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Med-Surgical Concept Map

Intervention 2

Administer Hydromorphone 1 mg as per MD order

  • R. Opioids are indicated for severe pain (Gulanick & Myers, 2014).

Intervention 1

Teach JK and family members the importance of frequent hand hygiene.

  • R. JK can spread infection from one part fo the body to another and hand washing reduces these risks (Gulanick & Myers, 2014).

Intervention 3

Assess for any adverse effects to the medication.

  • R. Opioids may cause side effects that range from hypotension to respiratory depression (Gulanick & Myers, 2014).

Intervention 3

Monitor WBC/vital signs.

  • R. An increase in WBC can indicate the body's effort to fight pathogens (Gulanick & Myers, 2014).
  • R.Temperature of 100.4 or higher, increased heart rate, decreased blood pressure are signs of infection (Phelps, Ralph & Taylor, 2017)

Intervention 1

Assess JK's pain characteristics by asking the patient for the location, onset, quality, severity, duration and any precipitating relieving factors.

  • R. Assessment of the pain is the first step in planning pain management strategy (Gulanick & Myers, 2014).

Short Term Goal :

  • JK will demonstrate increased comfort, such as relaxed muscle tone by end of shift.
  • JK will be able to reposition/ambulate with little to no pain by end of shift.

Long Term Goal :

  • Pt. will report a pain level of at least 3/10 by time of discharge.

Intervention 2

Administer Cefoxitin 1 gm as per MD order.

  • R. Administration of antibiotic can decrease the incidence of wound infection (Phelps, Ralph & Taylor, 2017).

Short term goal 1:

  • JK's abdominal wound sites will remain C/D/I during shift.
  • JK's vital signs and lab values will remain WNL during shift.

Long term goal:

  • JK's surgical incision sites will remain free from S+S of infection (redness, swelling, purulent drainage) during stay at hospital.

Intervention 4

Evaluate the effectiveness of the medication

  • R. Pain medications are absorbed and metabolized differently by patients (Gulanick & Myers, 2014).

Robotic Gastrectomy: Duodenal Mass removal

Intervention 4

Monitor for signs and symptoms of an infection at surgical puncture wounds.

  • R. Tenderness, erythema, warmth, swelling and drainage are classic signs of an infection (Gulanick & Myers, 2014).

Nursing Dx 3

Risk for infection related to Robotic Gastrectomy Procedure AEB

  • 5 puncture sites
  • Glucose: 157 (H)
  • Foley (16F)

Nursing Dx 1:

Acute pain related to surgical wounds AEB

  • Throbbing pain at abd. puncture sites and on her LUQ/side
  • Pain 6/10
  • Guarding of stomach
  • Facial grimacing

Evaluation

After administration of hydromorphone, JK's pain was not relieved and she was still unable to ambulate. In the afternoon, a second dose was administered - as per MD order- JK was able to transition to her chair and eventually ambulate within the hallway with little to no pain. J.K.'s pain level diminished to 3/10 by end of shift.

Christine Chung

Jazmin Londono

Evaluation

JK's abdominal puncture sites remained C/D/I during shift and vital signs remained WNL.

Short term goal:

  • JK will maintain adequate skin circulation during shift.

Long term goal:

  • JK's skin will remain intact AEB no redness over bony prominences by time of discharge.

Intervention 4

Assess treatment-related factors, such as side effects and interactions of medications.

  • R.Can affect nature and degree of activity intolerance (UCentral, 2017).

Nursing Dx 4

Activity intolerance related to pain secondary to Robotic Gastrectomy AEB

  • Exertional discomfort
  • Generalized weakness/fatigue
  • Pain 6/10 when repositioning
  • Diminished lung sounds bilaterally
  • Incentive spirometer reading: 1000 mL
  • O2/2L/min Nasal Cannula
  • Pt reports high levels of stress by stating "I can't believe this is happening to me!"

Nursing Dx 2:

Risk for impaired skin integrity related to lack of mobility secondary to pain from surgical incisions AEB

  • Hemoglobin: 9.1
  • Hematocrit : 26
  • Robotic Gastrectomy procedure
  • Throbbing pain and rates pain level 6/10.

Intervention 3

Assess emotional and psychological factors affecting the current situation.

  • R. Stress and/or depression may be increasing the effects of an illness, or depression might be the result of forced inactivity (UCentral, 2017)

Intervention 1

Change JK's position at least every two hours.

  • R. This measure reduces pressure on tissues, promotes circulation, and prevents skin breakdown (Phelps, Ralph & Taylor, 2017).

Short term goal

  • JK will participate willingly in necessary/desired activity during shift.
  • JK will exhibit tolerance while performing physical activity during shift.

Long term goal

  • JK will report the ability to perform required activities of daily living by time of discharge.

Intervention 1

Assess JK's ability to stand and move about and the degree of assistance necessary or use of equipment.

  • R. To determine current status and needs associated with participation in needed/desired activities (UCentral, 2017).

Intervention 3

Use pillows to keep bony prominences from direct contact with each other.

  • R. This measure reduces shearing forces on the skin (Phelps, Ralph & Taylor, 2017).

Intervention 4

Keep JK's skin clean and dry and lubricate with lotion as needed.

  • R. This measure promotes comfort and reduces risk of irritation and skin breakdown (Phelps, Ralph & Taylor, 2017)

Intervention 2

Assess cardiopulmonary response to physical activity, including vital signs, before, during and after activity. Note accelerating fatigue.

  • R. Dramatic changes in heart rate and rhythm, changes in usual blood pressure and progressively worsening fatigue result from imbalance of oxygen supply and demand (UCentral, 2017).

Intervention 2

Encourage ambulation at least every four hours.

