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CARE PLAIN FOR POST OP PATIENT FROM SPLEEN RUPTURE

Care plan for post operative patient from MVA suffering a rupture spleen
Course

Fundamentals of Nursing (PRN098)

8 Documents
Students shared 8 documents in this course
Academic year: 2021/2022
Uploaded by:
RJ
Roselande Joseph
McFatter Technical College
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CARE PLAN

Date :10/21/2021 Room:123 Age: 32 Hospital Day___1____ Patient’s Initials: T. Sex : M Diagnosis: Abrasions on legs, forehead, and ruptured spleen. Define: A ruptured spleen is an emergency medical condition that occurs when the capsule light covering of the spleen breaks open, pouring blood into abdominal wall. An abrasion is a partial thickness wound caused by damage to the skin can be superficial involving the epidermis to deep, involving the dermis. Textbooks Signs/Symptoms: Ruptured spleen S/S: Pain in the upper left part of the abdomen, tenderness, and abdominal area, especially when touch. Confusion, fainting, blurred vision, lightheadedness- results of the bleeding. Abrasion S/S: Intense pain, swelling on the skin, excess bleeding from site of injury. Tenderness on an around the area which forces when touched, weakness in the muscle surrounding the area or numbness. PT Stated “Nurse! I’m in pain, help! I’m having a hard time breathing with this discomfort”. Post-Op Day: 1 Surgical Procedure(s): Splenectomy for a ruptured spleen- Resulting from a motorcycle accident where the patient skidded and was thrown into a telephone pole.

ASSESSMENTS GOALS IMPLEMENTATION EVALUATION

Observations Nursing Diagnosis

Planning Nursing Measures Rationale for Nursing- Action(s)

O/Data: Abdominal surgical incision covered with a dressing; abrasions on both legs and forehead.

S/Data: “Nurse! I’m in pain, help! “

Pain related to surgical site as evidence by PT stating “Nurse! I’m in pain, help!” and post- operative procedure.

Patient will report pain to be between 0- within 30mins of analgesia administration per physician order.

  1. Assess client’s perception of the severity of pain using a pain intensity rating scale.

  2. Implement measures to reduce pain: set up and begin administration of the PCA pump immediately after pain assessment and give a bolus dose of morphine as ordered if no contraindication if found.

  3. Educate and Encourage client to use PCA device as instructed.

  4. Note response to PCA medication and closely monitor respiratory rate.

  5. An awareness of the severity of pain being experienced helps to determine the most appropriate interventions for pain management. Use of a pain intensity rating scale gives a clearer understanding of the pain the PT is experiencing. (U. Ch)

  6. Is pain controlled within 30 minutes? Pt stated pain level is 0- 1. (Williams)

  7. PT must know how to use the PCA pump and better understanding of the pain management treatment approach can help to improve control of pain. (U. Ch)

  8. Morphine can depress the respiratory rate. (Williams.

ASSESSMENTS GOALS IMPLEMENTATION EVALUATION

Observations Nursing Diagnosis Planning Nursing Measures Rationale for Nursing- Action(s)

O/Data: Shallow breathing, low oximetry reading SP02:93.

S/Data: “I’m having a hard time breathing and coughing with this discomfort “

Risk for impaired gas exchanged related to post- operative procedure.

Patient will achieve/maintain affective breeding pattern of respiration rates between 12 to 20 bpm, oxygen saturation within target range and verbalizing ease of breathing during post- operative care.

Patient will not develop atelectasis or hypoxia during postoperative care.

1 and reposition the client frequently and ambulated if not contraindicated. Re- assess pulse oximetry after measures are implemented.

2 the patient's vital signs and characteristics of respirations at least q 4hrs for signs of hypoxemia, eliminate the cause of hypoxemia, and notify RN/Surgeon immediately.

3 client how to splint the incision and encourage client to splint while coughing.

4 coughing, deep breathing and the use of the incentive spirometer at least q2h.

  1. Ambulation promotes greater lung expansion and deeper breathing repositioning helps provide comfort. Reassessment will determine if intervention implemented is effective. (Williams)

  2. Assessment will create an accurate diagnosis and monitor effectiveness; breath sounds may be absent or diminished. Rising temperature and increased respiration may indicated complications. (Williams)

  3. Splinting when coughing reduces pressure on the incision during coughing and helps prevent pain and dehiscence. Educating PT will allow for better understanding and willingness to complete task despite discomfort. (Williams)

  4. Sustain inspiration opens alveoli, encouraging coughing and deep breathing promotes lung expansion and an expulsion of secretions. (Williams. 763)

Body Structure Affected DIET Notes

Name of Structure: Incision located in the upper left abdominal quadrant (splenectomy). Abrasions on lower extremities and abrasion on forehead.

