The nurses in the short stay unit identify the following nursing diagnoses for Ms. Lynn after surgery.
• Impaired skin integrity, related to surgical incisions
• Pain, related to surgical intervention
• Anxiety, related to situational crisis
EXPECTED OUTCOMES
The expected outcomes for the plan of care are:
• Incisions will heal without infection or complications.
• Will verbalize adequate pain relief.
• Will verbalize decreased anxiety.
• Returns to preoperative activities.
PLANNING AND IMPLEMENTATION
The following nursing interventions are planned
and implemented for Ms. Lynn.
• Assess pain using a pain scale; provide analgesics as needed.
• Teach pain management following discharge.
• Teach abdominal splinting during coughing, turning, or ambulating as needed.
• Teach home care of incisions.
• Discuss activity limitations as ordered.
• Instruct to report fever or warmth, redness, or drainage from
the incisions.
EVALUATION
On discharge the following evening, Ms. Lynn is fully ambulatory.
Her appetite has returned, and she is tolerating food and fluids
well. Her temperature is normal.The nurse provides Ms. Lynn with
written and verbal information on postoperative care following an
appendectomy.