Tammy De Souza



Running head: CURRENT EVIDENCE-BASED PRACTICES IN NURSING CARE FOR THE MEDICAL-SURGICAL CLIENTCurrent Evidence-Based Practices in Nursing Care for the Medical-Surgical ClientTammy De SouzaNorQuest CollegeNFDN 2003ID 0235150Assignment 2 - Research and application to Nursing CareKim Harper October 20, 2013Clients with impaired mobility are at greater risk for developing serious health complications postoperatively. Clients at greater risk include elderly, diabetics, clients who suffered strokes, heart failure, as well as clients with debilitated health, altered sensory perception of pain and pressure, alteration in level of consciousness, and clients that are on bed rest for a long period of time after surgery. Some of the risks associated with decreased mobility are respiratory complications (e.g., acute atelectasis, pulmonary embolism, aspiration related to improper positioning, and suppressed swallowing ability secondary to analgesics and sedatives). Immobilized clients are also at risk for venous stasis, deep vein thrombosis, impaired skin integrity, and loss of muscle tone. Strategies that promote the health of medical-surgical clients in the hospital or following discharge include adequate nutritional intake and hydration for wound healing, skin care, proper repositioning while on bed rest, use of incentive spirometry, promotion of ambulation, and administration of analgesics and sedatives to improve clients’ levels of comfort and compliance while in hospital and after discharge. Nutritional intake plays an important role in optimizing the recovery of medical-surgical clients. Increased protein intake helps promote wound healing and prevents future wounds, as Potter & Perry (2010) state, “Increase protein intake helps rebuild epidermal tissue” (p. 1270). Increased fluid intake helps thin the lung secretions for easy removal post-surgery. According to Potter & Perry (2010), “The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2000ml/day’ (p. 928). Skin care is very important for clients who have impaired mobility. Proper skin care and maintaining skin dry helps with the prevention of skin break down. According to Potter & Perry (2010), moisture softens the skin and makes it more susceptible for developments of skin tears (p. 1245). Immobilized clients that are unable to take care of their own hygiene needs require close monitoring of the skin condition. Motivating medical-surgical clients to ambulate as soon as they are able to is very important for the prevention of deep vein thrombosis, venous stasis, pulmonary embolism, and muscle atrophy. As described by Potter & Perry (2010), leg exercises, ambulating, positioning changing, use of TED stocking, avoiding sitting for long periods of time and crossing legs, and ROM promotes venous return (p.1209). Over the past decade there has been an increased emphasis on mobilizing the client soon after surgery. This has been a change in practice from before as we now have a better understanding of the benefits of early ambulation. There is currently a lot research going into developing early mobilization protocol for postoperative clients, which suggests that is becoming more important in practice (Zomorodi, Topley, & McAnaw, 2012). Positioning and the use of incentive spirometry helps maintain and promote lung expansion in medical-surgical clients. Proper positioning of clients who are immobile helps maintain proper ventilation and oxygenation and reduces the risks of stasis of pulmonary secretion and decreased chest wall expansion (Potter & Perry, 2010, p. 913). The use of incentive spirometry is very important for post-surgery clients because it encourages deep breathing and prevents or treats atelectasis. As Potter & Perry (2010) affirms, “The use of incentive spirometry promotes lung expansion and thus prevents postoperative pulmonary complications” (p. 913). The incentive spirometer is an example of an improvement in care for medical-surgical clients, as this is a recent medical invention. Prior to 1970, the incentive spirometer did not exist and patients were only encouraged to breathe deeply. With this new technology, nursing practice for improving lung function in medical-surgical clients has improved (Mercer, 2011, p 1). The above strategies done by nursing staff promote optimal client recovery while in hospital, however there are also strategies that the client and family can do once the client is discharged; this requires educating the client and family. For example, teaching the client and family about proper nutritional intake once discharged is important to continue to promote wound healing at home. This involves teaching clients and families about the values in Eating Well with Canada’s Food Guide (Potter & Perry, 2010, p. 1066), along with any other surgery-specific dietary guidelines. The client and family should also receive education about the importance of mobilizing the client especially after surgery. As Day, Paul, Williams, Smeltzer, & Bare (2010) affirm that early ambulation reduces the risks for atelectasis, hypostatic pneumonia, stimulates peristalsis of the gastrointestinal tract, and increase circulation in the lower extremities therefore reducing the risks for thrombophlebitis or phlebothrombosis (p. 505). Having the client and family be aware of potential complications can help them to adhere better to discharge instructions. Teaching clients about the proper use of incentive spirometer, deep breathing and coughing exercises every two hours can help prevent pulmonary complications, as well as encourage client independence, as they can do this on their own (Day, Paul, Williams, Smeltzer, & Bare, 2010, p. 502). The current evidence-based strategies discussed in this paper are optimizing client recovery post-operatively. These strategies for nursing care are combined with educating clients