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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.
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Planning
Interventions
Evaluation
Intervention
The goal was met because
Impaired respiratory
function related to
pattern.
mobility as evidenced by
Literature Support
operatively.
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Intervention
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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)
Potential Nursing
Diagnosis
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Planning
Interventions
Goal
Intervention
Literature Support
disuse post-operatively.
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.
ambulation.
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Outcome
Intervention
limitations/restrictions without a
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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.
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Teaching Nursing
Diagnosis
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Planning
Interventions
Goal
Intervention
integrity related to
Evaluation
The interventions were
successful as evidenced by
the patients intact skin and
no signs of breakdown
upon discharge.
decreases.
Literature Support
ambulation.
postoperatively.
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.
Literature Support
Repositioning the patient every 1-2
hours reduces the risk for skin
breakdown and pressure ulcers
formation (Potter & Perry, 2010, p.
1205)
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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
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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.