Nursing diagnoses: 1.
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Risk for falls r/t medication regimen which includes narcotics Risk for impaired skin integrity r/t decreased mobility as evidenced by a low Braden Q score Impaired comfort r/t surgical site pain and infection as evidenced by patient‘s report of a 6 out of 10 on the pain scale and complaints of N/V Delayed surgical recovery r/t surgical site infection as evidenced by incisional pain, n/v, and readmission
Medications:
Gastrectomy Labs/Diagnostics: Possible/Potential Complications:
1. Infection 2. Post-gastrectomy Syndrome 3. Internal bleeding 4. Blockage of small intestine 5. Anastomotic leakage
Pt data: Age: 77 Sex: F HX: Chronic gastritis, pernicious anemia, atrial fibrillation
Focused Assessment: Auscultate the lungs for adventitious sounds and crepitus Monitor all four quadrants for bowel sounds Take vital signs and monitor for abnormalities, infection, or bleeding (esp. hypotension, tachycardia) Palpate the abdomen for signs of edema or distention Locate and assess wound site for redness, swelling, discharge (document if foul odor and color/consistency) Determine patient’s pain on a scale of 1-10 and perform COLDSPA assessment
Wound culture Hemoglobin/hematocrit Electrolytes Serum albumin Total protein WBC Biopsy
1. Heparin 2. Hydromorphone hydrochloride (Dilaudid) 3. Ondansetron 4. Cefazolin sodium Home meds: 1. OTC antacids 2. Digoxin
Nursing Care: RISK FOR FALLS 1. Nurse will make sure patient is identified as a falls risk 2. Keep call light within patient’s reach 3. Assist patient with ambulation, transfers, ect RISK FOR IMPAIRED SKIN INTEGRITY 1. Log roll patient Q2H 2. Change soiled linens promptly 3. Perform Braden Q assessment at change of shift, after any surgical procedure, after any change in patient status IMPAIRED COMFORT 1. Nurse will administer Diluadid for pain as needed 2. Nurse will administer Zofran for nausea as needed 3. Reposition patient to patient’s preference
Name: Courtney Turner References: http://www.nhs.uk/Conditions/Gastrectomy/Pages/Complications.aspx, http://www.nlm.nih.gov/medlineplus/ency/article/002945.htm, Livestrong.com,