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Running head: CURRENT EVIDENCE-BASED PRACTICES IN NURSING CARE FOR THE

MEDICAL-SURGICAL CLIENT

Current Evidence-Based Practices in Nursing Care for the Medical-Surgical Client

Tammy De Souza

NorQuest College

NFDN 2003

ID 0235150

Assignment 2 - Research and application to Nursing Care

Kim Harper

October 20, 2013

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Clients with impaired mobility are at greater risk for developing serious health

complications postoperatively. Clients at greater risk include elderly, diabetics, clients who

suffered strokes, heart failure, as well as clients with debilitated health, altered sensory

perception of pain and pressure, alteration in level of consciousness, and clients that are on bed

rest for a long period of time after surgery. Some of the risks associated with decreased mobility

are respiratory complications (e.g., acute atelectasis, pulmonary embolism, aspiration related to

improper positioning, and suppressed swallowing ability secondary to analgesics and sedatives).

Immobilized clients are also at risk for venous stasis, deep vein thrombosis, impaired skin

integrity, and loss of muscle tone.

Strategies that promote the health of medical-surgical clients in the hospital or following

discharge include adequate nutritional intake and hydration for wound healing, skin care, proper

repositioning while on bed rest, use of incentive spirometry, promotion of ambulation, and

administration of analgesics and sedatives to improve clients’ levels of comfort and compliance

while in hospital and after discharge.

Nutritional intake plays an important role in optimizing the recovery of medical-surgical

clients. Increased protein intake helps promote wound healing and prevents future wounds, as

Potter & Perry (2010) state, “Increase protein intake helps rebuild epidermal tissue” (p. 1270).

Increased fluid intake helps thin the lung secretions for easy removal post-surgery. According to

Potter & Perry (2010), “The best way to maintain thin secretions is to provide a fluid intake of

1500 to 2000ml/day’ (p. 928).

Skin care is very important for clients who have impaired mobility. Proper skin care and

maintaining skin dry helps with the prevention of skin break down. According to Potter & Perry

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(2010), moisture softens the skin and makes it more susceptible for developments of skin tears

(p. 1245). Immobilized clients that are unable to take care of their own hygiene needs require

close monitoring of the skin condition.

Motivating medical-surgical clients to ambulate as soon as they are able to is very

important for the prevention of deep vein thrombosis, venous stasis, pulmonary embolism, and

muscle atrophy. As described by Potter & Perry (2010), leg exercises, ambulating, positioning

changing, use of TED stocking, avoiding sitting for long periods of time and crossing legs, and

ROM promotes venous return (p.1209). Over the past decade there has been an increased

emphasis on mobilizing the client soon after surgery. This has been a change in practice from

before as we now have a better understanding of the benefits of early ambulation. There is

currently a lot research going into developing early mobilization protocol for postoperative

clients, which suggests that is becoming more important in practice (Zomorodi, Topley, &

McAnaw, 2012).

Positioning and the use of incentive spirometry helps maintain and promote lung

expansion in medical-surgical clients. Proper positioning of clients who are immobile helps

maintain proper ventilation and oxygenation and reduces the risks of stasis of pulmonary

secretion and decreased chest wall expansion (Potter & Perry, 2010, p. 913). The use of incentive

spirometry is very important for post-surgery clients because it encourages deep breathing and

prevents or treats atelectasis. As Potter & Perry (2010) affirms, “The use of incentive spirometry

promotes lung expansion and thus prevents postoperative pulmonary complications” (p. 913).

The incentive spirometer is an example of an improvement in care for medical-surgical clients,

as this is a recent medical invention. Prior to 1970, the incentive spirometer did not exist and

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patients were only encouraged to breathe deeply. With this new technology, nursing practice for

improving lung function in medical-surgical clients has improved (Mercer, 2011, p 1).

The above strategies done by nursing staff promote optimal client recovery while in

hospital, however there are also strategies that the client and family can do once the client is

discharged; this requires educating the client and family. For example, teaching the client and

family about proper nutritional intake once discharged is important to continue to promote

wound healing at home. This involves teaching clients and families about the values in Eating

Well with Canada’s Food Guide (Potter & Perry, 2010, p. 1066), along with any other surgery-

specific dietary guidelines. The client and family should also receive education about the

importance of mobilizing the client especially after surgery. As Day, Paul, Williams, Smeltzer,

& Bare (2010) affirm that early ambulation reduces the risks for atelectasis, hypostatic

pneumonia, stimulates peristalsis of the gastrointestinal tract, and increase circulation in the

lower extremities therefore reducing the risks for thrombophlebitis or phlebothrombosis (p. 505).

Having the client and family be aware of potential complications can help them to adhere better

to discharge instructions. Teaching clients about the proper use of incentive spirometer, deep

breathing and coughing exercises every two hours can help prevent pulmonary complications, as

well as encourage client independence, as they can do this on their own (Day, Paul, Williams,

Smeltzer, & Bare, 2010, p. 502).

The current evidence-based strategies discussed in this paper are optimizing client

recovery post-operatively. These strategies for nursing care are combined with educating clients

and their families to involve them in their own care. The recovery for medical-surgery clients has

been improving because of these strategies that promote client health and prevention of health

complications following stay in hospital and discharge.

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Nursing Care Plan (One Page per Nursing Diagnosis)

Nursing Diagnosis

Impaired breathing

pattern related to

decreased lung

expansion as

evidence by

shortness of breath,

use of accessory

muscles, and

decreased mobility.

Planning

Client Goals: Client will be

able to improve breathing

pattern and be able to breathe

with greater ease without using

the accessory muscles. This goal

was established by asking the

client what his goals were

regarding increasing the level of

comfort.

