Nursing Care Plan & Diagnostics: Hiatal Hernia

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Table of Contents

Overview with cultural considerations
Functional health pattern assessment
Conclusion
Self-critique of the plan
References

Overview with cultural considerations

My patient is a 30-year old white American, who was hospitalized with complaints about sharp and acute pain in his neck and shoulders. The patient is a Christian who, however, does not attribute much attention to religion in his life. The patient has a family, and his wife and 7-year old daughter are rather supportive to him. The patient is a highly open person using the eye-contact and touch in his communicational acts.

The urgent medical assessment and testing proved that the patient had a hiatal hernia and required an urgent laparoscopic gastric bypass surgery to be carried out. After this, the patient went through a set of tests to examine his blood, pulse, blood pressure, and urine. The results of the preliminary tests manifested the patient’s readiness for the surgery and the possibility of using general anesthesia.

So, the patient was prepared for the surgery and brought to the surgery room. The very laparoscopy started 5 minutes later when the general anesthesia started working. Four minor incisions were made in the right part of the patient’s abdomen and the hiatal hernia repair was carried out. No complications were observed before, during, or after the surgery. The patient recovered from the general anesthesia rather early, and the PACU score of the patient was 2, using the gradation in which late recovery is 0, intermediate recovery is 1, and early recovery is 2.

After the surgery, the patient was placed in an ordinary ward because he coped with all general anesthesia effects well, and no need was observed to place the patient into the reanimation ward. The drainage sponge was placed in one of the stitches left after the laparoscopy to prevent the remaining blood and ichor from accumulating in the wound. Daily bandaging was carried out for the patient, who started walking the next day after the surgery. Now, the patient is on a non-irritating diet that limits his vegetarian preferences to neutral drinks and food. The nursing care plan is developed on the basis of nursing diagnostics to present the patient with the highest care standards (Muller-Staub, et al., 2008, p. 293).

Functional health pattern assessment

General appearance

My patient is in his bed now. His conditions are rather good, as he tried to sit in the bed, walks to the bathroom with the help of a nurse, and starts eating the simplest products his diet allows him to.

Reason for hospitalization

My patient was admitted xx/xx/010 reporting the long-lasting sharp pain in his chest. According to his complaints, the pain had been lasting for 15 minutes before he was placed in the hospital, and this was not the first case of such a pain fit (Smeltzer and Bare, 2009, p. 692).

Past medical history

The patient has a past medical history of angina and sharp and continuous pain in his neck and shoulders.

Health perception

The patient was taken to the hospital and underwent the laparoscopic gastric bypass as soon as the testing procedures confirmed his health conditions to be acceptable for such a procedure.

Nutrition/Metabolic pattern

The patient is now on a non-irritating diet, drinking fluids containing no acids and eating only neutral products.

Elimination pattern

The elimination patterns of my patient are all in order. His bowel and bladder control functions are at the proper levels.

Exercise pattern

The patient displays normal levels of activity. He does physical exercises to maintain the tonus of his muscles and avoid complications.

Sleep/Rest pattern

The sleeping and rest patterns are displayed by the patient care at the proper level. The patient can fall asleep during bedtime without taking any medications.

Cognitive pattern

My patient is alert, he recognizes people and things that surround him, can remember his past and can project his future.

Self-perception pattern

The patient is a 30-year old man, who perceives himself adequately and realizes his position in the objective reality. The patient can also properly formulate his needs and wishes.

Role/Relation pattern

The patient has a family, i. e. a wife and a 7-year old daughter. They are very supportive and help him get through the hardships of the post-surgery period. As well, the patient’s parents often visit him to express their love and support. Finally, the patient has many friends, who also help him recover from the surgery and return to his active daily life.

Sexual/Reproductive pattern

As stated above, the patient is married and has a 7-year old daughter. As he is a father, he values his family even more and is committed to recovering for the sake of his daughter.

Coping pattern

The patient displays no signs of stress or any other psychological issues, which evidences that his pattern of coping with the post-surgery recovery is rather strong.

Value/Belief pattern

According to the patient’s words, he is a Christan but is not used to attending church on the regular basis. Moreover, the patient displays deeply philosophical beliefs, which are conditioned by his committed interest in the subject.

Respiratory

The patient experiences slight respiratory difficulties, i. e. a partially ineffective breathing pattern, caused by the still observed effects of the laparoscopic surgery. However, the general characteristics of the patient’s respiratory functioning are positive. His respiratory rate fluctuates between 18 and 20 breathing per minute.

Cardiovascular

The cardiovascular conditions of the patient are proper. The patient’s SE blood pressure is 120/80, while pulse rate is at the stable level of 93. Accordingly, the patient takes no medications facilitating the functioning of the cardiovascular system, but still, he is under the permanent control of a cardiologist, which is the measure to diagnose and eliminate any problem if it emerges.

Neurological

The neurological conditions of the patient are stable and there is no need for special treatment thereof. The patient realizes that the situation he is in now is rather problematic, but the successful laparoscopy is sure to make his post-surgery recovery fast and without any complications.

Gastro-intestinal

The patient underwent laparoscopic gastric bypass and hiatal hernia repair. The current condition of the patient is stable. The drain sponge is placed into a loose stitch so that the remains of blood and ichor from the wound could be eliminated from the organism. The patient takes ketorolac intravenously twice a day to cope with the post-surgery pain (Aschenbrenner, 2008, p. 416). No need for additional medications to be taken is observed.

