Med/Surg Nursing Diagnosis: Delayed surgical recovery r/t obesity aeb difficulty ambulating and decreased appetite.

Long-Term Goal: Pt will, and be free of further post-op complication.

Outcome
Criteria
One outcome criteria
for each intervention.
Number each one.

Interventions
Label each as
assess/monitor/independent/
dependent/teaching/collaboration

1. Pts temp will

remain between
96.9-100.4 F, HR
will remain
between 60-100
bpm with regular
rhythm, BP
between
120-139/80-89
mm
Hg, RR between
1220 breaths/min,
O2
sat 95-100% on
RA as assessed
q4h.

1. Monitor VS q4h

2. Pts lung
sounds will be
clear on
auscultation as

2. Auscultate lung sounds

q4h

Rationale
Answers why, how, what your interventions will help solve, prevent,
Or lesson the stated problem specific to each patient.

1. For the first 48-72 hours postoperatively,

temperatures of up to 101.3 are expected as a normal
stress response after major surgery. Beyond 72 hours,
temperature should return to the pts baseline.
Temperature spikes, usually occurring in the later
afternoon or night, are often indications of infection.
Other vital sign changes that indicate an emerging
infection is an increased heart rate, increased
respiratory rate, and a decrease in blood pressure.
When a microorganism enters the body, the normal
immune/inflammatory cascade responses are initiated.
This pt is at risk for developing pneumonia due to her
immobility. These compensatory mechanisms the body
has causes the heart rate to increase to compensate
for the decreasing blood pressure to try to keep
adequate perfusion to all the vital organs. The
respiratory rate increases to keep the blood adequately
oxygenated. A decreasing 02 saturation, less than
95%, indicates inadequate oxygen in the blood. Its
important to keep 02 sat above 95% to ensure tissues
are getting adequate oxygenation, to decrease the risk
for hypoxia. Its important to monitor VS frequently in
the post-op period so interventions can be
implemented early on to prevent worsening and
transition to sepsis. Lewis
2. Inadequate lung expansion can lead to the
development of atelectasis and pneumonia. When the
pt is immobilized they are unable to fully expand their
lungs, so it is important they know that deep breathing

Evaluation
Evaluate the patient
outcome, NOT the
intervention

1. Outcome partially
met; plan ongoing to
monitor for the onset
of an infection. Pt has
chronic a.fib causing
her HR to rise above
normal, remaining vital
signs remained in
normal limits.

2. Outcome met; plan

still ongoing to monitor
for the onset of a
pulmonary

assessed q4h

3. Pts abdomen
will be soft,
round, nontender, nondistended, and
have
normoactive
bowel sounds as
assessed q4h by
3/15.

3. Assess abdomen q4h

exercises can help prevent this. Auscultating the lung

fields allows the nurse to monitor for the onset of these
complications. Atelectasis is common in bedridden pts
and post-op abdominal and thoracic surgery pts.
Breath sounds will be diminished or absent over the
involved area. Development of pneumonia in the lower
dependent lobes of lung is common in immobilized
surgical pts. Crackled will be heard on auscultation in
the presence of pneumonia. Encouraging deep
breathing through TCDB and the use of an incentive
spirometer will keep the lungs expanded. Auscultating
the lungs helps in detection and early intervention.
This pt is at risk for these respiratory complications due
to her obesity and immobilization, so proper teaching is
important in preventing complications. Her lung
sounds were clear on assessment indicating no evident
problem. Deep breathing and incentive spirometer use
was reinforced throughout the shift. P&P
3. After surgery that involves direct manipulation of the
bowel, this temporarily stops peristalsis. This
condition, called paralytic ileus, usually lasts about 2448 hours. If the pt remains inactive or is unable to eat
after surgery, return of normal bowel elimination is
further delayed. Other factors such as narcotics
(morphine), and electrolyte imbalances (hypokalemia).
Being post-op pt is able to receive morphine per MD
order; this CNS depressant causes decreased
peristalsis. As well as when the potassium level drops
below 3.5 mEq/L, the smooth muscle function is altered
causing decreased GI motility. With these risk factors
the pt presents with, its important to implement
interventions such as; ambulation, increased fluid
intake, getting the pt to the commode instead of the
bedpan, and increasing fiber in the diet can help
prevent constipation. As well as following a bowel
regime such as establishing a regular time to defecate,

complication.

3. Outcome met; plan

ongoing due to the
recent abdominal
surgery to monitor the
emergence of any
complications.

