Nursing Care Plan


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Medical Diagnoses: Acute pain related to upper lumbar incision, impaired mobility and skin integrity, infection releated to incision and imbalanced nutrition.


1.Acute pain related to upper lumbar incision with wound vac placement

·         Pt. rates pain 8 out of 10 on pain scale before PO pain medication

·         Physician prescribes PCA of Morphine and PO of Oxycodone and Narcan

·         Pain increases during ambulation and repositioning

2.Impaired skin integrity related to incision

·         8 inch incision on lumbar spine with wound vac

·         Admitting wound infection

3.Infection related to incision

·         Purulent drainage from incision site

·         Incision site positive for bacteremia

5Impaired mobility related to acute pain and incision

·         Unable to position self comfortably

·         Cannot bend over

·         On fall preventions per hospital policy

·         Uses a walker for ambulation

Chief Complaint: A 67 year old, white female, with a wound infection from a previous upper lumbar spinal surgery related to small cell lung cancer metastasizing to the spinal bone.

 

Priority Assessment: Monitor vitals and pain level.  Practice standard and isolation precautious to help prevent reoccurring infection.  Monitor LOC and mobility. Monitor the volume and appearance of drainage. Assist with repositioning and monitor comfort.

8.Risk for falls related to acute pain and impaired mobility

·         On fall preventions per hospital policy

·         Pain and medication can have side effects that effect LOC

·         Uses a walker for ambulation

·         Pt. attached to wound vac

4. Ineffective tissue profusion related to incision

·         Wound vac placement

·         Compromised immune system

·         Metastasis cancer

6. Nausea related to acute pain and pain medication.

·         Physician prescribes pain medication that has effects of nausea

·         Physician prescribes pt. with medication that help with nausea

7. Imbalanced nutrition: less than body requirements related to acute pain, mobility and nausea


NANDA Diagnostic Statement:  Acute pain related to upper lumbar incision with wound vac placement AEB pain being 8 out of 10 on the pain scale.

Behavioral Outcome / Goal: Pt. will report a decrease in pain from 8 down to 4 on the pain scale by 11/5/2011.  Pt. will not use PCA of morphine only PO of Oxycodone for pain control by 11/5/20xx.  Blood cultures will remain free of bacteremia and incision will have unimpaired healing. Pt. will increase mobility safely without injury. 


Nursing Interventions:

 

1.      Monitor pt. for pain at least every 2 hours using the numeric pain scale and behavior assessment.

 

2.      Administer pt.’s PO pain medication (Oxycodone and Narcan) as prescribed.  Reassess pain level and relief and document the effects.

3.      Teach pt. how to use the PCA for pain as much as it allows and report pain as soon as it is not being relieved by PCA.  Also the description of pain and its contributing factors.

4.      Reposition pt. at least every 2 hours. Maintain alignment with pillows and monitor positioning around lumbar area.  Prevent skin breakdown

 

5.      Provide pt. a peaceful and quiet environment for resting and healing.________________________

Rationale:

 

1.      Pain is subjective in nature and only the client can fully describe it (Cox’s Clinical pg: 487)

2.      Response to pain and pain medication is unique to each client (Cox’s Clinical pg:488

 

3.      Pain is more readily controlled when it is treated early (Cox’s Clinical pg:487)

 

4.      Help stimulate circulation.  Alignment helps prevent pain malpractice and enhances comfort.  (Cox’s Clinical pg:488)

5.      Promotes action and effect of medication by providing decreased stimuli (Cox’s Clinical pg: 488)_______________________

Client Response:

 

1.      Pt.’s pain level at 8 while on PCA of morphine, after PO pain medication of Oxycodone pain level decreased to a 6.

2.      Pt. reported pain and asked for PO pain medication when PCA did not reduce pain.

 

3.      Pt. reported pain as soon as PCA medication wore off.  Pt. describes the pain is located in her neck and shoulders.

4.      Every 2 hours help pt. shift weight to different positions that do not affect incision site. Pt. hesitates during reposition, cautious around incision.

5.      Pt. has private room and on isolation precautious.  Television on but volume is down low.  Lights are dim and pt. calm.  Pt. rests after pain medication is given.  Pt. is stable._==============

Summarize impressions of client progress toward outcomes / problem resolution: Pt. is stable.  Pt. is experiencing a great deal of pain described as a 8 on the pain scale.  Physician prescribes Morphine through PCA and Oxycodone and Narcan orally. Pt will be weaned from PCA and only depend on PO’s for relief.  Pt. can eat regular diet prescribed by physician.  Pt. is voiding and having bm’s on own.  Incision site is located on lumbar spinal region.  Incision is 8 inches with a wound vac present.  No redness/edema around site.  300mg of orange, transparent serosanguinous drainage from incision.  Pt. is on isolation precautious due to the infection before wound debridement and wound vac placement.  Physician prescribed pt. on 1000mg/ NaCl 0.9% of IV solution of Vancomycin due to blood cultures being positive for cocci. After debridement and Vancomycin, blood cultures have been negative for sepsis.  Pt. has daughter visiting and once pt. is released the daughter is taking care of her after discharge of pt.  Pt. will be referred to a wound consult nurse and P.T

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