Care plan

Situation
Background
Assessment
Recommendations
Reason for admission:
Bowel resection r/t obstruction. Awaiting cytology for possible malignancy.
Admitted last night.
Surgery completed at 1100 today.
It is now 1800. Patient has arrived at unit.
Medical/Surgical History:
Transgender: Mastectomy in 1991.
Tracheostomy 1992 for laryngeal CA in 2000.
Large bowel obstruction with strangulation. 18 cm removed with anastomosis. 22 staples.
VS:
On admission:
T: 38.0 C
P:89
R: 22
144/95
94% on room air.
Assessments:
Wound: q1h
VS: q1h
Oxygenation: q1h
Repeat bloodwork at 1800

Safety:
No concerns.
Spiritual practices:
none
Labs: post op 1800 today.
CBC:
Hgb: 86 g/L
HCT: 0.24
WBC: 9.0 x 103/mm3
RBC: 3.5×10 (12) cells/L
Lytes:
Na: 135 mmol/L
K: 3.2 mmol/L
BUN:3.4 mmol/L
CR:77 mmol/L
Diet: Clear fluids when BS return.
Elimination: In and out catheter for residual of 250 ml or more. Foley indwelling catheter if residual is greater than 350 for 2 consecutive assessments.
Mobility:
Q1h up at bedside.
Language:
Diagnostics:
Bladder scan completed at 1815 with 400 ml residual noted.

IV: NS 125 ml/h.

Assistive devices: none
Next of kin:
Sub. Decision maker:
Social work:
Skin integrity:
ABD dry dressing, clean with NS PRN.

PT/OT:
Oxygenation: Trach suction prn. Dressing change every 2 days and PRN
O2: 2 L trach mask to keep spo2 above 92%.

Mr. Smith comes to your unit and must be admitted post operatively. You assume care of him.
Please complete all Questions:
Complete the nursing care plan below.
Assessment: what priority assessments must you complete?
4 marks
Diagnosis: Provide 2 NANDA Diagnoses that are a PRIORITY.
6 marks
Plan: List 3 important things that the client must achieve before discharge
3 marks
Interventions:
List 4 interventions with rationale.
8 marks
Evaluation: How will you evaluate the effectiveness of your interventions?
4 marks
Inspection: a quick head to toe assessment

Neurological:
Pain (PQRST), using pain scale 0 been the lowest pain and 10 been the highest-level pain
Watch for patient facial/ bodily expression of pain.
level of consciousness,
Vital signs

Surgery site to assess for excess bleeding

auscultate for bowel sounds

Ask if the patient has passed gas (flatulence).

Palpate the bladder area to identity a distended bladder.

Bladder scan to identity residual urine

Ineffective airway clearance r/t the presence of tracheostomy tube as evidence by excessive mucus secretion
Priority 1:
Suction patient q1h and PRN

Acute pain r/t surgical incision as evidence by bowel resection surgery
Priority 2:
Administer pain medication as prescribed/ PRN
Hourly VS assessment
Hourly assessment of the surgical site.

Ensure proper functioning of the bowel as evidence by an active bowel sound and smooth passage of BM

Surgical site completely free from any form of infection and healing
Properly.

Reduced level of pain as related to the surgery
Administer pain medication as prescribed for the patient and administer PRN doses if required.

Encourage early mobility

Commence graded oral sips at the presence of bowel sounds

Suction tracheal tube as required, ensure aseptic technic in tracheal tube care

Keep assessing VS hourly and as required ensuring the SPO2 is always above 95%

A repeat of the bloodwork, ensure the healthcare provider gets a copy of the blood work done

Foley catheter inserted since residual is more than 350ml

Incision site intact and 22 staples removed when ordered.

Patient pain under control as evidence by patient declaring a very low pain level.

Patient able to ambulate unassisted

Patient able tolerate oral water sips properly

Clear breath, no slugging in the trachea area

VS withing normal limits

Executive any intervention prescribed by the healthcare provider as regards to the blood work

Adequate drainage in the urine bag that is balance with patient input.

/25
(4 marks) At 1815 you insert the catheter and drain 500 ml of clear dark amber urine. At 2100, the client complains that they have not voided. You scan the bladder and 375 ml residual is seen.
What are your nest steps?
Since the residual is more than 350ml after 500ml was drained with in and out catheter, I will insert a Foley catheter.
Who will you call?
I will not call any body; I will work with the care plan that states that foley catheter should be inserted if residue is more than 350ml after in and out catheter has been used. but I will inform the charge nurse of what I want to do.

(4 marks) Mr. Smith had post operative bloodwork at 1800.
Are any values out of range? If yes, which ones?
His current bloodwork values are out of normal range.
CBC: Patient Present Value Normal Lab Value
Hgb: 86 g/L 120-160g/L
HCT: 0.24 0.350-0.450 L
WBC: 9.0 x 103/mm3 4.0-11.0 (leukocytes) 2.0-7.5 (Neutrophils)
RBC: 3.5×10 (12) cells/L 4.0-5.1 L
Lytes:
Na: 135 mmol/L 135-145 mmol/L
K: 3.2 mmol/L 3.5-5.2 mmol/L
BUN:3.4 mmol/L 2.5 to 7.1 mmol/L
CR:77 mmol/L 46-92 Umol/L

Are there any other tests that should be ordered?
I could carry out a general urine analysis, since the urine is clear dark amber in colour

(2 marks) The ordered IV is for normal saline at 125 ml/h.
Do you have any concerns over this IV? If yes, what?
I will have the healthcare provide recheck this order for normal saline, since the patient current blood pressure is on the high side at BP 144/95, giving normal saline will increase the patient’s blood pressure.
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