4. Pts incision
will be well
approximated
and free of
redness, edema,
ecchymosis, and
discharge as
assessed q4h

4. Monitor incision site q4h

and not avoiding the urge to defecate. This pt had a

laparotomy with lysis of adhesions for a small bowel
obstruction. The abdominal assessment is important in
the post-op period to monitor for complications.
Auscultate for the presence of bowel sounds, inspect
for distension, palpate for firmness and tenderness are
key assessments. The absence of bowel sounds or
hypoactive bowel sounds indicate paralytic ileus after
an abdominal surgery. A distended abdomen feels
tight like a drum; and the skin is taught and appears to
be stretched. This is common after abdominal surgery;
as long as the abdomen is soft on palpation and not
rigid there is no need to notify the MD. A big reason
the pts discharge home was delayed was her inability
to ambulate and not eating a regular meal. Deficiencies
in any of the nutrients result in impaired or delayed
healing. Physiological processes of wound healing
depend on the availability of protein, vitamins
(especially A and C), and the trace minerals zinc and
copper. Collagen is a protein formed from amino acids
acquired by fibroblasts from protein ingested in food.
Vitamin C is necessary for synthesis of collagen.
Vitamin A reduces the negative effects of steroids on
wound healing. After an abdominal surgery its
important to monitor how the pt tolerates solid food.
After the pts first meal an abdominal assessment
should be carried out, as well as assessing for nausea
and vomiting. P&P
4. Wound edges should remain approximated, without
tension, puckering, or open gaps between stitches or
staples. The incision is most vulnerable to injury in the
first 48 hours, before wound strength begins to
develop. Wound dehiscence occurs with excessive
stress on a new incision. Obesity or improper
techniques for mobility may add to stress on sutures
and contribute to dehiscence. This pt is at risk for

4. Outcome met; plan

ongoing due to the
staples are still in
place.

5. Pts blood
glucose will be
between 70-110
mg/dL with
insulin AC and HS

5. Perform accucheck AC
and HS

6. Pt will be OOB
to chair to
promote
strength, lung
expansion, and
peristalsis with
each meal

6. Encourage OOB to chair

tid

dehiscence because she is overweight, and struggles

to ambulate due to the weakness in her lower
extremities, increasing the risk for improper mobility. If
the site becomes reddened, theres presence of
drainage, becomes swollen and tender, this indicates
infection. The presence of either of these two needs to
be reported to the MD. Monitoring the incision is an
important post-op assessment to prevent infection and
improper opening of the incision, leading to an increase
length of stay in the hospital and increased recovery
time. P&P
5. Diabetes mellitus increases susceptibility to infection
and impairs wound healing from altered glucose
metabolism and associated circulatory impairment.
Stress of surgery often results in hyperglycemia, as
well as the stress from being hospitalized. This pt is
typically controlled through oral antidiabetic, and
glucose monitoring isnt as frequent. When in the
hospital it is important to keep a tight glucose control,
through the monitoring before meals and bedtime so
insulin coverage can be administered. This pts glucose
level was above normal (70-110 mg/dL), requiring
insulin coverage. This is an important assessment to
maintain the healing process post-op, and preventing
further delay. P&P
6. Early ambulation post-op leads to an increase in
general strength and lung expansion. Physical activity
also promotes peristalsis. Position changes optimize
circulation to all tissues and relieve pressure. Getting
the pt OOB to chair can aid in the recovery faster by
preventing multiple complications such as; atelectasis,
pneumonia, decreased muscle mass leading to
increased weakness, and constipation. Because
ambulating promotes increased strength in LE, lung
expansion, and increased peristalsis. In the pts
current situation, OOB to chair is the most realistic goal

5. Outcome unmet;
plan ongoing to
monitor for
hyperglycemia. Pts
blood glucose was
above normal limit at
165 and 164 on 3/15,
and 170 on 3/15.
Accuchecks still be
performed to control
glucose levels.

6. Outcome partially
met; plan ongoing to
build up strength after
abdominal surgery.
3/14 pt was not OOB
during dinner. 3/15 pt
was OOB for meal.

