The nurse is caring for a client who has a postoperative paralytic ileus following a bowel resection for colon cancer. The client is receiving patient-controlled analgesia (PCA) with morphine. Which nursing diagnoses (NDs) are appropriate to include in the client's care plan? Select all that apply.

Question

Quizplus · Accepted Answer

The following NDs are appropriate to include in this client's care plan: Acute pain related to tissue damage as evidenced by the use of PCA with an opioid. Pain is usually most intense 12-36 hours after surgery (Option A). Dysfunctional gastric motility related to bowel manipulation during surgery, anesthesia, and opioid analgesia as evidenced by absent or hypoactive bowel sounds 48-72 hours following surgery secondary to a paralytic ileus. It is a common complication following abdominal surgery (Option B). Imbalanced nutrition, less than body requirements related to the increased metabolic demand needed for tissue and wound healing as evidenced by the inability to ingest adequate caloric intake secondary to a paralytic ileus and the lack of interest in eating secondary to the ileus, the adverse effects of anesthesia, and analgesic medications (Option C). Risk for infection - The risk for being invaded by pathogenic organisms is increased in this client due to loss of primary defenses (ie, protective skin barrier), lack of adequate nutrition to meet the body demands, and altered immunity due to the presence of cancer cells (Option E). (Option D) Ineffective self-health management is the inability to integrate a therapeutic treatment regimen into one's own activities of daily living to meet specific health goals. There are no data to support this ND at this time. Educational objective: NDs associated with impaired skin integrity and wound healing following abdominal surgery that guide supportive and preventive nursing care include acute pain, dysfunctional gastric motility, imbalanced nutrition (less than body requirements), and risk for infection.

The Nurse Is Caring for a Client Who Has a Postoperative