Nursing Care Plan for Hysterectomies

PREOPERATIVE NURSING CARE PLAN #1 DATE CUES NURSING DIAGNOSIS SCIENTIFIC BASIS GOAL OF CARE NURSING INTERVENTION RATIONALE October 19, 2021 Wala ko kaybaw unsa akong angay buhaton. Naguol ko ug nakulbaan sa mga mahitabo sa akoa,” as verbalized by the patient. Anxiety related to lack of knowledge regarding symptoms, progression of condition, and treatment regimen. Anxiety is the vague uneasy feeling of discomfort or dread accompanied by an autonomic response. SHORT TERM: After 2 hours of nursing intervention within the shift of the nurse, the patient will be able to: Independent: 1. Assess and recognize awareness of the patient’s level of anxiety Independent: 1. To establish a baseline observation of the anxiety level and to validate the patient's feelings. Objective: - Slight trembling of the hands - Quivering of voice is noted. Restlessnes s - V/S are taken as follows: T: 36.7 degrees C Reference: Doenges, M., Moorhouse, M. F., & Murr, A. (2019). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales (10th ed.). F.A. Davis Company. Pathophysiological Basis Knowledge of one’s own disease has been emphasized as an important 2. Establish and maintain a trusting relationship by listening to the client, answering questions directly, being available, and respecting the patient's use of personal space. EVALUATION SHORT TERM: After 2 hours of the nursing intervention, the patient was able to: 2. Therapeutic skills need to be directed toward putting the patient at ease in order to promote 1.Verbalize communication. understanding about the 1. Verbalize condition, and her feelings of concerns related concerns. 3. Encourage the patient's 3. Relaxation exercises are effective to the condition. participation in relaxation nonchemical ways that provide the 2. Appears exercises such as deep breathing, patient with a variety of ways to relaxed and 2.The patient guided imagery, and meditation. manage anxiety. reports that appeared calm, anxiety is was able to ask reduced to a questions about 4. Familiarize the patient with the level that is the surgery to the environment and new experiences 4. Awareness of the environment manageable. nurse on duty, or people as needed. promotes comfort and may and expressed decrease anxiety. feelings of 3. Participate in 5. Explain all activities, concern. the relaxation procedures, and issues while exercises and using nonmedical terms, and calm, 5. With patient education, the identify ways to slow speech. patient will experience less anxiety, 3.The patient express anxiety. emotional distress, and have participated in Dependent: increased coping skills. relaxation techniques such 6. Administer medications as 4. Verbalize as performing understanding ordered by the physician such as Dependent: deep breathing sedatives or hypnotics. of condition, 6. Sedatives may be prescribed for symptom short-term anxiety relief to enhance exercises. PR:110 bpm RR:18 cpm BP: 90/60 mmHg cognitive factor that can have a considerable progression and treatment regimen. coping abilities. Hypnotics promote sleep the evening before surgery. 7. Discuss postponement or cancellation of surgery with physician, anesthesiologist, 7. This may be necessary if overwhelming anxiety or fear are not POST-OPERATIVE NURSING CARE PLAN #2 DATE CUES NURSING DIAGNOSIS SCIENTIFIC BASIS October 20, 2021 Subjective: “Magsakit akong tahi inig lihok ra og gamay,” as verbalized by patient Acute pain related to surgical incision as evidenced by pain scale of 6/10, 10 as the highest and facial grimacing. Definition of the Nsg Dx Acute pain is experienced immediately after surgery (up to 7 days) and pain which lasts more than 3 months after the injury is considered to be chronic pain. Objective: - Pain scale of 6/10 - Facial grimace upon moving - V/S are taken as follows: T: 37.0 degrees C PR:90 bpm RR:19 cpm BP:110/90m mHg Reference: Gupta, A., Kaur, K., Sharma, S., Goyal, S., Arora, S., & Murthy, R. S. (2010). Clinical aspects of acute postoperative pain management & its assessment. Journal of advanced pharmaceutical technology & research, 1(2), 97–108. GOAL OF CARE NURSING INTERVENTION Short Term: Independent 1)Encourage deep breathing exercises. Independent 1)To inhibit pain. Hormones such as nitrous oxide increase in the blood, reducing tension in the body during deep breaths. 2)Obtain client’s VS including the pain scale. 