Expected Outcomes : Client

respiratory rate will decrease

within 24hs by monitoring

respiratory rate every hour.

Interventions

List Interventions:

Administration of

bronchodilators as prescribed by

physician’s order.

Monitor O2sats hourly.

Teach client inspiratory muscle

training and breathing retraining

Rationale for Interventions:

Bronchodilators help smooth

muscle relaxation, thus dilating

constricted bronchial tubes

helping with breathing (Day,

Paul, Williams, Smeltzer, and

Evaluation

Achievement of Expected

Outcomes:

Goal met when

respiratory rate and

O2sats are within

normal range (with

monitoring

respiratory status).

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Bare, 2010, p. 705).

O2sats reading helps to monitor

and maintain O2 levels within

normal range and evaluate the

effectiveness of interventions

(Jarvis, 2009, p. 171).

Inspiratory muscle training and

breathing retraining are designed

to achieve more efficient and

controlled ventilation. Therefore

decrease the work of breathing

and improve breathing pattern

(Day, Paul, Williams, Smeltzer,

and Bare, 2010, p. 691).

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Nursing Care Plan (One Page per Nursing Diagnosis)

Nursing Diagnosis

Risk for impaired

skin integrity related

to decreased

mobility as

evidenced by client

bed-bound

secondary to recent

surgery.

Planning

Client Goals: Client will

maintain skin integrity and be

free of skin irritation or pain.

This goal was established by

asking the client what his goals

were regarding increasing the

level of comfort.

Expected Outcomes : Client

skin will be free of skin tears,

ulcers, and erythemas upon

discharge by monitoring client

skin for skin breakdown every 8

hours.

Interventions

List Interventions:

Proper skin care (ensure skin

is dry and clean).

Assess lower extremities for

deep vein thrombosis (DVT).

Turn client every two hours.

Rationale for Interventions:

Excessive moist on skin

softens the tissue therefore

increases the risk for ulcer

formation. Keeping skin dry

and clean promotes skin

integrity (Potter & Perry,

Evaluation

Achievement of Expected

Outcomes:

Goal met when skin is

intact, as noted in skin

assessment.

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2010, p. 1245).

Turning client every 1-2

reduces the risk for skin

break down and pressure

ulcer formation (Potter &

Perry, 2010, p. 1205).

Deep vein thrombosis (DVT)

is a hazardous of restricted

mobility, therefore close

assessment of the calves for

redness, warmth, and

tenderness is important

(Potter & Perry, 2010, p.

1201).

Nursing Care Plan (One Page per Nursing Diagnosis)

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Nursing Diagnosis

Deficient knowledge

related to outcome of

surgery and

postoperative course

as evidenced by

anxiety, fear, and

noncompliance.

Planning

Client Goals: Client will attain

adequate knowledge regarding

pre and post surgery, and

therefore have decreased levels

of anxiety fear, and

noncompliance with regiment.

This goal was established by

asking the client what his goals

were regarding increasing his

level of comfort, and compliance

with nursing care plan.

Expected Outcomes : Client

obtained all the information

required regarding surgery

therefore decreasing anxiety,

Interventions

List Interventions:

Explain the purpose of

surgery, procedure and

interventions to promote level

of comfort post surgery.

Explain to the client the

importance of early

ambulation after surgery thus

increasing compliance.

Panning and teaching client

self-care by discharge.

Rationale for Interventions:

By addressing concerns, what

to expect, providing

reassurance and information

about hospital procedures to

Evaluation

Achievement of Expected

Outcomes:

Goal met by assessing

client’s knowledge,

asking client

questions regarding

understanding of

surgery, procedure,

and importance of

early ambulation.

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fear, and about regimen post

surgery prior to procedure by

assessing clients’ knowledge.

increase level of comfort

after surgery can reduce

anxiety and fear (Day, Paul,

Williams, Smeltzer, and

Bare, 2010, p. 513).

Clients might be reluctant to

ambulate after surgery,

explaining further

complications that can occur

regarding immobility can

encourage early ambulation

(Day, Paul, Williams,

Smeltzer, and Bare, 2010, p.

505).

Planning and teaching prior

to discharge can reduce

anxiety, address concerns,

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and increase level of comfort

while performing preventive

health measures at home

(Day, Paul, Williams,

Smeltzer, and Bare, 2010, p.

515).

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References

Day, R. A., Paul, P., Williams, B., Smeltzer, S. C., & Bare, B. (2010). Textbook of

medical/surgical nursing (2nd Cdn. ed.). Philadelphia, PA: Lippincott Williams &

Wilkins.

Jarvis, C. (2009). Physical Examination & Health Assessment. (1st Canadian ed.). Toronto:

Sauders Elsevier.

Mercer. L. (2011). “Incentive spirometry vs. diaphragmatic breathing Exercise.” Livestrong.

Retrieved September 22, 2013, from Google Scholar:

http://www.livestrong.com/article/52540-incentive-spirometry-vs.-diaphramatic-

breathing/#page=2

Potter, P. A., & Perry, A. G. (2010). Canadian Fundamentals of Nursing. (4th ed. Rev.). Ross-

Kerr, J. C., & Wood, M. J. (Canadian ed.). Toronto, ON: Elsevier

Zomorodi, M., Topley, D., & McAnaw, M. (2012). “Developing a mobility protocol for early

mobilization of patients in a surgery/trauma ICU.” Critical Care Research and Practice,

2012(964547), p. 10. Retrieved September 22, 2013, from Google Scholar:

http://www.hindawi.com/journals/ccrp/2012/964547/