Nursing Care Plan - Case Study Example

Nursing care plan for post-operative patient (CA colon) with prolonged ICU stay due to prolonged ventilator support al affiliation) Introduction Nursing care plan is an effective nursing tool that is important in designing and planning the care of Ms Max after surgery. Among the objective of the care plan is to ensure Ms Max is able to adjust to actual or perceived changes, to prevent complications, to meet self care needs through assistance by a medical practitioner or by self, to help the patient understand the procedure, therapeutic regimen and potential complications related to surgery as well as to put plans in place in order to meet discharge needs (A Shared Nursing Care Plan, 2010). This can be achieved through nursing interventions that includes assisting the patient in psychological adjustment, prevention of complications, supporting independence in self care as well as providing information about prognosis, treatment needs, expected complications and community resources that can be utilized to meet the needs of the patients. The paper will focus on three nursing diagnosis with eight intervention related to the postoperative complication of the patient. Literature review According to Bischof, Maier, Smith, Fitch & Wright (2011), Colon cancer is the common type of cancer that affects the gastro intestinal system. Appropriate nursing and medical intervention can help reduce the post operative period and reduce complications such as infections. Colostomy and ileostomy are some of the procedures done during surgery. Even though post operative period is often long, some people are able to recover and resume normal activities after six to eight weeks (Brubakken & Cheney, 2010). The number of death resulting from colon cancer was 15.9 in every a hundred thousand women and men every year with 43.7 in every a hundred thousand women and men per year of new cases. Surgery, chemotherapy and radiotherapy can be used to prevent spread of colon cancer. Nursing Care Plan Medical Diagnosis: Septic shock induced by faucal peritonitis with total colectomy with ileostomy done Date of Client Assessment: __3rd April, 2015 Diagnostic statement (PES): Dysfunctional ventilator weaning response related to muscle weakness and fatigue and ineffective airway clearance secondary to severe disease process. Assessment Diagnosis Goal/ Expected Outcomes Interventions Rationale Evaluation Subjective Date: Patient states that she is unable to breathe especially at night and is over relying on the ventilator machine for breathing. Objective Data: The patient is experiencing prolonged intubation. Surgical tracheotomy tube still in place. The patient is weaned during the day and ventilated at night using the SIMV mode, FiO2 0.3 Dysfunctional Health Pattern: The patient is unable to sleep as a result of breathing problems Problem: The patient is experiencing difficulty in breathing as a result of ineffective airway clearance and muscle weaknesses following surgery Etiology: the problem occurred after surgery and is due to fecal peritonitis that resulted to septic shock Defining Characteristics Signs & Symptoms: The patient is having fever, epigastric pain, erosive esophangitis, has duodenal polypus with coffee ground vomiting Goal: To restore normal breathing pattern within four days of hospitalization by helping the patient to wean and avoid continuous over reliance on the ventilator. Expected Outcomes: Patient to stop using the ventilator after four days of hospitalization. Patient to report ease of breathing after four days of hospitalization -Reduce the amount of time that the patient spends on the ventilator machine from 12 hours to eight hours in the first day, from eight hours to six hours in the second day and from six hours to four hours in the third day. -Ensure that the airway of the patient is cleared after every ten minutes. -Administering medication as prescribed to facilitate healing and prevent septic shock -Conduct Daily ileostomy care until the patient is able to do it. -Administer antiemetic and restrict oral foods and fluids to prevent vomiting -Help the patient in performing activities of the daily living -Maintain an input and output chart - Feed the patient on Isocal 50ml/hr and Alitraq + Beneprotein 50nk/hr Weaning from the ventilator machine is important to the patient as it help the patient to support themselves and be in control (DONALD & VIAR, 2010). It is also an indication that the original cause of the respiratory failure has been dealt with (Taylor, 2010). Feeding the patient is important in energy provision and boosting of the body’s immunity The patient has been able to reduce the time on the ventilator machine by two hours on the first day (Chang, 2013). This has been effective through the use of daily screening of respiratory functions and breathing trials. Patient reports improved breathing after the three days of hospitalization. This has been possible as a result of continuous sucking of the secretions and assisting the patient to wean from the ventilator machine (Fjørtoft et al., 2013). Nursing Care Plan Medical Diagnosis: _Septic shock induced by faucal peritonitis with total colectomy with ileostomy done Date of Client Assessment: __3rd April, 2015 Diagnostic statement (PES): Impaired physical activity related to muscle weakness and fatigue as evidenced by patients’ immobility and intact surgical tracheotomy __________________________________________________________________________________________________________________ Assessment Diagnosis Goal/ Expected Outcomes Interventions Rationale Method of Evaluation Subjective Date: The patient reports fatigue and muscle weaknesses and requests for assistance to enable her turn while in bed Objective Data: Patient is bed ridden The patient has a tracheotomy tube intact and utilizes a ventilator support for breathing at night the patient is unable to turn without support Dysfunctional Health Pattern: the patient is unable to conduct the activities of the daily living. Problem: