CHEO Placement Care Plan

NSG 3135; Practicum Acute Care

CHEO Placement Care Plan

November 24, 2004



Care Plan

About the Patient

Patient is a nine year old African American girl previously diagnoses with sickle cell anemia. Patient admitted for a laparoscopic spleenectomy at CHEO. Patient deals with pain and procedures best with distraction and adequate medication. Patient requires lots of encouragement to move in bed and for use of the incentive spiro meter. When receiving this patient post operative, she had a nasogastric tube and a peripheral intravenous in each hand; one for replacing NG losses and the other for fluid maintenance. She also had 5 small dressings on her abdomen. She was on bedrest and NPO. Parents were both present and supportive at the bedside post operation.



Medical Diagnosis

Hyperspleenism (spleen destroys, in excessive numbers, blood cells) secondary to sickle cell anemia. She was at CHEO for a laparoscopic spleenectomy.

Nursing Diagnosis (A)

Acute pain related to surgical procedure.


Nursing Interventions
Rationales

(i) Assess pain level using a self-report measurement tool (scale from 1-10).
(i) Use of tool promotes communication and evaluation of pain control.

(ii) Administer pain medication as ordered, and assess effectiveness. (acetaminophen)
(ii) Use of opioids which bind to opiate receptors to decrease sensations of pain.

(iii) Instruct patient about the importance of pain control prior to pain becoming severe (re use of PCA Morphine).
(iii) A preventative approach to pain control reduces anxiety and promotes a consistent level of relief and overall comfort.

(iv) Use nonpharmacologic pain reduction measures.
(iv) Distraction (movies, etc), proper positioning can increase the effects of pain medication therefore increasing comfort level.


Outcomes

The patient will be more comfortable, as evidence by verbalizing that discomfort is reduced, and moving in bed with less pain.



Nursing Diagnosis (B)

Risk for infection related to surgical wounds, increased environmental exposure to pathogens in hospital, immobility and inadequate secondary defenses.



Nursing Interventions
Rationales

(i) Administer antibiotics as ordered and monitor effectiveness. Monitor vital signs especially temperature and surgical wound sites.
(i) Use of antibiotics decreases likelihood of developing infection. Early detection of infection allows for early interventions to decrease severity.

(ii) Turn patient in bed as ordered and monitor skin integrity paying special attention to pressure points.
(ii) Skin breakdown may occur if patient lies immobile. With skin breakdown risk of infection increases.

(iii) Keep patient clean with regular bed baths and change soiled linen. Monitor dressings to eliminate possible contamination of surgical sites.
(iii) All patients are at risk for nosocomial infections in hospitals. Regular washing eliminates bacteria and decreases risk for infection.

(vi) Ensure immunizations are up to date.
(vi) With the removal of the spleen special attention to immunizations is important.


Outcomes

The patient will maintain infection free status as evidence by afebrile status.