Question

Scenario: The patient has returned from surgery and is laying quietly in bed. Upon assessment, you note Respiratory Rate as 26, Heart Rate 98, BP 180/85. A patient does not want to participate in the assessment and when asked to rate his pain he states “4/10”. The patient grimaces with movement and does not want to talk. His surgical site is clean and dry.

Assessment Data (Include at least three-five subjective and/or objective pieces of data that lead to the nursing diagnosis)

Nursing Diagnoses (Include two NANDA approved nursing diagnoses for the patient)

Planning and Goals (List at least three nursing goals for each diagnosis using SMART goals.)

Interventions (Provide an intervention for each goal so that you can achieve the outcomes)

Outcome Evaluation & Replanting (Was goal met? How would you revise the plan of care according to the patient’s response to the current plan ?)

outcome 1

outcome 2

Answer 1

●Nursing Diagnosis

Activity intolerance related to surgery as evidenced by

grimace,elevated blood pressure, lack of interest,increased respiratory rate

Assessment

Subjective data

• very mild pain

Objective data

• RR:26
• HR:98
• BP:180/85
• Grimacing
• Not communicating actively

Goals

• To make patient to involve in activities
• To mobilize the patient
• To relieve any discomfort

Intervention

• Assess the patient's underlying cause for lack of interest to communicate and participate in the care
• Provide pain relief measures in case if the patient is at time for medication
• Monitor the patient's vital signs periodically as it is the baseline to provide care
• Provide psychological support to the patient because there are chances for the patient to feel depressed post surgery
• Provide support services,relaxation techniques to get diverted

Outcome :

• The patient is able to participate in activities
• Able to move out of bed

●Nursing diagnosis

Risk for Impaired cardiac output related to vasoconstriction as evidenced by increased blood pressure

Assessment

Objective:

BP:18/85

HR:98

Goals:

• To control and maintain the blood pressure
• To prevent complications due to increased blood pressure

Intervention

• Monitor vital signs to plan for care
• Administer medication as per order to control blood pressure
• Assess periodically for circulatory functions to prevent post op elevation of blood pressure

Outcome

The patient will have a normal blood pressure

Maintain hemodynamic stability