Nursing Diagnosis Statement (include subjective and objective data): Delayed surgical recovery r/t extensive surgical procedure, pain, obesity,
postoperative surgical site infection AEB, perception that more time is needed to recover, report of pain, loss of appetite with nausea, evidence of interrupted healing of
surgical area (dehisedx2, abcess).
Subjective: pt reports pain at surgical site, not interested in food, states usually has poor wound healing
Objective: dehiscence x2, abscess, need for wound vac, delayed healing
SMART GOALS
INTERVENTIONS(specific, individualized) and patient centered)
Consider the following categories for interventions
Assess/Monitor:(5)
1. Perform pain assessment
Short term goal:
2. Determine age, developmental level, and general state of health
Pt will have a pain score of 6 or
less by end of shift
3. Assess circulation and sensation in surgical area.
4. Determine nutritional status and current intake
5. Note lifestyle factors: obesity, cigarette smoking,
sedentary lifestyle.
Long term goal: Pt will be able to
Administer/Treat: (5)
state 5 reasons for poor wound
6. Practice and instruct clients and caregivers in proper hand hygiene and aseptic
healing related to her lifestyle
technique for incisional care.
before discharge.
7. Provide optimal nutrition with adequate protein.
8. Employ non pharmacological healing measures as indicated.
9. Inspect incisions or wounds routinely, describing changes as necessary
Giddens Concepts
10. Administer antibiotics as appropriate, and medications to manage
2 Functional ability
postoperative discomforts, as well as other concurrent or underlying conditions.
6 Adherence
11. Change wound dressing as ordered per wound nurse.
13 Nutrition
14 Elimination
Education/teaching: (5)
22 Infection
12. Instruct client and caregiver in routine inspection of wound and report
24 Tissue Integrity
changes in wound indicative of failure to heal.
26 Pain
13. Refer to physical or occupational therapist, wound care specialist, as
indicated, discuss what services they will provide.
14. Identify community resources, suggest resources to utilize and what services
they provide.
15. Refer for counseling or support, discuss importance of mental health therapy.
16. Discuss the possibility of alternative placement, explain why it may be
necessary and what benefits it will provide.