2)To assess the effectiveness of nursing Interventions and obtain baseline for future comparison; to alleviate pain. 3)Encourage verbal report during and after each nursing intervention 3)Because pain is highly subjective 4)Assist patient in different position like sitting and side lying position 4)It reduces muscle tension and fatigue. Dependent 5)Administer pain relief medication as per doctor’s order Dependent 5)To relieve patient’s pain Collaborative 6)Cooperate with the family of the client to document the health of the patient Collaborative 6)To be able to follow up the situation of the patient After 4 hours of nursing interventions within the shift, the client will manifest a decrease in pain scale from 6/10 to 3/10 or lower. Long Term: The patient will be able to move and do exercises and activities of daily living independently after six to eight weeks. RATIONALE EVALUATION Short Term: After 4 nursing intervention the client was able to manifest and verbalized a decrease in pain scale from 6/10 to 2/10 Long Term: After six weeks, the patient was able to move and do exercises and activities of daily living independently. Pathophysiolo gical Basis Surgical tissue trauma leads to nociceptor activation and sensitization. As a result, individuals suffer ongoing pain at rest and increased responses to stimuli at the site of injury (primary hyperalgesia) Reference: Posso, I. D. P. (2017). Global Year Against Pain After Surgery. Revista Dor, 18. Rationale: Acute pain serves a protective purpose by informing and educating the patient about the presence of an injury or illness. POST-OPERATIVE NURSING CARE PLAN #3 DATE CUES NURSING DIAGNOSIS SCIENTIFIC BASIS GOAL OF CARE Octobe r 20, 2021 Subjective: “Naguol ko kay di na kaayo ko ka-enjoy sa beach. Mauwaw na man ko mag-expose sa ako panit oy tungod aning uwat sa akong tahi,” as verbalized by the patient. Disturbed body image related to abdominal scarring after surgery Body image is a complex construct. Disturbed body image is a confusion in the mental picture of one’s physical self. Distortions in body image are painful and can influence physical and psychological health. As a significant component of one’s selfconcept, body image disturbance can have an intense impression on how individuals see their overall selves. SHORT TERM After 2 hours of nursing intervention, the patient will be able to verbalize her own understanding of her own bodily changes. Objective: Pfannenstiel incision scar noted. -frustrated look -social withdrawal gestures -Focusing behavior on changed body part References: https://www.cm tcalliance.org/di After 8 hours of nursing intervention, the patient will be able to apply acne scar gel in her incision. LONG TERM After 3 days of nursing intervention, the patient will be able to verbalize relief of anxiety and adaptation to altered body image. NURSING INTERVENTION RATIONALE Independent: Independent: Encourage patient discuss her feelings about herself and listen To help patient feel valued Assess the patient’s response to changes in body To determine the extent of body image disturbance Promote accepting and non judgemental attitude To respect the patient’s sensitivity to body image changes Evaluate level of client’s knowledge of and anxiety towards the situation To observe emotional changes which may indicate acceptance or no acceptance of situation Dependent: Apply Silicone gel to the incision as prescribed by the physician. Dependent: Silicone gel heals scars by increasing hydration of the stratum corneum (the uppermost layer of the skin) Collaborative: Refer to physical and occupational therapy, vocational counselor, psychiatric counseling, clinical specialist psychiatric nurse, social services, and psychologist, as needed. Collaborative: These are helpful in identifying ways/devices to regain and maintain independence. Patients may need further assistance to resolve persistent emotional problems. EVALUATION SHORT TERM After 2 hours of nursing intervention, the patient was able to verbalize his understanding of his own bodily changes. After 8 hours of nursing intervention, the patient will be able to apply acne scar gel in her incision. LONG TERM After 3 days of nursing intervention, the patient was able to verbalize relief of anxiety and adaptation to altered body image. -Intentional hiding of body part sturbed-bodyimage/ https://www.ncb i.nlm.nih.gov/bo oks/NBK54658 2/ Pathophysiolo gical Basis Large or highly visible scars are often an unavoidable result of injury or surgery. The soft tissues surrounding a wound may change shape, dimple, or become sunken, uneven, or raised as the wound heals. When a surgical incision is healing, stitches—or sutures—can alter the look of a scar. Surgery for scars & keloids. Patient Care at NYU Langone Health. (n.d.). Retrieved October 30, 2021, from https://nyulango ne.org/condition s/scarskeloids/treatme nts/surgery-forscarskeloids#:~:text= Large%20or%2 0highly%20visib le%20scars,the %20look%20of %20a%20scar. Rationale: Appropriate care for distorted body image is a significant step to recovery. Cognitive Behavioral Therapy, an approach where irrational thoughts are recognized, analyzed, and restructured to more rational self-talk, is frequently used in planning care to address body image disturbance. Geddie, R., Vera, M., & Miller, L. (2020, September 7). Disturbed body image – nursing diagnosis & care plan. Nurseslabs. Retrieved October 30, 2021, from https://nursesla bs.com/disturbe d-body-image/.