PRIMARY HEALTH PROBLEM: radical prostatectomy
PRIORITY ASSESMENTS: condition of wound, level of comfort, knowledge of care requirements when discharged,ability to manage home care, and emotional response to changes from surgury
Nursing Diagnosis: acute pain related to incisional trauma
- Winces when incision is palpated
- Acknowledges pain over incision
- Rates discomfort a 7 on a scale of 0 to 10
- Asks if pain medicine is available
Interventions:
-administer analgesic routinely as ordered
-teach progressive relaxation
-use a calm approach
-have patient splint incision when moving
Nursing Diagnosis: impaired physical mobility related to incisional pain
- Has not turned since some time last night
- Lies flat in bed w muscles tensed
- Reports discomfort of incision
Interventions:
-administer pain medicine every 30 minutes before turning and ambulation
-Teach progressive relaxation
-explain importance of becoming mobile after surgery
Nursing diagnosis: deficient knowledge related to inexperience w surgery
- Requests information about postoperative care
- Has no knowledge about postoperative wound care
- Ask questions
- Has no previous experience w wound care
Interventions:
-explain and demonstrate catheter and wound care
-include wife in instruction sessions
-discuss signs of wound infection
-explain activity restrictions to follow when discharged
Nursing diagnosis: anxiety
- States, "I am worried about me and my wife"
- States, "doctor told me surgery could change our ability to have sex"
- States, "I have a friend who died from cancer"
- Has uncertainty
- Has poor eye contact
Interventions:
-use a calm, reassuring approach in discussions
-have patient verbalize his perceptions, feelings, and fears -discuss concerns w Mr. Jones and Mrs. Jones together
-consult w surgeon regarding implications of surgery |