Genito-urinary

The genitor-urinary function of the patient’s organism is at the proper level of performance. The patient is continent with his bladder.

Musculoskeletal

The musculoskeletal system of the patient is functioning properly. On the whole, the musculoskeletal activities of the patient are voluntary and proper. No muscle strains and/or other problems can be noticed.

Integumentary

The patient’s skin is majorly intact and displays no obvious signs of damages or infections. The only places where the skin is damaged are laparoscopic stitches, around which slight red spots can be observed.

Care plan

NURSING DIAGNOSIS	DESIRED OUTCOMES	NURSING INTERVENTION	EVALUATION	EVALUTATION
Acute pain related to the post-surgery recovery process	Goal: – Client will experience no, or less, pain during the post-surgery recovery period. Short-term desired outcome: – Client will report the reduction of pain levels after taking the medication. Long-term desired outcome: – Client will experience the reduction and elimination of post-surgical pain symptoms.	– Hear the client out, analyze his complaints, and make necessary conclusions. At the same time, assure the client that his issue will be solved shortly. – Consult the doctors regarding the medications that should be given to the client that underwent laparoscopic gastric surgery and hiatal hernia repair. Next, administer the medication and record preliminary results. – Monitor the medication results for this specific patient and administer the medication on the regular basis if it brings relief from post-surgical pain. – Use another medicationifs the selected one is not effective with this client. – Carry out regular monitoring of the patient’s condition regarding the post-surgical pain and the effectiveness of the administered medication.	– Polite communication and attention to the client’s issues will ensure him that he is given the high-standard care. As well, his post-surgical pain will be made milder if he knows that pain-killing medications will soon be prescribed for him (Muller-Staub, et al., 2008, p. 294). – Qualified and professional opinions of doctors should be addressed while selecting the medication to reduce or eliminate the post-surgical pain of the client. Although the nurse has no doubts about the medication selection, consulting another professional will reduce the risk of mistake to the possible minimum. – One time administration of the medication will allow to trace its effectiveness and either keep using it or search for another one. – Regular monitoring of medication effectiveness will allow changing the medication timely if it stops being effective. As well, such an approach will allow tracing and eliminating any side-effects of the medication on the client.	The goal was met, the patient actually experienced acute pain related to the post-surgery recovery process, and the nursing interventions helped in solving this issue.
Partially ineffective breathing pattern	Goal: – Client will not experience ineffective breathing patterns. Short-term desired outcome: – Client will see what techniques increase his breathing pattern effectiveness. Long-term desired outcome: - Client will experience a perfectly effective breathing pattern.	– Hear out and record all clicliencomplaintss regarding the ineffective breathing pattern. – Analyze techniques to increase breathing pattern effectiveness. – Present several techniques to enhance the client’s breathing pattern. – Monitor the effectiveness of each of the techniques. – Decide, together with the client, which technique is the most effective and keep on practicing it. – Regularly monitor the process of increasing the client’s breathing pattern effectiveness.	– Positive environment will increase the client’s confidence and recovery speed; – Analysis of the techniques will minimize the chance of failure. – Several techniques will allow selecting the most effective one; – Monitoring will condition the proper choice of technique (Muller-Staub, et al., 2008, p. 293). – Joint decision will include the client into the process of recovery and speed it up essentially. – Monitoring will allow tracing the progress of the intervention and making improvements.	The goal was met, as the client actually experienced the partially ineffective breathing pattern, but the nursing interventions allowed eliminating this issue.

Conclusion

So, my patient is a 30-year old American who has a family, recognizes the right of all people to be equal and to live properly. This patient has undergone laparoscopic gastric bypass surgery and hiatal hernia repair. Before the hospitalization, he experienced regular fits of sharp pain, which evidenced that he had a hiata al hernia. The surgery has been carried out successfully, and now my patient is in the stage of recovery. Thabove-presenteded care plan reflects the basic interventions I carry out to solve two major problems of my patient, i. e. partially ineffective breathing pattern and post-surgical pain (Muller-Staub, et al., 2008, p. 294). So, to achieve the goal of overcoming these problems, I plan to use both medications and breathing improvement techniques after prior analysis of both issues from a professional point of view.

Self-critique of the plan

The self-critique of the presented care plan for my patient allows making rather high assessments of the plan components. First, the RCC Evaluation Guidelines require any nursing care plan to include five major columns to reflect the nursing diagnosis, desired outcomes, nursing interventions, rationale for the latter, and evaluation of the effectiveness of goal achievement (RCC, 2010). The care plan I developed for my patient obviously has all these obligatory elements. Further on, the nursing diagnosis column should identify the patient’s state from the nursing viewpoint, and my care plan complies with this requirement as well (RCC, 2010). Desired outcomes are measurable and specific as the RCC standards require, while the list of nursing interventions always starts with hearing the client out and analyzing his problem. Further on, every nursing intervention is assessed and has its rationale presented, while the overall goal evaluation is presented in the context of achieving/not achieving the major goal of the client. Accordingly, the presented care plan conforms to all RCC requirements for nursing care plans.

References

Aschenbrenner, D. (2008). Drug Therapy in Nursing. Philadelphia: Lippincott Williams & Wilkins.

Muller-Staub, M. et al. (2008). Implementing nursing diagnostics effectively: cluster randomized trial. Journal of Advanced Nursing 63(3), 291–301.

RCC. (2010). Practical Nursing Program. Web.

Smeltzer, S. and Bare, B. (2009). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. Philadelphia: Lippincott Williams & Wilkins.

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