Hello, this is an assignment from the Medical-Surgical Nursing Lab and the teacher wants a nursing note related to Postoperative Nursing Care (No less than 10 sentences). Please create a real case on an unreal patient and You must complete the attached file with the patient’s nursing care notes. Bibliography: 1. Ignatavicius, D., & Workman, M. (2015). Medical-Surgical Nursing (8th ed.). St Louis, Missouri: Elsevier. ISBN: 9781455772551.
Nursing Note: Postoperative Nursing Care
Patient Information:
Name: John Doe
Age: 55 years
Admission Date: January 1, 2022
Procedure: Laparoscopic cholecystectomy
Subjective Data:
– Patient reports mild-to-moderate incisional pain.
– Patient expresses concerns about postoperative complications.
– Patient states feeling anxious about the surgical site and wound healing.
– Patient verbalizes discomfort while moving or coughing.
Objective Data:
– Vital signs within normal range with stable blood pressure and heart rate.
– Surgical incisions intact and without signs of redness, swelling, or drainage.
– Dressing clean, dry, and intact.
– Adequate respiratory effort observed with clear bilateral breath sounds.
– Ambulating independently without difficulty.
– Normal gastrointestinal functioning with flatulence and tolerance to oral intake.
Assessment:
– Patient is experiencing mild-to-moderate pain at the surgical incision site, as reported by the patient.
– Patient is anxious about postoperative complications and wound healing.
– No signs of infection or impaired wound healing observed upon examination.
– Patient’s vital signs are stable.
– Normal gastrointestinal functioning observed, indicating effective postoperative recovery.
– Patient’s independent ambulation and adequate respiratory effort suggest an overall positive outcome after surgery.
Plan:
1. Pain management:
a. Administer prescribed analgesics as scheduled to maintain patient comfort and manage incisional pain.
b. Assess pain level using a validated pain assessment tool at regular intervals.
c. Encourage patient to report any increase in pain or any new discomfort.
2. Wound care and assessment:
a. Monitor surgical incisions and dressing for signs of infection, such as redness, swelling, warmth, or purulent drainage.
b. Keep dressing clean, dry, and intact to promote wound healing.
c. Educate the patient on proper incision care, including signs of infection and when to seek medical attention.
3. Anxiety management:
a. Provide emotional support and reassurance to the patient regarding postoperative complications and wound healing.
b. Educate the patient on common postoperative experiences and the expected recovery process.
c. Encourage relaxation techniques, such as deep breathing exercises, to reduce anxiety.
4. Respiratory management:
a. Monitor respiratory rate and effort regularly to ensure adequate oxygenation.
b. Encourage frequent deep breathing and coughing exercises to prevent respiratory complications.
c. Educate the patient on the importance of early ambulation and mobility in promoting effective lung expansion.
5. Ambulation and mobility:
a. Encourage the patient to ambulate regularly to promote circulation, prevent complications, and enhance recovery.
b. Ensure a safe environment for ambulation and provide assistance as needed.
6. Nutrition and hydration:
a. Ensure the patient’s nutritional needs are met by offering a balanced, regular diet.
b. Encourage adequate fluid intake to prevent dehydration and promote wound healing.
This nursing note reflects the postoperative nursing care provided to John Doe, a 55-year-old patient who underwent a laparoscopic cholecystectomy. The patient’s pain management, wound care, anxiety management, respiratory management, ambulation and mobility, and nutrition and hydration have been addressed in the plan. These interventions aim to facilitate the patient’s recovery, prevent complications, and ensure a positive postoperative outcome.
References:
Ignatavicius, D., & Workman, M. (2015). Medical-Surgical Nursing (8th ed.). St Louis, Missouri: Elsevier. ISBN: 9781455772551.