Nursing Management (specific care and teaching to give this patient)

Physiologic
o Neurological
 Monitor mental status (early sign of impaired gas exchange)
 Assess if patient is awake and oriented
 Assess for PERRLA
 Monitor for confusion r/t neurological dysfunction secondary to chronic
confusion
 Determine client’s normal routine and attempt to maintain them
 Begin each interaction with identifying yourself and calling
patient by name
 Impaired memory r/t anemia

o Cardiac
 Intermittent pneumatic compression devices, knee high (post-op)
 Monitor HR
 Monitor BP
o Respiratory:
 Delayed surgical recovery r/t decreased oxygen supply to body,
increased cardiac workload
 Assess lung sounds, monitor oxygen saturation level with pulse
oximetry
 Administer oxygen as ordered: Maintain SpO2 >92%
 Administer humidified oxygen through appropriate device
 Teach: incentive spirometry (every hour while awake), cough &
deep breath
o Endocrine
 No problem noted
o GI
 Risk for constipation r/t abdominal procedure:
 Promote ambulation
 Promote adequate fluid intake
 Promote nutritional intake of food with increased fiber
o GU
 UTI:
 Insert or maintain foley catheter, as indicated
o Discontinue morning of postoperative day one
 Assess for pain
 Assess urine output (color, odor, blood)
 Teach: proper perineal care
o Urinate when urge to void
o Wipe front to back
o Increase fluid intake
o Change diaper/chuck when soiled
o Musculoskeletal
 ROM activities, ensure pillow supports pt with no skin breakdown
 Activity: up ad lib (ambulate patient as tolerated)
o Skin/ Wounds
 Risk for impaired skin integrity r/t age, imbalanced nutritional state
(obesity), impaired circulation
 Assess skin
 Turn pt q2h
 Apply sensicare and mepilex, as needed
o Fluids & Electrolytes
 Monitor intake and output every shift
 Promote fluid intake
Nutrition
 Cardiac diet for low sodium and cholesterol, no caffeine
 Promote proper nutritional intake (especially of iron, folic)
o Other
 Vital signs per unit standard, q3h
 Sleep deprivation r/t breathing difficulties when lying down
 Risk for infection: risk factor: stasis of respiratory secretions
Psychosocial
o Anxiety r/t cause of disease
 Assess client’s level of anxiety and physical reactions to anxiety (e.g.
tachycardia, nonverbal)
 Use relaxation techniques such as music therapy or guided imagery
 Refer to psychiatrist or social worker, if needed
 Use therapeutic communication: open-ended questions or closed-ended
questions appropriately
 Use therapeutic touch
o Ineffective health maintenance r/t deficient knowledge regarding nutritional and
medical treatment of anemia.
 Help client choose healthy lifestyle and to have appropriate diagnostic
screening tests.
 Assist the client in reducing stress.
 Identify complementary healing modalities, such as herbal remedies,
acupuncture, healing touch, yoga, cultural shamans that the client uses
in addition to or instead of the prescribed allopathic regimen.
 Refer client to appropriate services as needed.
Safety
o Fall Risk, Risk for Injury r/t alteration in peripheral sensory perception
 Thoroughly orient the client to the environment.
 Teach patient to use call light to get help to ambulate
 Ensure call light is within reach.
 Keep upper two rails up.
 Keep tray close by to patient to reduce need to ambulate.
 Ensure wheels on bed are in locked position.
 Maintain bed in low position.
 Ensure commode is close by and preferred side of bed for patient.
 Ensure there is proper lighting during the day.
 Keep dim light in room at night.
 Assess fall risk using scale.
 Remove all possible hazards in environment such as razors,
medications, and matches.
 Place an injury prone client by the nurse’s station.
 Wear socks when ambulating to prevent falls.
 Encourage client to wear glasses and hearing aids and to use walking
aids when ambulating.
 If client experiences dizziness with orthostatic hypotension, teach client
to sit for several minutes before standing, flexing feet upward several
times while sitting.
 Refer to PT for strengthening exercises and gait training to increase
mobility.
 Evaluate client’s medications to determine whether medications increase
risk of falling: consult with physician regarding client’s needs for
medication if appropriate.
o Activity intolerance r/t imbalance between oxygen supply and demand
 Assess pt’s ability to ambulate
 Ambulate OOB to chair evening of surgery, then tid
o
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o
o
Monitor for increased dyspnea, loss of ability to control breathing
rhythmically, use of accessory muscles, nasal flaring, appearance of
facial distress, skin tone changes such as pallor and cyanosis
Do not administer medications patient may be allergic to
Use at least two methods to identify the client before administering medications,
blood products, treatments, or procedures.