3 restlessness during recovery period due to patient

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3. Restlessness during recovery period due to patient not able to care for children due to incisions made on stomach. Patient will experience some discomfort or pain while bending down or turning body side to side (Taylor, et al., 2015).
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NURSING CARE PLAN Potential Health Deviations: aka Risk Diagnoses (AT LEAST TWO) Include THREE independent nursing interventions for each ( RISK FOR XXX, AS EVIDENCED BY XXX ) Inter-professional Consults, Discharge Referrals, & Current Orders (include diet, test, and treatments) with Rationale Supported with Evidence Based Citations At risk for infection as evidence by 4 small incisions on abdomen. 1. Inspect dressing for foul odors and any abnormal discharge. 2. Monitor vital signs and asses patient. 3. Provide adequate nutrition and fluids. At risk for aspiration as evidence by induction of general anesthesia. 1. Raise head of bead to at least 30 degrees. 2. Maintain patent airway. 3. Asses for the presence of gag reflex. Respiratory therapist: Respiratory therapist will teach patient to turn, cough, and deep breathe. Respiratory therapist will also teach patient breathing exercises with incentive spirometer (Lewis, 2017). Surgeon: Surgeon will be the first to asses patients dressing and stitching (Lewis, 2017). Physiotherapists: Will provide patient exercise to do at home that will make daily living tasks more comfortable until pain subsides for patient (Lewis, 2017). Dietitian: Will provide certain foods and liquids that patient can consume after discharge while at home. (Lewis, 2017). Priority Nursing Diagnosis (at least 2) Written in three-part statement * Risk Diagnoses NEVER go in this section . Planning (outcome/goal) Measureable goal during your shift (at least 1 per Nursing Diagnosis) * Think SMART GOAL * Prioritized Independent and collaborative nursing interventions; include further assessment, Intervention and teaching (at least 4 per goal) Rationale Each must be supported with Evidence Based Citations Evaluation Goal Met, Partially Met, or Not Met & Explanation 1. Acute pain related to cholecystectomy as evidence by 4 incisions on abdomen. After one to two hours after analgesic administration, patient will demonstrate behaviors to relieve pain herself. 1. Monitor and document vital signs. 2. Asses frequency, severity, and characteristics of pain experienced by patient. 3. Administer medication as ordered by MD. 1. To obtain baseline assessment data on patients’ pain (Lewis, 2017) 2. Pain should be reported and determined by patients’ level of pain tolerance (Lewis, 2017). 3. To minimize and to relieve patients’ pain (Lewis, 2017) Goal was met. After one to two hours, patient was able to demonstrate behavior to relieve pain.
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NURSING CARE PLAN 4. Provide non-pharmacological interventions to patient. 4. Provide comfort to patient and to relieve discomfort (Lewis, 2017) 2. Impaired physical mobility related to pain as evidence by cholecystectomy.
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