NANDA-NursingPlan Area 11 Safety/Defense

NANDA-nursing plan 00100 Delayed surgical recovery 

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/Protection No danger, physical injury or damage to the immune system, loss prevention, guarantee of safety and security
Category 2 Bodily injury Bodily harm or injury

Nursing Diagnosis ” Delayed surgical recovery ” 00100

Nursing diagnosis: Delayed surgical recovery
Definition: Increased number of days required after surgery to resume activities that sustain life, health and well-being.

1. What is postoperative recovery delay?

1) How to think about “postoperative recovery delay”

When considering postoperative recovery delay, it is necessary to know the general postoperative course. Delayed recovery is when there is a deviation from the normal course.
Since “delayed postoperative recovery” is a real-life nursing diagnosis, it targets people whose postoperative course is actually delayed at the time of planning.
When planning for a high-risk person who is likely to deviate preoperatively, it is advisable to plan for a “postoperative recovery delay risk condition”.

2) General postoperative course

Next, let us consider the general postoperative course. Do you know Moore’s classification? Moore is an American surgeon (died 2001). The postoperative biological changes are explained in an easy-to-understand manner in four stages. Please refer to the table below.

✩☆彡The point here ✩☆彡
The point here is that, as shown in Moore’s classification in the table below, no matter how healthy a person is, they will follow the course below due to surgical intervention.
Depending on the number of days after surgery, high blood sugar and decreased urine volume are not necessarily abnormal. It is important where the usual “normal” is not normal.
Then, in the postoperative course, what is normal and what is abnormal… This article does not cover that, so please do your own research.

★Moore’s Classification (See Wikipedia)

3) Complications that are likely to occur after surgery

The table below summarizes the complications that are likely to occur after surgery. Does your patient have any of the following symptoms? If such symptoms are prolonged, it can be said that the normal physiological response is deviated.

Complications that are likely to occur after surgery

2. Indications for Nursing Diagnosis “Delayed surgical recovery”

It is defined as “a condition in which the number of days required to resume life, health and well-being activities is prolonged after surgery”.
By looking at the frequency of postoperative complications and the general course (Moore’s classification), which I have introduced so far, I think that indications for this nursing diagnosis will come to mind.
・Variance from the clinical path
-Patients with postoperative complications.
・Reluctance to leave the bed. (mood, pain, respiratory symptoms, gastrointestinal symptoms, etc.)

3. aim setting

Goal setting by linkage (listed in the second half of the NOC)
* “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)
・Preparation for discharge: independent living (0311)
(Definition: Patient readiness to transition from health care facility to independent living)
・Discharge preparation: life support (0312)
(Patient readiness to transition from health care facility to life with lower levels of support)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”

・If you experience any abnormalities such as pain, bleeding, increased phlegm, or difficulty breathing after surgery, consult a medical practitioner.

・ Demonstrate willingness to get out of bed early (verbalize and actively participate in efforts to get out of bed).

・Can effectively expectorate sputum.

*Nurse goals include:

・Relieves the patient’s symptoms 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

・Awareness level
・For ventilator management, setting, circuit abnormality, humidification, actual value
・Installation of biological monitoring monitors such as electrocardiograms and SPO2 (whether they are removed or attached correctly)
・Respiration rate
・Left-right difference between breathing air and breath sounds
・Oxygen content, 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.)
・Body temperature
·blood pressure
・Pulse, arrhythmia, heart murmur
・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
〈Preparation for discharge: independent living and life support〉
・Understanding of diseases
・Understanding of prescription drugs
・Understanding of the risk of complications
・Knowledge of social resources

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 leading to 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.
– 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.)
・Collaborate with the Discharge Support Office for diseases that can be used under the social security system (intermediary with patients).

3) Education plan( EP)

• 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.)
 Baxter HP reference: Baxter Infuser | Baxter Pro (baxterpro.jp)
・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.)

References

T. Heather Hardman, Shigemi Kamitsuru, Camila Takao Lopez. (July 1, 2021). NANDA-I Nursing Diagnosis – Definition and Classification 2021-2023 Original 12th Edition. Igaku Shoin Co., Ltd.
T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Toyoaki Yamauchi. (date unknown). Physical Assessment Guidebook. Igaku Shoin.


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