Student Name: __________________________
Date: ______________________
Client Gender: ____________ Client Age: ________
Client Diagnosis: __________________________________________________________________________________________________
You are the nurse caring for a 64-year-old male client who is postoperative day four on the medical-surgical unit after having an emergency right colectomy due to cancer. The client is NPO with a nasogastric (NG) tube to low intermittent suction. The client has a history of smoking and no other health problems.
Vital signs:
- Temperature: 99.2° F
- Heart rate: 91 beats/min
- Respirations: 20 breaths/minute
- O2 saturation: 93% on 2L oxygen via nasal cannula
- Blood pressure: 110/68 mm Hg
- Pain: “6/10”
Focused assessment findings:
- Alert and oriented to person, place, and time
- Moves all four extremities, refuses to ambulate
- Apical pulse is regular at 91 beats/minute
- Lungs clear to auscultation, diminished bilaterally
- Bowel sounds hypoactive, abdomen soft, tender in all four quadrants
- Midline abdominal incision well approximated with staples intact, no erythema, Penrose drain intact with scant serous drainage
- Right lower quadrant Jackson-Pratt drain with sutures intact, no erythema, 30 mL of serosanguineous drainage
Instructions
Using the information from the scenario, create a care plan using the attached template.
| Assessment data for Nursing Diagnosis | Nursing Diagnosis (3) | Expected Outcomes with Indicators
(1 per Nursing Diagnosis) |
Nursing Interventions
(2 per Expected Outcome) |
Evidence-based Rationale for each Nursing Intervention (Cited/referenced) | Evaluation
(How do you know it worked?) |
Respond to this critical thinking question:
Describe evidence-based precautions to prevent this client from obtaining a nosocomial infection. Provide supporting rationales.
Support your response with evidence from credible sources.
Assessment data for Nursing Diagnosis:
Nursing Diagnosis (3):
- Risk for impaired skin integrity related to surgical incision and drainage tubes.
- Risk for infection related to the presence of an open surgical incision and drainage tubes.
- Risk for constipation related to decreased bowel motility and opioid pain medication use.
Expected Outcomes with Indicators:
- The client will have intact and healing surgical incisions and drainage sites without signs of infection.
- The client will remain free from healthcare-associated infections.
- The client will have regular bowel movements without discomfort or straining.
Nursing Interventions:
- Provide frequent assessment and care of surgical incision sites and drainage tubes.
- Implement infection control measures, including hand hygiene, contact precautions, and sterile technique during dressing changes and tube care.
- Encourage regular physical activity, adequate hydration, and fiber intake to promote bowel motility.
- Administer opioid pain medication as prescribed and monitor for side effects, such as constipation.
- Consider prophylactic antibiotic use as appropriate for the client’s surgical procedure and risk factors for infection.
Evidence-based Rationale for each Nursing Intervention:
- Frequent assessment and care of surgical incision sites and drainage tubes can prevent infection and promote healing. Dressing changes, wound cleaning, and tube care are opportunities to detect and address any signs of infection or impaired healing.
- Infection control measures are essential for preventing healthcare-associated infections, particularly in clients with open wounds and tubes. Hand hygiene, contact precautions, and sterile technique are evidence-based strategies to reduce the risk of infection transmission.
- Encouraging regular physical activity, hydration, and fiber intake can prevent constipation and promote bowel motility. Studies have shown that early ambulation and fiber supplementation can reduce the risk of postoperative constipation (Cavalcante and Sampaio, 2017).
- Opioid pain medication is commonly used for postoperative pain management but can cause constipation as a side effect. Monitoring for constipation and providing appropriate interventions, such as stool softeners and laxatives, can reduce discomfort and prevent complications (Kane et al., 2014).
- Prophylactic antibiotic use is sometimes recommended for surgical clients to reduce the risk of surgical site infections. However, antibiotic use should be based on evidence-based guidelines and the individual client’s risk factors to avoid contributing to antibiotic resistance (Allegranzi et al., 2016).
Evaluation:
Regular assessment of the client’s surgical incisions and drainage tubes, infection control measures, and promotion of bowel motility can help prevent nosocomial infections and promote healing. By monitoring for signs of infection and promoting healthy bowel function, the nurse can help prevent complications and promote a smooth recovery for the client.
Critical thinking question:
Describe evidence-based precautions to prevent this client from obtaining a nosocomial infection. Provide supporting rationales.
Nosocomial infections, also known as healthcare-associated infections, are a significant risk for clients in healthcare settings, particularly those with surgical wounds and drainage tubes. Evidence-based precautions to prevent nosocomial infections include:
- Hand hygiene: Hand hygiene is a critical measure to prevent the transmission of infectious agents in healthcare settings. The World Health Organization (WHO) recommends that healthcare workers perform hand hygiene before and after contact with each client, as well as before and after performing any invasive procedure (WHO, 2009). Hand hygiene can help prevent the spread of infectious agents, including those that can cause surgical site infections and other healthcare-associated infections.
- Contact precautions: Contact precautions are a type of infection control measure used for clients with known or suspected infectious diseases. Contact precautions include the use of gloves and gowns when entering the client’s room, as well as dedicated equipment and environmental