2. The nurse receives a 12-year-old girl from the operating room after an emerge
ID: 247966 • Letter: 2
Question
2. The nurse receives a 12-year-old girl from the operating room after an emergent appendectomy due to ruptured appendix. Upon arrival to the postanesthesia care unit, the patient is drowsy, but arousable to voice; she was extubated in the operating room and is receiving oxygen by facemask at 40%. She has two peripheral IVs in her left arm that are infusing Lactated Ringers solution at 100 mL/hr. A nasogastric tube is attached to low constant suction, and a small amount of aspirate is noted. She has a urinary catheter that is draining clear, yellow urine Her abdominal dressing is dry and intact. Upon arousal, she complains of abdominal pain. (Learning Objective 5) a. What NANDA-approved nursing diagnoses may be relevant to this patient? b. Once the nursing diagnoses are determined, what steps does the nurse take to complete the Planning Phase of the Nursing Process? C. What is the difference between nursing diagnoses and collaborative problems?Explanation / Answer
a.Acute pain in the abdomen related to surgical incision as evidenced by pain scale score.
Impaired gas exchange related to post operative period as evidenced by saturation level.
Impaired skin integrity related to surgical incision as evidenced by physical examination.
Activity intolerance related to surgical procedures as evidenced by less mobility .
Sleeping pattern disturbance related to pain as evidenced by surgical procedures.
Fear and anxiety related to diseases conditions as evidenced by frequent asking questions.
Risk for infection related to catherzation.
Risk for infection related to surgical incision.
Risk for infection related to cannulasation.
b.acute pain in the abdomen related to surgical incision.
Provide comfortable position.
Assess pain level,noting specific location and intensity.
Encourage early ambulatation.
Encourage users of relaxation techniques.
Watch closely for possible surgical complications.
Administere analgesics.
Impaired gas exchange related to post operative period as evidenced by saturation level.
Elevated head of bed that is easy to breath.
Administered oxygen
Monitor spo2 level.
Encourage the patient on diaphragmatic breath.
Administere the brochodilator.
Impaired skin integrity related to surgical incision as evidenced by physical examination.
Assess general condition of skin.
Assess for edema fecal and urinary incontinence.
Position patient every 2 hours.
Provide comfortable wrinkle free linen and air bed if required.
Encourage patients maintain functional body alignment.
Clean ,dry ,moisture skin
Insert bedpan gently.
Increase tissue perfusion
Encourage adequate nutrition and hydration.
Activity intolerance related to surgical incision as evidenced by less mobility.
Assess patient ability to perform ADLs effectively.
Keep side rails
Monitor input and output chart.
Turn and position every 2 hours.
Clean ,dry,moisture skin as needed.
Maintain limbs in functional alignment.
Use antipressure device.
Note present medical diagnosis and regimen.
Sleeping pattern disturbance related to pain as evidenced by surgical procedures.
Avoid day time sleeping.
Identify factors that may facilities or interference with normal patterns
Instruct to avoid large fluid intake before bed time.
Advice to take warm milk before bedtime.
Administer sedative as per doctor order.
Fear and anxiety relatedto surgical procedures as evidenced by frequent asking questions.
Assess client for signs and symptoms of fear and anxiety.
Oexplain about surgical procedures.
Maintain calm ,supportI've, confident manner when interacting with clients.
Assure client that staff member are near by respond to call signal as soonew as possible.
Use simple language.
Encourage rest period and to take divertional therapy.
Provide positive feedback.
Risk for infection related to catherzation.
Monitor for the following signs of infection (redness, pain,swelling, purulent discharge )
Assess for presence, existence history of risk factors.
Maintain aseptic in wound care.
Monitor white blood count.
Wash hands before contact with patients between procedure with patients after procedure.
Administer antimicrobial agent.
C.nursing diagnosis;
Clinical judgment about individual, family, community experience and responsibilities statement about the clients actual and potential health problems and life process.
Minor problem nurses treat independently.
Collaborative problem;
Potential complications of a client conditions that a nurse cannot treat independently.
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