Running head: Research of Best Practice and Application to Nursing Care

Research of Best Practice and Application to Nursing Care

Catherine Fedoruk
Norquest College
NFDN 2003
Assignment 2
Jasmine Guanlao Sagun
Feb 10, 2016

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Research of Best Practice and Application to Nursing Care

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Research of Best Practice and Application to Nursing Care

Evidence-based practice has shown that "early ambulation is the most significant general
nursing measure to prevent postoperative complications" (Lewis, Heitkemper, & Dirksen, 2004,
p. 401). Early ambulation can reduce venous stasis, simulate circulation, increase muscle tone
and coordination, and prevent deep venous thrombosis/pulmonary embolism, among other
things. Early ambulation is important in all medical-surgical patients, but those at greater risk of
complications postoperatively tend to be elderly, diabetic, or mobility-impaired; or have recently
had strokes, heart failure, or altered sensory perception. Patients with impaired mobility are at
particularly high risk for developing serious complications postoperatively. Risks associated with
impaired mobility include acute atelectasis, pulmonary embolism, aspiration, suppressed
swallowing, impaired skin integrity, loss of muscle tone, venous stasis and deep vein thrombosis.
Postoperative procedures have been implemented to improve patient outcomes following
surgery. Frequently repositioning patients with limited mobility; using incentive spirometry to
improve respiratory function; and promoting ambulation, skin care, and wound care are some of
the techniques implemented. Sedatives and analgesics help improve the patients level of comfort
both in and out of the hospital. Proper nutritional intake provides an important role in patients
overall health. Proper protein intake improves wound healing, prevents future wounds, and helps
rebuild the epidermal tissue.
Hygiene and skin care to both the surgical wound and overall patient can also impact the
patients recovery times and complications. Ensure the patients skin is dry and intact, as
moisture softens the skin and makes it more susceptible to the developments of skin tears (Potter
& Perry, 2010) Patients with impaired mobility are often unable to reposition themselves or
perform their own hygiene, and therefore are at greater risk for impaired skin integrity and must

Research of Best Practice and Application to Nursing Care

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be positioned frequently, have pressure points supported, and be checked frequently for signs of
skin breakdown.
Evidence-based practice has shown that clients overall health improves with early
ambulation. Patients are encouraged to ambulate as early as they can tolerate. Motivating
medical-surgical clients to ambulate is important for the prevention of deep vein thrombosis,
venus stasis, pulmonary embolism and muscle atrophy. If patients cannot tolerate walking, they
can still be encouraged to ambulate by sitting up in bed or in a chair with their legs dangling for
short periods of time or by attempting range of motion exercises. Even simple exercises like
raising or lowering legs while seated can help patients to ease into mobilization. As described by
Potter & Perry (2010), leg exercises, ambulating, positioning changing, use of TED stocking,
avoiding sitting for long periods of time and crossing legs, and ROM promotes venous return (p.
1209).
The use of an incentive spirometry is a recent advancement for medical-surgical patients;
prior to 1970, patients were only encouraged to breathe deeply to promote lung expansion. Along
with proper positioning, the incentive spirometry can help maintain ventilation and oxygen and
reduces the risk of stasis of pulmonary secretion and decreased chest wall expansion (Potter &
Perry, 2010, p. 913). Teaching clients every two hours how to independently use the incentive
spirometer and perform deep diaphragmatic breathing can prevent pulmonary complications and
encourage client independence (Day, Paul, Williams, Smeltzer, & Bare, 2010, p. 502). Deep
breathing can help oxygenate tissue and reduce stress; in some cases focusing on breathing
techniques can also decrease pain.
These techniques, along with patient education, provide optimal patient recovery both in
and out of the hospital. Discharge teaching is done with the patient on many aspects of their care,

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such as proper medication administration, wound care, and mobilization schedules. The
discharge teaching can also extend to include lifestyle teaching, such as following the Canadian
Food Guide to improve nutritional intake, smoking cessation, and healthier lifestyle changes.
Including the family in discharge teaching can help the patient adhere to discharge instructions.
The recovery rates have been improving for medical-surgical patients with the use of
these strategies. This, along with discharge teaching, has shown to reduce major complications
associated with the medical-surgical patient while in the hospital and after discharge.

