Scenario
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:
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- 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:
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- 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.
Student Name: __________________________
Date: ______________________
Client Gender: ____________ Client Age: ________
Client Diagnosis: __________________________________________________________________________________________________
| 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.
Student Name: [Your Name]
Date: [Current Date]
Client Gender: Male
Client Age: 64
Client Diagnosis: Postoperative day four after an emergency right colectomy due to cancer.
Nursing Diagnosis 1: Impaired Gas Exchange related to hypoventilation as evidenced by O2 saturation of 93% on 2L oxygen via nasal cannula.
Expected Outcome: The client will maintain O2 saturation levels ≥ 95% on 2L oxygen via nasal cannula within 24 hours.
Nursing Interventions:
- Administer oxygen as prescribed and monitor O2 saturation continuously.
- Encourage deep breathing exercises and ambulation if possible.
Evidence-based Rationale:
- Administering oxygen helps maintain adequate oxygen levels in the bloodstream.
- Deep breathing exercises can improve lung expansion and reduce the risk of atelectasis, improving gas exchange.
Evaluation: The client’s O2 saturation levels were monitored, and they maintained levels ≥ 95% on 2L oxygen via nasal cannula within 24 hours.
Nursing Diagnosis 2: Acute Pain related to surgical incision as evidenced by the client rating pain as “6/10.”
Expected Outcome: The client will report a pain level of ≤ 3/10 on the pain scale within 48 hours.
Nursing Interventions:
- Administer analgesics as prescribed and assess pain regularly.
- Teach relaxation techniques and reposition the client for comfort.
Evidence-based Rationale:
- Administering analgesics as prescribed helps manage pain effectively.
- Relaxation techniques and repositioning can aid in pain relief and promote comfort.
Evaluation: The client reported a pain level of ≤ 3/10 on the pain scale within 48 hours.
Nursing Diagnosis 3: Risk for Infection related to surgical wound and indwelling tubes as evidenced by abdominal incision and the presence of Jackson-Pratt and nasogastric tubes.
Expected Outcome: The client will remain free from signs and symptoms of infection throughout the hospital stay.
Nursing Interventions:
- Maintain strict aseptic technique during wound care and tube management.
- Educate the client and family about proper hand hygiene and infection prevention.
Evidence-based Rationale:
- Strict aseptic technique reduces the risk of introducing pathogens into the wound or tubes.
- Educating the client and family about hand hygiene and infection prevention helps create a safe environment and reduces the risk of nosocomial infections.
Evaluation: The client remained free from signs and symptoms of infection throughout the hospital stay.
Critical Thinking Response:
To prevent nosocomial infections in this client, evidence-based precautions include:
- Hand Hygiene: Ensure that all healthcare providers and visitors practice proper hand hygiene with soap and water or hand sanitizers. Hand hygiene is crucial to prevent the transmission of pathogens from one person to another.
- Aseptic Technique: Maintain strict aseptic technique when caring for the surgical wound, Jackson-Pratt drain, and nasogastric tube. This includes using sterile gloves, sterile dressings, and sterile solutions when performing wound care or handling the tubes. Aseptic technique minimizes the risk of introducing bacteria into the surgical site or tubes.
- Appropriate Use of Antibiotics: Administer prophylactic antibiotics as prescribed by the physician, following established guidelines for timing and duration. Antibiotics can help prevent surgical site infections, but their use should be based on evidence-based protocols to reduce the risk of antimicrobial resistance.
- Daily Assessment of Surgical Site and Tubes: Regularly assess the surgical incision, Jackson-Pratt drain, and nasogastric tube site for signs of infection, such as redness, swelling, increased drainage, or foul odor. Promptly report any concerning changes to the healthcare provider for early intervention.
- Patient and Family Education: Educate the client and their family on the importance of infection prevention, proper hand hygiene, and signs and symptoms of infection. Encourage the client to ask questions and be actively involved in their care.
- Proper Tube Care: Ensure that the Jackson-Pratt drain and nasogastric tube are securely in place and functioning correctly. Follow aseptic techniques when changing dressings or emptying drainage bags to prevent contamination.
- Environmental Hygiene: Maintain a clean and sanitary patient environment by regularly cleaning and disinfecting surfaces, equipment, and the patient’s immediate surroundings.
These precautions are based on evidence-based practices aimed at reducing the risk of nosocomial infections and promoting the overall well-being of the postoperative client. Adhering to these precautions can help prevent infections and improve patient outcomes.