Nursing Care Plan Date: Patient: Room: Age: Date of Surgery: Mar.

14 Type of Surgery: Abdominal perineal resection & flap from L thigh Diagnosis: Rectal Ca PMHx: Arrhythmia, chemo preop Diet: General Activity: Treatments: Complex rectal dressing (RN to do) , L thigh dressing OTA, L JP drain, R Abd hemovac, S.L., colostomy Medications: ASA, Bisoprolol, Esomeprazole, Ferrous Gluconate, Pip/Taz IV, Flomax, Coumadin PRN Medications: Tylenol, Beadryl, Dilaudid, Narcan, Zofran, Stemetil, Imovane STUDENT: VALIDATION PROCESS ASSESSMENT Wednesday PM How will I assess each problem? EVIDENCE Thursday PM Data collected to indicate a valid problem INTERVENTIONS Wednesday PM What will I do for each of the potential problems both nursing interventions and medical interventions? EVALUATION/FOLLO W-UP

Potential Problems What are the anticipated problems for this patient and what is potentially causing these problems, (due to or related to). Risk for infection r/t prolonged hospitalization (post op day 24??), type of Sx abdominal perineal resection & flap from thigh, several areas of breakage in skin tissue ie rectal, thigh, abdomen, IV/drains/hemovac, colostomy, possible physiological stress, possible decreased mobility (ie bedrest) therefore at risk for pneumonia, Dx of rectal ca & chemo

Assess surgical sites for signs of infection: reddened, warm to touch, inflamed Monitor WBC count and if may indicate infection Monitor VS especially for and in temperature Monitor IV for S&S of infection (ie redness, swelling, warmth, pain, etc. Assess VS (and respiratory) and ask pt if he feels

If signs of infection was noted will report and document appropriately Notify RN if notice the dressing is saturated; appropriately describe the drainage appearance and amount (ie serous, sang, serosanguineous, purulent; minimal, moderate, large) Encourage pt to ambulate, do deep breathing & coughing exercises, maintain 1

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Potential Problems therapy preop possible immunecompromised?

VALIDATION PROCESS stressed/anxious

INTERVENTIONS HOB at 30 degree angle to decrease risk of pneumonia Obtain specimens for culture if requested Ie urine analysis Apply moisturizer to skin to hydrate dry skin Check IV site for signs of swelling, redness etc. and address if required Encourage fluid intake Encourage pt to mobilize as much as possible (ROM); repositioning, ambulating etc

EVALUATION/FOLLO W-UP

Risk for impaired skin integrity d/t multiple breakage in skin tissue ie rectal, thigh, JP drain, abd hemovac, colostomy site, IV, prolong hospitalization increase bedrest and decreased mobility?, decrease nutrition? (d/t cancer? pain? stress? etc)

assess bony prominences, heels, elbows for blanching/breakdown & assess perianal area for signs of redness/soreness, assess IV site for signs of skin breakdown & possible edema if IV had been moved assess signs of hydration such as dry skin/mucous membrane, c/o thirst assess nutrition & diet Assess for exertional discomfort or dyspnea Assess pts sleep pattern Assess pts pain level & how it is affecting him Assess pts nutritional intake & diet type? (NPO) & Assess pts desire to eat/appetite Ask about pts normal

Risk for fatigue r/t cancer, prolonged hospitalization & possible nutritional intake, disturbed sleep pattern, possible low Hg, iron or low hemocrit level assoc with fatigue (pt taking Ferrous gluconate)

Encourage adequate rest periods especially before ambulation, exercise sessions and other ADLs Schedule times for patient to ambulate & rest Administer analgesics (per ordered) before mobilizing if pt has pain Teach patient to 2

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Potential Problems

VALIDATION PROCESS activity/energy level Assess pts lab values: Rbc Hg, iron, Hct,

INTERVENTIONS recognize signs of overexertion Assess if iron supplement is adequate (monitor lab values ie iron, hg, hct, etc) Ensure adequate nutrition is being provided (energy) Administer antiemetic (ie gravol) as needed for nausea/vomiting (per ordered - advise RN)

EVALUATION/FOLLO W-UP

Risk for bowel incontinence r/t dx (rectal cancer) and Sx, (possible anal sphincter muscle/ nerve damage, scarring??), possible history of chronic diarrhea/constipation, tumor, - pt currently has colostomy (is this permanent?), pain/physiological stress may also contribute to bowel incontinence?

Assess for leakages (ie diarrhea) Assess for sensation and urge to have BM (damage to rectal muscles/nerves?) Assess for history of chronic bowel illnesses ie diarrhea or constipation Assess if Sx included having rectum closed up - pt currently has colostomy assess if this is permanent Assess dietary plan, history of BM

Encourage pt to do Kegel exercises (biofeedback) Encourage pt to develop regular patterns of bowel movements) Encourage dietary planning (avoid certain foods such as chocolates, tea & coffee that contain caffeine which relaxes the anal sphincter Encourage pt to eat smaller meals and drink more fluids Note: this may not be a potential problem for pt if pt has permanent colostomy bag

Risk of chronic pain r/t cancer (ie pt may have

WPC #32187 02/13

Ask pt if he is in pain Assess pain using

Ask what has worked for himin the past to 3

Potential Problems cancer pain especially if it had metastasized)

VALIDATION PROCESS LOTARP and pain scale (0-10) both at rest and on movement Assess for non-verbal signs of pain (guarding, wincing, irritability) Assess other possible causes of discomfort (postioning?) Assess for what works at home

INTERVENTIONS pain Reposition as needed Provide additional comfort measures (ex. Massage, hot and cold therapy) Encourage pt to use relaxation techniques (deep breathing, visualization etc) Administer pain medication as appropriate and evaluate effectiveness Read chart to find out planned length of recovery Teach pt importance of doing these exercises in relation to recovering and being able to go home Teach pt importance of managing pain so he can recover more quickly (lack of pain can mobility) Teach pt to recognize S & S of infection & to report asap Teach importance of having support while recovering at home Provide appropriate material (brochures) r/t wound healing, condition,

EVALUATION/FOLLO W-UP

D/C Teaching

Assess pts knowledge of recovery (how long to expect to stay in hospital and to recover from surgery) Assess pts understanding of pain management & Coughing &DB, mobilization to reduce risk of infection Assess pts knowledge of S&S of infection Determine pts living situation and support system once D/Cd

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Potential Problems D/C Planning

VALIDATION PROCESS Assess pts ability to perform ADLs independently Assess pts ability to mobilize Monitor pts VS and ensure stable Assess if pt has help/support at home Assess pts level of anxiety r/t D/C (ability to handle recovery at home)

INTERVENTIONS Be there for support, & encourage pt to do as much on own so he/she can regain strength and chance of going home Encourage frequent ambulation w/adequate rest periods See chart for assessments by Health care team ie dietician, doctor etc to see overall status of pt Document accurate information re: activity level

EVALUATION/FOLLO W-UP

WPC #32187 02/13