Research of Best Practice and Application to Nursing Care

Student Name: Catherine Fedoruk
Actual Nursing
Diagnosis
Goal

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Planning

Interventions

Evaluation

Intervention
The goal was met because

Impaired respiratory

Patient will have improved

Instruct client to sit up in Fowlers

function related to

breathing pattern with equal

position (or semi-Fowlers position if

diminished lung/chest wall

expansion within 24 hours as

they cannot tolerate a Fowlers position)

patients respiratory rate

and O2 stats are within
normal range and equal
expansion associated with

evidenced by a normal breathing

to aid in airway and lung expansion.

lung/chest wall expansion.

weakness and decreased

pattern.

mobility as evidenced by

Literature Support

client on bed rest post-

Postural drainage by means of

operatively.

positioning patients to aid in the

removal of secretions from specific
segments of the lungs and bronchi into
the trachea. In this case, a high-Fowlers
position is used to aid the patient.
(Potter & Perry, 2010, p.905)

Research of Best Practice and Application to Nursing Care

Outcome

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Intervention

Patient will experience adequate

Instruct client to use the incentive
respiratory function as evidenced
spirometer 10 times every hour to
by normal rate, rhythm, depth of
increase lung expansion.
respirations, symmetrical chest
excursion and oximetry results
within normal range.
Literature Support
The incentive spirometer is used to
retrain breathing and muscles to achieve
a more efficient and controlled
ventilation and, in turn, decrease the
workload of breathing and improve
breathing patterns (Day, Paul, Williams,
Smeltzer, and Bare, 2010, p. 691).

Research of Best Practice and Application to Nursing Care

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Intervention
Repositioning of patient every two hours
to maintain and promote chest
expansion. This can be done alongside
repositioning for skin integrity.
Literature Support
Proper ventilation is maintained in a
healthy individual by frequent
positioning and changes in ADLs,
however patients with limited mobility
are at risk for decreased respiratory
function. Frequent changes in
positioning of the patient can aid in
maintaining chest expansion and stasis
of secretions. (Potter & Perry, 2010, p.
913)

Research of Best Practice and Application to Nursing Care

Potential Nursing
Diagnosis

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Planning

Interventions

Goal

Intervention

Risk for activity

Patient will be walking

Provide pain management to patient in

intolerance related to loss

unassisted and able to perform

the form of an analgesic PRN.

of muscle mass, tone and

their own ADLs within a week

strength associated with

post-op. Patient will report no

Literature Support

disuse post-operatively.

fatigue, discomfort (pain) or

Once pain is experienced, a cycle of

difficulty when performing these

events begins that, if left untreated or

Evaluation
The goal was met when
patient was able to perform
their own ADLs and walk
unassisted around the unit
without fatigue or
discomfort, as stated by the
client.

tasks. This goal was established

unrelieved, can significantly diminish

by working with the patient to

the meaning and quality of a persons

create a reasonable timeline for

life. (Potter & Perry, 2010, p. 1012) If a

ambulation.

patient is experiencing pain they are less

likely to want to ambulate or maintain a
positive outlook on recovery.

Research of Best Practice and Application to Nursing Care

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Outcome

Intervention

Patient will report no fatigue or

Perform actions to maintain muscle

weakness and be able to perform

mass such as performing exercises while

ADL within physical

seated, leg and arm lifts, ROM exercises

limitations/restrictions without a

and ensuring proper protein intake.

significant change in vitals. This

Literature Support
will be evidenced by patient
As proteins break down, patients lose
statements and vitals.
lean body mass and muscle. ROM
techniques allow you to assess your
patients tolerance for activity while
improving your patients activity
tolerance. This, along with proper
nutrition and health promotion, will
encourage and help your patients to
ambulate better (Potter & Perry, 2010, p.
1190-1207).

Research of Best Practice and Application to Nursing Care

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Intervention
Health promotion and reassurance that
their immobilization is a side effect of
analgesic used during surgery.