and their families to involve them in their own care. The recovery for medical-surgery clients has been improving because of these strategies that promote client health and prevention of health complications following stay in hospital and discharge.Nursing Care Plan (One Page per Nursing Diagnosis) Nursing DiagnosisImpaired breathing pattern related to decreased lung expansion as evidence by shortness of breath, use of accessory muscles, and decreased mobility.Planning Client Goals: Client will be able to improve breathing pattern and be able to breathe with greater ease without using the accessory muscles. This goal was established by asking the client what his goals were regarding increasing the level of comfort. Expected Outcomes: Client respiratory rate will decrease within 24hs by monitoring respiratory rate every hour. Interventions List Interventions: Administration of bronchodilators as prescribed by physician’s order. Monitor O2sats hourly. Teach client inspiratory muscle training and breathing retraining Rationale for Interventions: Bronchodilators help smooth muscle relaxation, thus dilating constricted bronchial tubes helping with breathing (Day, Paul, Williams, Smeltzer, and Bare, 2010, p. 705).O2sats reading helps to monitor and maintain O2 levels within normal range and evaluate the effectiveness of interventions (Jarvis, 2009, p. 171).Inspiratory muscle training and breathing retraining are designed to achieve more efficient and controlled ventilation. Therefore decrease the work of breathing and improve breathing pattern (Day, Paul, Williams, Smeltzer, and Bare, 2010, p. 691).EvaluationAchievement of Expected Outcomes: Goal met when respiratory rate and O2sats are within normal range (with monitoring respiratory status).Nursing Care Plan (One Page per Nursing Diagnosis)Nursing DiagnosisRisk for impaired skin integrity related to decreased mobility as evidenced by client bed-bound secondary to recent surgery.Planning Client Goals: Client will maintain skin integrity and be free of skin irritation or pain. This goal was established by asking the client what his goals were regarding increasing the level of comfort. Expected Outcomes: Client skin will be free of skin tears, ulcers, and erythemas upon discharge by monitoring client skin for skin breakdown every 8 hours. Interventions List Interventions: Proper skin care (ensure skin is dry and clean).Assess lower extremities for deep vein thrombosis (DVT). Turn client every two hours.Rationale for Interventions: Excessive moist on skin softens the tissue therefore increases the risk for ulcer formation. Keeping skin dry and clean promotes skin integrity (Potter & Perry, 2010, p. 1245).Turning client every 1-2 reduces the risk for skin break down and pressure ulcer formation (Potter & Perry, 2010, p. 1205).Deep vein thrombosis (DVT) is a hazardous of restricted mobility, therefore close assessment of the calves for redness, warmth, and tenderness is important (Potter & Perry, 2010, p. 1201).EvaluationAchievement of Expected Outcomes: Goal met when skin is intact, as noted in skin assessment.Nursing Care Plan (One Page per Nursing Diagnosis)Nursing DiagnosisDeficient knowledge related to outcome of surgery and postoperative course as evidenced by anxiety, fear, and noncompliance. Planning Client Goals: Client will attain adequate knowledge regarding pre and post surgery, and therefore have decreased levels of anxiety fear, and noncompliance with regiment. This goal was established by asking the client what his goals were regarding increasing his level of comfort, and compliance with nursing care plan.Expected Outcomes: Client obtained all the information required regarding surgery therefore decreasing anxiety, fear, and about regimen post surgery prior to procedure by assessing clients’ knowledge. Interventions List Interventions: Explain the purpose of surgery, procedure and interventions to promote level of comfort post surgery. Explain to the client the importance of early ambulation after surgery thus increasing compliance. Panning and teaching client self-care by discharge.Rationale for Interventions: By addressing concerns, what to expect, providing reassurance and information about hospital procedures to increase level of comfort after surgery can reduce anxiety and fear (Day, Paul, Williams, Smeltzer, and Bare, 2010, p. 513).Clients might be reluctant to ambulate after surgery, explaining further complications that can occur regarding immobility can encourage early ambulation (Day, Paul, Williams, Smeltzer, and Bare, 2010, p. 505).Planning and teaching prior to discharge can reduce anxiety, address concerns, and increase level of comfort while performing preventive health measures at home (Day, Paul, Williams, Smeltzer, and Bare, 2010, p. 515).EvaluationAchievement of Expected Outcomes: Goal met by assessing client’s knowledge, asking client questions regarding understanding of surgery, procedure, and importance of early ambulation. ReferencesDay, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2010). Textbook of medical/surgical nursing (2nd Cdn. ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Jarvis, C. (2009). Physical Examination & Health Assessment. (1st Canadian ed.). Toronto: Sauders Elsevier.Mercer. L. (2011). “Incentive spirometry vs. diaphragmatic breathing Exercise.” Livestrong. Retrieved September 22, 2013, from Google Scholar: Potter, P. A., & Perry, A. G. (2010). Canadian Fundamentals of Nursing. (4th ed. Rev.). Ross-Kerr, J. C., & Wood, M. J. (Canadian ed.). Toronto, ON: ElsevierZomorodi, M., Topley, D., & McAnaw, M. (2012). “Developing a mobility protocol for early mobilization of patients in a surgery/trauma ICU.” Critical Care Research and Practice, 2012(964547), p. 10. Retrieved September 22, 2013, from Google Scholar: ................
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