7. Pt will use
incentive
spirometer to
1000 mL to
expand lungs qh
while awake

7. Encourage use of
incentive
spirometer qh while awake

8. Pt will have no
falls during stay
through the use
of a wheeled
walker with every
ambulation, at

8. Encourage use of
wheeled walker with every
ambulation

for her, being so weak in the lower extremities

ambulating longer distances would have led to a fall.
Maintaining the pts strength is important so she
doesnt further loose muscle mass, and continue to get
weaker. Moving to the side of the bed and dangling the
legs, and bear weight just for a few steps to the chair
can help keep up strength. A big reason her discharge
was delayed from the original date is because she
hadnt been getting out of bed and was weak. This can
be prevented if early ambulation is incorporated in the
post-op period to maintain that strength. P&P
7. The use of an incentive spirometer encourages
voluntary deep breathing, while also providing visual
feedback to the pt. Through slow inhalation the lungs
are able to maximally inflate and sustain inflation in all
lobes of the lungs promoting gas exchange. It is
important in the post-op period when the pt is
immobilized in bed to ensure maximal gas exchange.
The proper instruction on how to use the device is
imperative in ensuring the patient is receiving the full
effect or full lung inflation. This pt was encouraged to
use the incentive spirometer qh, getting to the
maximum inflation of 500 mL. Encouraging increasing
tidal volume with each use, is important in allowing
maximum inflation. This patient would benefit from
this because of the increased time lying in bed to
prevent atelectasis and pneumonia delaying the
surgical recovery. Also encouraging use at home will
prevent respiratory complications once discharged
from the hospital.
8. The proper use of assistive devices such as;
wheelchairs, canes, and wheeled walkers can promote
activity and reduce the danger of falls. When
transferring from the bed to the chair, or ambulating
around the room when pt is ready the use of a assistive
device will help keep the pt steady, allowing them to

7. Outcome partially
met; plan ongoing. Pt
reached maximum
volume of 500 mL,
deeper breaths
encouraged. Used IS
qh WA on 3/15.

8. Outcome met; plan

ongoing to prevent
falls during
ambulation.

least 50 feet a
day by 3/14

9. Pt will
consume 100%
of consistent
carb diet tid.

9. Encourage intake of
consistent carb meals tid

10. Pts WBC

count will remain
between 5,00010,000/mm3 as
monitored when
ordered

10. Monitor CBC when

ordered

ambulate more often than if they didnt have an

assistive device. When the pt is ambulate more they
can build up their strength and prevent immobility.
Safety is the main priority in pts with weakened lower
extremities, because they are at a greater risk to fall.
This pt benefited from the use of the wheeled walker
because she was able to use it to get to and from the
bed, allowing her to bear weight on her legs,
preventing atrophy. Gulanick
9. Each gram of carbohydrate produces 4kcal/g and
serves as the main source of glucose for the brain,
skeletal muscles during exercise, erythrocyte and
leukocyte production, and cell function of the renal
medulla. This pts diet order was consistent carbs with
no free sweets, because she is diabetic and this helps
with glucose control. A minimum of 130g/day of carbs
is recommended for diabetic pts. The diet should
include carbohydrate from fruits, vegetables, whole
grains, legumes, and low-fat milk. Nutrient balance of a
diabetic diet is essential to maintain blood glucose
levels. This intake of a balanced diet, as well as
consuming food high in fiber can aid in normal
peristalsis, preventing the onset of a paralytic ileus.
When the pt is consuming a well-balanced diet and
taking into consideration her diabetes, the healing
process can take place and lead to a quicker recovery.
P&P, Lewis
10. An elevated white blood cell count is typically an
indication of infection. Monitoring for
infection/inflammation is important in the post-op
period, and this can be done through the monitoring of
vital signs and monitoring labs like CBC, specifically the
white blood cell count, and monitoring the incision site.
Systemic manifestations of inflammation include an
increased WBC count with a shift to the left, malaise,
nausea and anorexia, increased pulse and RR, and

9. Outcome not met;

plan ongoing to meet
bodys need for
healing and building
strength. Pt did not
consume all of meals.
On 3/15 only ate 25%
of meal, stating she
didnt have an
appetite.

10. Outcome met; plan

ongoing while in
hospital when blood is
drawn to monitor for
the presence of
infection.

11. Pts
extremities will
be without DVT
as assessed q4h

11. Administer Heparin

5,000 units/ml subcut q12h

fever. Leukocytosis results from an increased release

of leukocytes from the bone marrow. The causes of the
systemic changes are not fully understood, but the
changes are probably due to complement activation
and release of cytokines. This pt is at risk for
developing pneumonia due to her immobility, also
diseases such as diabetes mellitus are associated with
an increased frequency of gram-negative bacilli in the
oropharynx increasing risk to develop pneumonia. This
pt was admitted to the hospital a week prior due to a
UTI. With the risk factors that this pt has (obesity,
female gender, recent surgery requiring foley catheter,
and incontinence), she is at higher risk for this infection
to go into the blood stream, if not properly taken care
of while in the hospital. With this increased risk for
developing infection it is vital to ensure proper
precautions are maintained, and interventions put in
place to prevent these complications. Such as
ambulating, incentive spirometer, proper fluid intake,
proper peri care, and increase in acidic fluid intake.
Monitoring for the increase of the WBCs gives more of
a definite indication of infection along with the VS.
Catching these signs early is imperative in
implementing rapid intervention to prevent further
complication. Lewis
11. Thrombophlebitis, inflammation of the veins often
accompanied by clot formation, is a potential
complication in the post-op period. Veins in the legs
are most commonly affected. This can occur from
prolonged sitting or immobilization which aggravates
venous stasis. Signs and symptoms include swelling
and inflammation of the involved site and aching or
cramping pain. Heparin is an anticoagulant that can be
used prophylactically against thrombus formation.
Heparin works by potentiating the inhibitory effect of
antithrombin on factor Xa and thrombin. This pt is at

11. Outcome met; plan

ongoing while on
heparin therapy.