The patient is less active and bed ridden. Etiology: The problem occurred after surgery and is due to fecal peritonitis that resulted to septic shock following the surgical process Defining Characteristics Signs & Symptoms: Patient is unable to turn without assistance Patient is unable to conduct activities of the daily living Goal: To help restore the physical activity of the patient after one week of hospitalization. Expected Outcomes: The patient should be able to conduct activities of the daily living without assistance by the end of the week. In addition, the patient should be able to get out of bed without help from a medical assistance at the third week. -Administer medication as prescribed -Daily dressing of the wound by utilizing normal saline -Cover the wound to prevent entry of micro-organism Conduct -Daily ileostomy care until the patient is able to do it. -Administer antiemetic and restrict oral foods and fluids to prevent vomiting -Help the patient in performing activities of the daily living -Help the patient to turn and maintain a turning chart -Maintain an input and output chart The administration of Hydralazine 25mg BD, Isordil 10mg Q8H, Norvasc 5mg daily, Carvedilol 12.5mg BD drugs will be essential in maintaining the hemodynamic status of the patient (Greenwald, 2010). Daily dressing and covering of the wound will help prevent infections and promote the healing process (Cameron & Fone, 2010). Antiemetic will prevent help control vomiting (Kaufman, 2012). Ileostomy care will ensure the patient remains clean and free from infections. Assisting the patient in patient in performance of the daily living (Rose, 2010). Maintaining the input and output chart will help assess and balance body fluids. The patient begins participating in some physical activities such as turning without assistance after seven days of hospitalization (Symposium on cancer of the colon and rectum, 2012). Some physical activities are important to help take part in improving the activities of the daily living (Guner, Akin & Durna, 2013). The patient is able to get out of bed and perform some activities of the daily living after three weeks of hospitalization. Nursing Care Plan Medical Diagnosis: _Septic shock induced by faucal peritonitis with total colectomy with ileostomy done Date of Client Assessment: __3rd April, 2015 Diagnostic statement (PES): Impaired tissue integrity related to surgical procedure as evidenced by abdominal wound of size 18x12x3cm with tension stitches and a tracheotomy gapped wound. __________________________________________________________________________________________________________________ Assessment Diagnosis Goal/ Expected Outcomes Interventions Rationale Method of Evaluation Subjective Date: the patient complains of irritation in the abdominal wound. Objective Data: The patient has two wounds, an abdominal wound which is of size 18x12x3 cm with three tension stitches and the tracheotomy gapped wound. Dysfunctional Health Pattern: the patient reports pain at the incision site which may be as a result of infection Problem: Impaired tissue integrity. Etiology: Impaired tissue integrity is as a result of total colectomy and ileostomy done Defining Characteristics Signs & Symptoms: Moderate haemo-serous discharge from the abdominal wounds Goal; to restore tissue integrity before the patient is discharged Expected Outcomes: The wound to heal after two weeks of protection as dressing using normal saline To ensure the wound is free from infection four days after admission -Daily dressing of the wound using normal saline -Administer antibiotics and other drugs as prescribed -Asses the patients’ need for information and provide relevant information -Change dressing daily and cover the wound -Asses any sign of infection at the wound site -Secure the wound with tegaderm and sterile and cover the outer wound with hole gauze -Allow the patient to verbalize her concerns -Monitor input and output chart -Feed the patient on Isocal 50ml/hr and Alitraq + Beneprotein 50nk/hr Daily wound dressing promotes healing and restores the integrity of the tissues (QAMAR, 2009). Antibiotics help to boost the body’s immunity and therefore help the body fight infections (Lee, 2009). Change of dressing and covering of the wounds helps to protect the wound from infection. Assessing the sign of infection such as color and smell of discharge will help to intervene and prevent spread of infection Allowing the patient to verbalize her concern will help relay anxiety (MADDEN, 2010). Monitoring input and output balance will help balance fluids and electrolytes in the body (QAMAR, 2008). Administration of feeds will help boost the immunity of the patient and allow the healing process to take place. Ms Mak’s wounds show signs of healing after a one and half week of hospitalization. There are no discharges from the site and the wound is drying up (Kaufman, 2012). The wounds have are not completely healed at the end of the second week and therefore new interventions should be put in place to promote healing. Ms Max wounds are free from infections after four days of hospitalization as a result of continuous dressing and cover of the wounds (Levin, 2010). In conclusion the learning objectives were achieved. The learning objective of the discussion was to ensure that Ms Max is able to adjust to actual or perceived changes, to prevent complications, to meet self-care needs through assistance by a medical practitioner or by self, to help the patient understand the procedure, therapeutic regimen and potential complications related to surgery as well as to put plans in place in order to meet discharge needs. Some of the difficulties encountered include lack of better implementation and intervention skills that will help reduce the post-operative period and reduce complications such as infections. There were also problems in the coordination of the outcomes and the methods of evaluation. References A Shared Nursing Care Plan. (2010). 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