Peter Kim
Desired Outcomes
Pain:
1.
2.
Patient reports satisfactory pain control at a
level less than 3 to 4 on a 0 to 10 rating scale.
Patient exhibits increased comfort such as
baseline levels for pulse, blood pressure,
respirations, and relaxed muscle tone or body
posture.
Respiratory Depression:
1. Patient exhibits baseline levels for respirations,
breathing patterns, and depth, pulse and O2
saturation levels.
Altered Nutrition/Fluid & Electrolyte Imbalance:
1. Patient will maintain fluid and electrolyte
balance within normal limits.
Risk for Bleeding:
1. Patient has reduced risk for bleeding, as
evidenced by normal or adequate platelet
levels, hemoglobin and hematocrit levels, and
RBCs.
Risk for Infection:
1. Patient remains free of infection, as evidenced
by normal vital signs and absence of purulent
drainage from incision.
Risk for Fluid Overload:
1. Patient maintains normal fluid volume, as
evidenced by balanced intake and output,
absence of edema, and absence of excessive
weight gain.
Interventions
Pain:
1.
Assess pain location, quality, onset frequency,
radiation, duration, precipitating and relieving
factors.
2. Pt on PCA device.
3. Assess for respiratory depression due to PCA.
4. Assess GI status, especially pain in the
abdomen.
5. Non-pharmacologic interventions for pain.
6. Dressing changes and wound assessments.
7. Once PCA has been discontinued, oral pain
medications.
Respiratory Depression:
1. Assess patient’s respiratory system for any
signs of respiratory depression.
2. Administer narcan if showing S&S of
respiratory depression due to PCA.
3. Discontinue PCA if S&S develop.
Altered Nutrition/Fluid & Electrolyte Imbalance:
1. Assess for signs of dehydration and fluid
overload.
2. Daily weights.
3. Monitor lab values (electrolytes, kidney
function, CBC).
4. Strict I&Os because of surgical procedure in
the GI.
5. Oral care and oral fluids (clear liquid diet).
Risk for Bleeding:
1. Assess for signs of hypovolemia.
2. Monitor platelets, H&H, and RBCs.
3. Strict I&Os.
4. Hydrate patient and provide IV fluids.
5. Assess incision and dressing for blood.
Risk for Infection:
1. Assess patients vital signs, temperature for
fevers, rigors and chills.
2. Assess incision for any swelling, redness,
purulent discharge as they may be signs of
infection to the site.
3. Monitor CBC with differential and culture and
sensitivity.
4. Administer antibiotics as prescribed.
5. Assess patient’s nutritional status.
Risk for Fluid Overload:
1. Daily weights.
2. Monitor strict I&Os.
3. Assess for S&S of fluid overload, such as
edema, distended jugular veins, ascites,
respiratory system (shortness of breath and
crackles).
4. Administer diuretics as prescribed.
5. Monitor sodium levels.
6. Position pt in a semi-Fowler’s or high-Fowler’s
position.
Peter Kim
Immobility:
1. Patient will be able to ambulate as tolerated and
transfer to chair 2-3 times a day.
Immobility:
1. Assess patient’s ability to ambulate in and out
of bed and in the hallways.
2. Provide pain medication before any activity
such as with PT or when ambulating.
3. Pt education on non-pharmacologic measures
for pain management.
4. Use proper techniques such as log rolling when
getting out of bed due to abdominal surgery.
5. Assist patient to ambulate with an assistive
device if not able to walk on own strength.
Evaluation
During the patient’s care, I assessed patient pain and he was able to maintain his pain level around 2-3/10. He had
pain at the surgical site of the abdomen. Patient’s goal for pain was met because he was able to control it. Patient
felt a slight increase in pain during ambulation but it was tolerable. He was on a PCA device with Fentanyl, so also
assessed pt’s respiratory system for any signs of respiratory depression. Pt’s respirations and breathing patterns
were regular. Pt’s vital signs are stable during the care. Pt showed no signs of respiratory distress. He was on TPN,
IV fluids and with a clear liquid diet so he was at risk for fluid overload. Monitor his I&Os during the care. Also
monitored his lab results, make sure his electrolytes and H&H were within normal ranges. Assessed pt for signs of
edema, crackles and shortness of breath, ascites, jugular venous distention. Pt showed no signs of fluid overload. Pt
shows no signs of fever, rigors and chills. The surgical site had small amounts of serosanguinous discharge but no
purulent discharge. The site was slightly red without edema and dressing was changed.
Discharge Plan/Patient Teaching
Pt will be going home once discharged from the hospital. He is currently living with his wife, who is his caregiver.
She is very supportive and with husband everyday during the hospital stay. Pt is able to ambulate to the bathroom
and in the halls with assistance. He may need an assistive device depending on his progress. Pt will need supplies
for wound care. Patient is a visual learner and he does not have any barriers to learning. Topics to be addressed are
signs and symptoms of hemorrhagic shock due to bleeding because of GI surgery, education of medications
prescribed (side effects to be aware of and when to contact the physician), contacting his primary care provider for
signs and symptoms of infection, increasing pain, dehiscence and embolism (leg pain or chest pain), follow up visits
with the physician after discharge, financial status with the MSW, proper use of assistive devices, logrolling in and
out of bed, pt diet and nutrition, activity levels as tolerated, dressing changes for the primary caregiver, how to
prevent dehiscence by avoiding activities that may bring intense pressure in the area of the abdomen (bearing down,
lifting heavy items, bending over).