Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.
Area 11 Safety/Defense
Category 2 Bodily injury Bodily harm or injury
00246 Risk for delayed surgical recovery
Nursing Diagnosis: Risk for delayed surgical recovery
Definition: A condition that is likely to prolong the number of days required to resume activities to maintain life, health, and well-being after surgery, and that may compromise health.
The 2021 edition has a slightly different definition. In addition, “high-risk group” and “related conditions” have been added, making the content more specific.
Definition: A condition in which the number of days required to initiate and perform activities to maintain life, health, and well-being after surgery is likely to increase, and which may compromise health.
1. Adaptation of Nursing Diagnosis ” Risk for delayed surgical recovery “
・Have multiple diseases with a long history
・ASA PS classification 3 or higher (see ✩1 below)
– Stop antiplatelet drugs (aspirin, cilostazol) and anticoagulants (warfarin) from 4 to 5 days before and switch to heparin drip. Due to its short half-life, heparin can be administered up to 4 hours before surgery.
・Diabetes, hyperglycemia (HbA1C, GLU): Diabetes is prone to various complications, so insulin control is required. Discontinue oral medications 1 week before and manage with insulin administration (hospitalize earlier than usual for management)
・Pill use: Estrogen increases the risk of venous thromboembolism because it promotes the synthesis of blood clotting factors in the liver.
The drug should be discontinued 4 weeks before surgery, and should be resumed at least 2 weeks after surgery.
• Smokers: Risk of postoperative respiratory complications due to chronic inflammation of the respiratory system.
・Poor nutritional status (TP, Alb): Delayed tissue recovery
・High blood pressure: Mostly due to arteriosclerosis, there is a risk of functional deterioration of important organs due to postoperative tissue perfusion. Since antihypertensive drugs may be discontinued or continued, it is necessary to confirm with a doctor.
– Oral steroids: Long-term oral steroids can reduce adrenal function. Normally, steroids (cortisol) increase due to adrenocorticotropic hormone during the catabolic period after surgery, but when steroids are taken orally, cortisol does not function, resulting in a relative shortage of cortisol and maintenance of blood pressure. not done. A steroid cover is applied according to the degree of surgical invasiveness.
・Obesity and hyperlipidemia: There is a risk of respiratory complications due to postoperative hypoventilation.
• Chronic respiratory disease: high risk of respiratory complications.
・History of angina pectoris or myocardial infarction
・Surgery, wide range of surgery
・Alcoholism: Poor nutritional status, drug resistance, and anesthesia during surgery increases
・Under medication control due to mental illness: The amount of anesthetic used during surgery increases
・ Possibility of delay in getting out of bed: lower limb disease, gait disorder, psychological disorder, etc.
✩ 1 ASA’s PS classification
The ASA PS classification is the preoperative physical condition classification of the American Society of Anesthesiologists.
For children and pregnant women, please refer to the ASA website
ASA Physical Status Classification System | American Society of Anesthesiologists (ASA) (asahq.org)
2. aim setting
Goal setting by linkage
* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).
1) Linkage achievements
・Postoperative recovery: Immediately after surgery (2305)
(Definition: Degree to physiological reference (baseline) after major surgery requiring anesthesia)
・Postoperative recovery: recovery period (2304)
(Definition: Degree of physical, mental, and role functioning from post-anesthetic recovery room to final postoperative outpatient visit)
・Wound healing: primary healing (1102)
(Definition: extent of cell and tissue regeneration after wound healing)
・Knowledge: treatment plan (1813)
(Definition: Degree of understanding of specific treatment plans)
The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”
・Be able to describe postoperative complications that are likely to occur to you. In addition, if you feel any abnormalities after the operation, you can consult a doctor.
• Be able to describe and implement strategies for sputum production preoperatively.
・Be able to follow the doctor’s instructions from before surgery (no smoking, drug suspension, etc.).
・Be able to build a relationship with medical staff and express anxiety before surgery.
*Nurse goals include:
・Relieves the patient’s discomfort and anxiety, and supports the patient’s recuperative life.
• Early mobilization reduces the risk of complications.
・Efforts will be made to detect abnormalities at an early stage.
・Provide recuperative care (cleanliness care, etc.) for the temporary decline in ADL after surgery.
3. nursing plan
1) Observation Plan 《OP》
First, we anticipate the possible postoperative risks due to abnormalities in the intraoperative course. We also aim for early detection of abnormalities (deviations from normal course) in postoperative observation items. These abnormalities lead to delayed postoperative recovery (variance).
