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
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.