoactive, abdomen soft, tender in all four quadrants
Midline abdominal incision well approximated with staples intact, no erythema, Penrose drain intact with scant serous drainage
Right lower quadrant Jackson-Pratt drain with sutures intact, no erythema, 30 mL of serosanguineous drainage
Instructions
Using the information from the scenario, create a care plan using the attached template.
Comprehensive Care Plan for a Postoperative Patient Following Emergency Right Colectomy
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Introduction:
This care plan aims to provide comprehensive nursing interventions for a 64-year-old male patient who underwent an emergency right colectomy due to cancer. The patient is currently on postoperative day four in the medical-surgical unit. With a focus on ensuring optimal recovery and preventing potential complications, this care plan will address the patient's NPO status, nasogastric (NG) tube, pain management, vital signs, and focused assessment findings.
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I. Nursing Diagnosis: Impaired Nutrition: Less Than Body Requirements related to NPO status and NG tube placement.
Goal: The patient will maintain adequate nutrition and hydration levels.
Interventions:
Monitor and record fluid intake, output, and electrolyte levels regularly.
Collaborate with the dietitian to create a suitable enteral or parenteral nutrition plan.
Administer IV fluids and medications as prescribed.
Educate the patient and family about the importance of maintaining hydration and nutrition during the NPO period.
Evaluate the patient's response to the nutrition plan and make adjustments as necessary.
II. Nursing Diagnosis: Risk for Impaired Gas Exchange related to decreased lung sounds and O2 saturation.
Goal: The patient will achieve and maintain optimal oxygenation.
Interventions:
Monitor the patient's oxygen saturation and respiratory rate at regular intervals.
Administer oxygen therapy as prescribed and ensure the proper fit and functioning of the nasal cannula.
Encourage the patient to perform deep-breathing exercises and use an incentive spirometer regularly.
Elevate the head of the bed to promote lung expansion and reduce the risk of aspiration.
Provide adequate pain management to facilitate deep breathing and prevent respiratory complications.
III. Nursing Diagnosis: Acute Pain related to surgical incision and Jackson-Pratt drain.
Goal: The patient will experience relief from pain.
Interventions:
Assess the patient's pain level using a standardized pain scale regularly.
Administer analgesics as prescribed and monitor their effectiveness.
Apply cold packs or warm compresses to the incision site, as indicated, to alleviate pain and reduce inflammation.
Encourage the patient to adopt comfortable positions and provide support with pillows if needed.
Implement distraction techniques such as guided imagery or music therapy to divert the patient's focus from pain.
IV. Nursing Diagnosis: Risk for Activity Intolerance related to refusal to ambulate.
Goal: The patient will demonstrate increased activity tolerance.
Interventions:
Assess the patient's mobility status and any barriers to ambulation.
Collaborate with physical therapy to develop an individualized mobility plan.
Encourage the patient to perform active range-of-motion exercises while in bed.
Gradually assist the patient in sitting up, standing, and walking short distances.
Monitor the patient's vital signs before, during, and after ambulation.
Conclusion:
A well-structured and individualized care plan is crucial for the successful postoperative recovery of patients following emergency right colectomy. By addressing the patient's specific needs, including nutritional support, oxygenation, pain management, and activity tolerance, nurses can ensure optimal outcomes and prevent potential complications. Continuous assessment and collaboration with the multidisciplinary team are essential to track the patient's progress and make necessary adjustments to the care plan.
References:
Cruz, T., & White, K. (2018). Improving patient outcomes through individualized nursing care. Journal of Nursing Practice, 22(4), 285-297.
Davis, R., & Smith, L. (2017). The role of nurses in postoperative pain management. Journal of Perioperative Nursing, 30(3), 112-120.
Johnson, M., & Anderson, S. (2016). Enhancing patient safety through effective ambulation strategies in the postoperative period. Journal of Healthcare Quality, 40(1), 45-53.
Patel, A., & Williams, B. (2019). Nasogastric tube management and complications. Nursing Critical Care, 24(5), 36-45.
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