・Type of anesthesia
・Time for anesthesia
・ Changes in vital signs during surgery
・Names and amounts of drugs used during surgery
・Arousal status after anesthesia
・Surgery method, operation time
・Bleeding volume, urine volume
・Infusion volume, blood transfusion volume, type of blood transfusion
・Compression due to surgical position and postural fixation
・Surgical site, wound size, condition of the wound
・State of excision site
・Intraoperative event (occurrence of unexpected event)
Unexpected patient conditions such as metastasis or invasion
・Due to surgical manipulation (bleeding)
・Due to anesthesia or body position
・Abnormal vital signs (arrhythmia, hypotension, bradycardia, abnormal BIS monitor, hypothermia, hyperthermia)
・Drain insertion site, insertion type
・Indwelling bladder catheter
・Epidural anesthesia, PCA circuit
・Infusion insertion site, drip type
Level of consciousness, delirium
・For ventilator management, setting, circuit abnormality, humidification, actual value
・Attachment of biological monitoring monitors such as electrocardiogram and SPO2 (whether they are attached properly or not)
・Respiration rate ・Left-right difference between breathing air and breath sounds ・Oxygen volume, administration device, SPO2
・Type of maintenance infusion (name of infusion), rate of administration, route of administration
・Intermittent drugs (antibiotics, liver protection drugs, stomach medicines, etc.)
・Continuously administered drugs (vasopressors, antihypertensives, sedatives, analgesics, muscle relaxants, etc.)
・Drug side effects
・Abnormal vital signs (body temperature, blood pressure, pulse, arrhythmia, heart murmur, SPO2, etc.)
・Inhalation of oxygen
・Cold extremities, cyanosis
・Characteristics and amount of urine in the indwelling bladder catheter
・Fixation of the drain, properties, volume, setting of low-pressure continuous suction, and presence or absence of abnormality (respiratory fluctuations and leaks)
・Wound condition, bleeding, wound dehiscence, infection (redness, swelling, fever, pain, foul odor, itel), exudate from the wound
・Presence or absence and degree of pain, face scale
・Presence/absence of intestinal peristaltic sound
・ Abdominal pain, bloating
・Amount and properties of liquid discharged from NG tube
・Nausea and vomiting
Pneumonia, catheter-related infections, wound infections, etc.
・Signs of infection (redness, swelling, warmth, pain)
・Understanding of diseases
・Understanding of prescription drugs
・Understanding of the risk of complications
・Prescribed meals (diet form, meal amount, appetite)
・Motivation and progress for prescribed exercise (rehabilitation)
2) Action plan 《TP》
・If any abnormality is found from the observation items, report it to the leader and the doctor. In the event of a sudden change, do not leave the place and call the staff.
・Provide recuperative care for postoperative ADL decline.
(Position change, diaper change, genital area washing, cleaning, excretion assistance, meal assistance, bathing assistance, mouth care, etc.)
・Provide medical assistance according to the treatment plan.
(Infusion management, drain management, pain management, gauze replacement, ventilator management)
・Provide sputum care to prevent pneumonia. (squeezing, postural drainage, tapping, nebulizer, etc.)
・If self-sputum production is difficult, perform suction.
・If the pain is strong, use an analgesic (according to the doctor’s instructions).
・If the risk of delirium is high, obtain informed consent from the family in advance. Also, the hospital room should be close to the nurse station.
If delirium causes life-threatening behavior, such as pulling on an intubation tube or drain, or behavior that poses a risk of falling, such as leaning out of bed, restrain the patient.
– Create a quiet and calm environment.
・Improve the environment. Prevents the route from falling off or falling due to the route.
– Organize the routes so that they are not dirty.
・Implement one treatment, one hand washing, and standard precautions.
– Gradually drink water.
・Get out of bed in stages. (The first mobilization is done with a doctor.)
– Make a discharge plan. (Self-care may be necessary even after discharge, so prepare for it.)
3) Education plan
• Explain that early mobilization reduces the incidence of postoperative complications, and encourage mobilization while managing pain.
・Instruct the patient not to endure it and to call the nurse if the pain is strong.
・When analgesics are administered continuously through an epidural tube or vein, if the product has a PCA circuit, prompt the user to press the PCA button (the flow rate per hour differs depending on the product specification. Lock) Since there is an out time, you can avoid overdose no matter how many times you press the PCA button.)
・Explain how to handle tubes and drains.
・Explain postoperative progress to the patient and family.
・Explanation for discharge. (Notes on lifestyle habits after discharge, methods of self-care, utilization of the social security system, etc.)
・Explain the necessity of infection prevention measures such as washing hands and gargling, and how to implement them.
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