Literature Support
Immobilization may lead to emotional
and behavioural responses, sensory
alterations, and changes in coping.
(Potter & Perry, 2010, p. 1192). Patients
vary in their tolerance for ambulation.
While some are willing to participate,
some may be feeling some psychosocial
effects from their immobility;
reassurance and health promotion is
important. Finding an ambulation
schedule that works with your patient is
also important.

Research of Best Practice and Application to Nursing Care

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Research of Best Practice and Application to Nursing Care

Teaching Nursing
Diagnosis

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Planning

Interventions

Goal

Intervention

Risk for impaired tissue

Patient will maintain skin

Determine patients risk for skin

integrity related to

integrity and show no signs of

breakdown using the Braden scale

decreased oxygen and

skin breakdown upon discharge

several times over the course of

nutrient supple to the skin

from the hospital.

treatment as ambulation increases or

Evaluation
The interventions were
successful as evidenced by
the patients intact skin and
no signs of breakdown
upon discharge.

and subcutaneous tissue

decreases.

associated with reduced

blood flow resulting from

Literature Support

prolonged pressure on the

Visual examination of the skin along

tissue from reduced

with the Braden scale is useful in

ambulation.

identifying the risk of developing

postoperatively.

pressure sores in all patients. Patients

must be reassessed regarding their
overall health, time, and duration in bed,
along with any changes. (Potter & Perry,
2010, p. 1248-1250)

Research of Best Practice and Application to Nursing Care

Outcome
Patient will maintain skin
integrity as evidenced by no skin
breakdown, absence of redness
or irritation. This will be

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Intervention
Re-positioning the patient every 2 hours
unless contraindicated, and ensuring all
pressure points are supported to prevent
skin breakdown.

evidenced by monitoring patient

skin for breakdown every 8
hours, as well as patient stating
any discomfort.

Literature Support
Repositioning the patient every 1-2
hours reduces the risk for skin
breakdown and pressure ulcers
formation (Potter & Perry, 2010, p.
1205)

Research of Best Practice and Application to Nursing Care

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Intervention
Reducing friction on skin by
maintaining proper hygiene, ensuring
skin is clean, dry and intact; ensuring
sheets and blankets are wrinkle-free, and
external devices such as braces, casts
and restraints applied properly. If
needed, a special mattress to relieve
pressure points may also be used.

Literature Support
Evidence-based practice has shown that

Research of Best Practice and Application to Nursing Care

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maintaining proper hygiene and
ensuring skin is clean and dry helps
maintain skin integrity (Potter & Perry,
2010, p. 1240-1283). The reduction of
wrinkles in sheets and blankets,
unnecessary external devices and the use
of special air mattresses have reduced
the incidences of pressure spots and
pressure ulcers, there by maintaining
skin integrity.

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References
Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2010). Textbook of medical/surgical
nursing (2nd Cdn. ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Dixon, A. (2011). The volumetric exerciser spirometer vs the incentive spirometer. Retrieved from
http://www.livestrong.com/article/52540-incentive-spirometry-vs.-diaphramaticbreathing/#page=2
Gardiner, L. (2008). Evidence-based best practice in maintaining skin integrity. Wound Practice and
Research 16 (2), 5-15.
Harvard Medical School. (2015). About relaxation techniques: Breath control helps quell errant
stress response. Retrieved from http://www.health.harvard.edu/mind-and-mood/relaxationtechniques-breath-control-helps-quell-errant-stress-response
Morris, A., Benetti, M., Marro, H. & Rosenthal, C. (2010). Clinical practice guidelines for early
mobilization hours after surgery. Retrieved from http://www.nursingcenter.com/cearticle?
an=00006416-201009000-00003&Journal_ID=403341&Issue_ID=1092086
Lewis S. L., Heitkemper M. M., Dirksen S. R. (2004). Medical-surgical nursing: Assessment and
management of clinical problems (6th ed.). St. Louis, MO: Mosby.
Potter, P. A., & Perry, A. G. (2010). Canadian fundamentals of nursing. (4th ed. rev.). Toronto, ON:
Elsevier.