Updated Care Plan for Post Abdominal Surgery

Category / Primary Body System:

Post-Surgical Care / Gastrointestinal and Integumentary Systems

Problem:

Patient is at risk for complications following abdominal surgery.

Goal:

The patient will have no signs or symptoms of infection at the incisional site for 90 days.

Plan/Approach:

1. Incision Monitoring:

   • Step: Monitor the surgical incision closely for signs and symptoms of infection, including redness, swelling, purulent drainage, dehiscence, warmth, and fever.
   • Rationale: Early detection of infection signs allows for prompt intervention, reducing the risk of complications.
   • Actions: Inspect the incision site at least once per shift, document findings, and report any abnormalities to the attending MD and/or surgeon.

2. Infection Notification:

   • Step: Notify the attending MD and/or surgeon with any signs or symptoms of infection.
   • Rationale: Prompt communication with the healthcare provider ensures timely treatment of potential infections.
   • Actions: Immediately report any signs of infection, including changes in the incision site appearance, to the appropriate medical personnel.

3. Respiratory Monitoring:

   • Step: Monitor lung sounds daily and notify MD with any adventitious lung sounds.
   • Rationale: Monitoring lung sounds helps detect respiratory complications early, such as atelectasis or pneumonia.
   • Actions: Auscultate lung sounds daily, document findings, and notify the MD of any abnormal sounds.

4. Cough and Deep Breathing:

   • Step: Encourage the patient to cough and deep breathe regularly.
   • Rationale: Deep breathing and coughing exercises help prevent respiratory complications by promoting lung expansion and clearing secretions.
   • Actions: Instruct the patient on proper techniques for coughing and deep breathing, and encourage frequent practice.

5. Incisional Splinting Education:

   • Step: Provide teaching regarding splinting the incisional area with a pillow during coughing or sneezing to reduce pain.
   • Rationale: Splinting helps reduce pain and prevent strain on the incision site during coughing or sneezing.
   • Actions: Demonstrate the technique of using a pillow to splint the incision site, and ensure the patient understands and practices it.

6. Mobility and Rehabilitation:

   • Step: Assist with mobility and provide rehab services as ordered to increase function.
   • Rationale: Early and safe mobilization aids recovery, reduces the risk of complications such as deep vein thrombosis, and improves overall function.
   • Actions: Assist the patient with mobility exercises and coordinate with rehabilitation services for a structured mobility plan.

7. Laboratory Monitoring:

   • Step: Monitor labs as ordered and report to the MD.
   • Rationale: Regular lab monitoring helps track the patient’s recovery and detect any underlying issues early.
   • Actions: Schedule and review lab tests, document results, and report any abnormalities to the MD.

8. Vital Signs Monitoring:

   • Step: Monitor vital signs frequently and notify MD of any changes.
   • Rationale: Monitoring vital signs provides early detection of potential complications, such as infection or bleeding.
   • Actions: Check vital signs according to protocol, document findings, and report significant changes to the MD.

9. Activity Restrictions:

   • Step: Instruct the patient to avoid heavy lifting, pushing, or pulling for 6 weeks.
   • Rationale: Limiting strenuous activities helps prevent strain on the incision site and promotes healing.
   • Actions: Educate the patient on activity restrictions and ensure they understand the importance of adhering to them.

10. Bowel Movement Monitoring:

    • Step: Monitor bowel movement patterns closely and intervene early for constipation.
    • Rationale: Preventing constipation reduces strain on the abdominal muscles and incision site.
    • Actions: Track bowel movements, provide dietary recommendations, and administer laxatives or stool softeners as needed.

11. Pain Management:

    • Step: Actively manage pain according to the pain care plan.
    • Rationale: Effective pain management enhances patient comfort, facilitates mobility, and promotes recovery.
    • Actions: Assess pain levels regularly, administer prescribed pain medications, and use non-pharmacological pain relief methods as appropriate.