12. Pts blood

glucose will be
between 70-110
mg/dL as
monitored AC
and HS

12. Administer insulin

aspart per sliding scale
subcut AC and HS

13. Pt will
verbalize 3
reasons on the
importance of
ambulating after
surgery

13. Teach benefits of

ambulating by end of first
post-op day

14. Pts K will

14. Administer

an increased for thrombus formation due to being

overweight and being in bed for a prolonged period of
time. Administering heparin is important in the post-op
period to prevent DVTs and further complications postop. P&P, Davis
12. This pt has diabetes mellitus type 2 usually
controlled on oral diabetic agents. This pt came in with
a SBO, requiring surgical intervention, and had surgery
on 3/12. Stress of surgery results in hyperglycemia
and increases insulin requirements. Insulin aspart is a
rapid acting insulin, typically given before meals and at
bedtime, to lower high blood glucose levels. The action
of insulin is lowering the blood glucose by stimulating
glucose uptake in skeletal muscle and fat, and
inhibiting hepatic glucose production. The peak of this
medication is at 1-2 hours after administration, and is a
key time to monitor for signs of hypoglycemia.
Ensuring tight control of glucose is important in wound
healing, preventing further complications in the postop period. Davis
13. The pt may not want to ambulate after surgery
due to pain or fear of being too weak. Ensuring they
have the proper education on why ambulating soon
after surgery can give them the boost to follow
through. The effects of immobility on the
musculoskeletal system include permanent or
temporary impairment. Restricted mobility can result
in loss of endurance, strength, and muscle mass and
decreased stability and balance. Loss of endurance,
decreased muscle mass and strength, and joint
instability put pts at risk for falls. This pt was reluctant
to get out of bed because she was too weak. Even
though she did not want to get out of bed right away,
the proper education should be carried out because if
she were to continue to stay in bed it would delay her
recovery even more. Gulanick
14. Fluid and electrolyte balance plays an important

12. Outcome met; plan

ongoing to prevent
complications from
hypoglycemia,
decreasing the bodys
healing ability.

13. Outcome met; plan

ongoing to reinforce
the importance of
ambulation.

14. Outcome met; plan

remain between
3.5-5.0 mEq/L as
assessed when
ordered by MD

1000ml NaCl 0.9% with20

mEq KCl IV at 75ml/hr
continuously

15. Pt will
receive
consultation with
PT to receive
training in
rehabilitation
post-op.

15. Consult with PT for

results of consultation by
3/14

role in homeostasis. Maintenance of the composition

and volume of body fluids within narrow limits of
normal is necessary to maintain homeostasis. NacL
0.9% is an isotonic solution, used to expand
intravascular volume and replace extracellular fluid
losses. This contains Na and Cl in excess of plasma
levels. An isotonic solution is the ideal fluid
replacement for a pt with and ECF volume deficit.
Potassium is added to the solution to replace any
potassium loss, preventing hypokalemia (potassium
less than 3.5, normal being 3.5-5.0 mEq/L).
Hypokalemia can result from a shift of potassium from
ECF to ICF. In this pts case this could occur from NG
suction, diuretics, or tissue repair post-op. Its
important to prevent hypokalemia because of the
negative effects it can have on the body such as;
fatigue, muscle weakness, N/V, paralytic ileus,
paresthesias, decreased reflexes, polyuria,
weak/irregular pulse, and hyperglycemia. These are
important to avoid to prevent further complication is
the pts recovery. Preventing the further delay of
gastric motility, any further weakness in the
extremities, and any increase in the pts blood glucose
being the key symptoms that would add to the already
happening delay. Monitoring her fluid and electrolytes
aids in knowing if fluids or electrolytes need to be
replaced or taken away.
15. Physical therapists can provide specialized services
to promote effective mobility. Pt will work with the pt
on strengthening and endurance, gait training, transfer
training, and developing a patient education program.
This pt could really benefit from a physical therapists
help once discharged from the hospital to ensure the pt
is safe and developing a steadier gait. This pt had a
wobbly gait with the help of a wheeled walker, and had
trouble standing up to transfer from the chair to the

ongoing. As of 3/13
when latest labs were
drawn pts potassium
remained between
normal, being at 4.3
mEq/L

15. Outcome met; plan

ongoing to prevent
immobilization. PT
evaluation was put in
place on 3/14,

bed. This pt needs to gain strength back through

measures carried out during hospital stay, and once
discharged to prevent immobility. Knowing the results
of the consultation with PT helps the nurse in preparing
the pt, and planning schedule of care throughout the
day. Lewis