Type: Clear Diet Breakfast 1 glass pulp-free fruit juice 1 bowl gelatin 1 cup of coffee or tea, without dairy products Sugar or honey, if desired Snack 1 glass fruit juice (pulp-free) 1 bowl gelatin Lunch 1 glass pulp-free fruit juice 1 glass water 1 cup broth 1 bowl gelatin Snack 1 pulp-free ice pop drink 1 cup coffee or tea, without dairy products, or a soft Sugar or honey if desired Dinner 1 cup pulp-free juice or water 1 cup broth 1 bowl gelatin 1 cup coffee or tea, without dairy products Sugar or honey, if desired

Start oral diet with clear liquids and advance to solid foods. Eat small, frequent meals. Avoid greasy and fried foods. Limit consumption of raw fruits and vegetables, initially. Gradually increase as tolerated.

Foods Allowed : Water (plain, carbonated, or flavored)

Fruit juices without pulp, such as apple or white grape juice Fruit-flavored beverages, such as fruit punch or lemonade Carbonated drinks, including dark sodas (cola and root beer) Gelatin Tea or coffee without milk or cream Strained tomato or vegetable juice Sports drinks Clear, fat-free broth (bouillon or consommé) Honey or sugar Hard candy, such as lemon drops or peppermint rounds Ice pops without milk, bits of fruit, seeds, or nuts

Function: The spleen is an organ that sits under your rib cage on the upper left side of your abdomen. It helps fight infection and filters unneeded material, such as old or damaged blood cells, from your blood. (Mayo .2021)

Foods to Avoid: Milk Cream Milkshakes Tomato juice Orange juice Grapefruit juice Cream soups Any soup other than broth Oatmeal Anything with red or purple food coloring gelatin, popsicles and hard candy

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CARE PLAIN FOR POST OP PATIENT FROM SPLEEN RUPTURE

Course: Fundamentals of Nursing (PRN098)

8 Documents
Students shared 8 documents in this course

University: McFatter Technical College

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CARE PLAN
Date :10/21/2021 Room:123 Age: 32 Hospital Day___1____
Patient’s Initials: T.J. Sex: M Diagnosis: Abrasions on legs, forehead, and ruptured spleen.
Define: A ruptured spleen is an emergency medical condition that occurs when the capsule light covering of the spleen breaks open, pouring blood into
abdominal wall. An abrasion is a partial thickness wound caused by damage to the skin can be superficial involving the epidermis to deep, involving the
dermis.
Textbooks Signs/Symptoms: Ruptured spleen S/S: Pain in the upper left part of the abdomen, tenderness, and abdominal area, especially when touch.
Confusion, fainting, blurred vision, lightheadedness- results of the bleeding.
Abrasion S/S: Intense pain, swelling on the skin, excess bleeding from site of injury. Tenderness on an around the area which forces when touched,
weakness in the muscle surrounding the area or numbness. PT Stated “Nurse! I’m in pain, help! I’m having a hard time breathing with this discomfort”.
Post-Op Day: 1 Surgical Procedure(s): Splenectomy for a ruptured spleen- Resulting from a motorcycle accident where the patient skidded and
was thrown into a telephone pole.
ASSESSMENTS GOALS IMPLEMENTATION EVALUATION
Observations Nursing
Diagnosis
Planning Nursing Measures Rationale for Nursing- Action(s)
O/Data:
Abdominal
surgical
incision
covered with
a dressing;
abrasions on
both legs and
forehead.
S/Data:
“Nurse! I’m in
pain, help! “
Pain related to
surgical site as
evidence by PT
stating “Nurse!
I’m in pain,
help!” and post-
operative
procedure.
Patient will report
pain to be
between 0-2
within 30mins of
analgesia
administration per
physician order.
1. Assess client’s perception of the
severity of pain using a pain
intensity rating scale.
2. Implement measures to reduce
pain: set up and begin
administration of the PCA pump
immediately after pain assessment
and give a bolus dose of morphine
as ordered if no contraindication if
found.
3. Educate and Encourage client to use
PCA device as instructed.
4. Note response to PCA medication
and closely monitor respiratory rate.
1. An awareness of the severity of pain being experienced
helps to determine the most appropriate interventions
for pain management. Use of a pain intensity rating
scale gives a clearer understanding of the pain the PT is
experiencing. (U.Canale. Ch.4)
2. Is pain controlled within 30 minutes? Pt stated pain
level is 0- 1. (Williams.762)
3. PT must know how to use the PCA pump and better
understanding of the pain management treatment
approach can help to improve control of pain.
(U.Canale. Ch.4)
4. Morphine can depress the respiratory rate. (Williams.
762)

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