  • R. Ambulation promotes circulation and relieves pressure (Phelps, Ralph & Taylor, 2017).

Evaluation

JK willingly ambulated to and from bathroom, and within the hallways - JK exhibited tolerance to activities. Vital signs remained WNL before, during and after activity.

Evaluation

JK's skin remained C/D/I and maintained adequate circulation AEB SpO2 of 100% on 2L/NC and capillary refill <3 seconds.

Works Cited

Gulanick, M., & Myers, J.L. (2014). Nursing Care Plans. Philadelphia, PA: Elsevier.

Hoffman, J.J. & Sullivan, N.J. (2017). Medical-Surgical Nursing. Philadelphia, PA: FA-Davis.

Tokunaga M, Kaito A, Sugita S, Watanabe M, Sunagawa H, Kinoshita T.(2017) Robotic gastrectomy for gastric cancer. Retrieved from http://tgh.amegroups.com/article/view/3772/4558

Ucentral. (2017). Davis’s Lab & Diagnostic Test [Mobile application software]. Retrieved from http://unboundmedicine.com

J.K.

Client

J.K. is a 63 yr old female , who came into the ED with complaints of abdominal pain and GI bleeding.

  • Currently is the owner of a dry cleaning shop and lives with husband and daughter.

Medical Hx.

Admitting Dx:

  • Disease of the stomach

Final Dx:

  • Duodenal mass

Diet:

  • NPO transitioned to clear liquids by start of second day. J.K. consuming full liquids by end of 2nd day.

Patient Information

Past Medical Hx:

  • Anemia, Asthma, Tuberculosis, Hypothyroidism

Activity

  • Encouraged to use incentive spirometer 10x/hr and to ambulate in hallway - POD 1 & 2
  • 1000 mL reached POD 1

Robotic Gastrectomy : Duodenal Mass Removal

Pathophysiology

JK had a gastrectomy performed as part of her diagnosis of having a mass towards the end of her stomach and beginning of the duodenum.

  • A robotic gastrectomy consists of removing a portion or the entire stomach, mostly indicated in patients who have gastric cancer. In this particular case, the patient's mass was diagnosed benign. The procedure consists of 5 puncture sites made by articulated devices, meant for minimally invasive surgery versus other current surgery options like laparoscopic surgery or cutting the abdomen open. With this procedure there is less chance of bleeding and having damage done to the vital organs. Many surgeons opt for the Robotic gastrectomy as it allows them to them have a three-dimensional surgical field unlike other surgical options which allow only two dimensional fields of view. (Tokunaga, 2017)

Abnormal labs

  • Hemoglobin : 9.1 ( L)
  • Hematocrit : 26 (L)........... These values are prominent due to J.K's anemic state.

  • Glucose : 157 (H)....... Elevation may be due to trauma done to body from surgical procedure and high stress. High glucose levels can lead to poor wound healing.

  • Chloride: 110 (H)...... A significant factor demonstrating dehydration as can be expected from patient on NPO status

Diagnostic Tests

Radiology reports

  • CT of ABd + Pelvis- revealed presence of gastric mass/perigastric nodes, small liver hypodensities and uterine fibroids.

Assessment

Subjective

  • J.K. complained of 6/10 throbbing pain of abdominal wall
  • Patient grimaced and guarded her stomach
  • J.K. constantly remarking about dry mouth symptoms
  • J.K. exclaims " I can't believe this is happening to me."

Physical exam

Objective

  • Mental Status: AAOx3
  • Circulation: Cap refill <3 seconds; O2 Nasal Cannula 2L/MIN
  • Mucous membranes : Dry mouth
  • Respiratory: diminished breath sounds bilaterally
  • Skin: 5 surgical puncture sites with gauze and tegaderm: C/D/I
  • GU: Hypoactive bowel sounds x4 quadrants
  • Abdomen soft and tender to touch; non-distended
  • Muscle strength : strong and equal
  • Lower extremities: edema not noted
  • + pedal pulses
  • + peripheral pulses
  • Drainage: 16 F Foley ( C/D/I); UTI Prevention protocol in place
  • IV: Left 20 Gauge C/D/I

  • Current vitals:
  • Temp: 97.7 (oral)
  • Pulse: 71 bpm
  • RR: 21
  • BP: 118/83
  • SpO2: 100% on 2L/min NC

Health Promotion Strategies

Health Promotion

Issue:

  • J.K. did not understand and was afraid to use incentive spirometer post op.

Teaching plan:

  • Taught J.K. to use pillow as a splint over abdominal area while performing deep breathing exercises.
  • Taught J.K. how to use incentive spirometer and asked for return demonstration
  • Deep breathing exercises help prevent lung complications such as Pneumonia.

Issue:

  • Although patient was transitioning from clear to full liquids, patient needs to be educated on what to eat/not to eat after a gastrectomy.

Teaching plan:

  • Teach pt. to avoid high fiber foods as they can fill you up quickly and

add to the abdominal discomfort. Teach pt. to focus on high protein

foods (meat, fish, dairy) and to eat several, small meals per day

to avoid complications like dumping syndrome.

Issue:

  • J.K. did not want to ambulate in fear of added pain.

Teaching plan:

  • Encouraged progressive low tolerance exercises like walking and deep breathing to increase overall strength and tolerance to perform ADLs successively.

Medications

  • Cefoxitin ( Mefoxin)
  • Anti-infective - to prevent infection post-surgery

  • Hydromorphone ( Dilaudid)
  • Opioid analgesic - for moderate pain relief for pain rated 6/10.

  • Acetaminophen -codeine (Tylenol Codeine #3)
  • Narcotic - For moderate pain relief

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