00100 Delay In Surgical Recovery

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00100
Nanda label: surgical recovery delay
Diagnostic focus: surgical recovery
Approved 1998 • Revised 2006, 2013, 2017, 2020 • Evidence level 3.3

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « delay in surgical recovery is defined as: increased number of postoperative days necessary to initiate and carry out activities for the maintenance of life, health and Welfare.

Definite characteristics

  • Anorexia
  • Difficulty moving
  • Difficulty in recovering employment
  • Time required for excessive healing
  • Express discomfort
  • Fatigue
  • Interruption of the cure of the surgical area
  • Perceive the need for more time for recovery
  • Delay in the return to work
  • Requires help for self -care

Related factors

  • Delirium
  • deterioration of physical mobility
  • Increase in blood glucose level
  • Malnutrition
  • Negative emotional response to the surgical result
  • Obesity
  • Persistent nausea
  • Persistent pain
  • Persistent vomiting
  • smoking

Risk population

  • People> 80 years of age
  • People who experience intraoperative hypothermia
  • People who require emergency surgical intervention
  • People who require perioperative blood transfusion
  • Score ? 3 according to the classification of the physical state of the American Society of Anesthesiologists (ASA)
  • People with a history of myocardial infarction
  • People with low functional capacity
  • People with preoperative weight loss> 5 %

Associated problems

  • Anemia
  • Diabetes mellitus
  • Extensive surgical procedure
  • Pharmacological preparations
  • Prolonged duration of the perioperative infection of the surgical wound
  • Psychological disorder in the postoperative period
  • Surgical wound infection

Suggestions of use

The defining characteristics for this diagnosis represent other nursing diagnoses: deterioration of skin integrity, risk of nutritional imbalance, nausea, deterioration of physical mobility, deficit of self -care, fatigue and pain. If only one or two of the defining characteristics are present, these individual diagnoses must be used. If there are several characteristics, the delay in surgical recovery should be applied.

Suggested alternative diagnostics

  • Activity, intolerance to
  • Self -care, deficit of
  • Nutritional imbalance: intake less than needs
  • Pain
  • Fatigue
  • Cutaneous integrity, deterioration of the
  • Physical mobility, deterioration of

NOC Results

  • Wound healing: First intention: scope of cell regeneration and tissue after an intentional closure
  • Deamulation: Ability to walk from one place to another independently, with or without auxiliary devices
  • Gravity of infection: Intensity of infection and associated symptoms
  • Nausea and vomiting: severity of the symptoms of nausea, arcades and vomiting
  • Pain level: gravity of pain observed or referred
  • Recovery after a procedure: degree to which an individual recovers its initial operation after the application of procedures that require anesthesia or sedation
  • Resistance: Ability to maintain an activity

Evaluation objectives and criteria

The patient will be able to:

  • • Recognize and effectively face surgery anxiety
  • • Recover the level of energy prior to surgery, as evidenced by a rested, the ability to concentrate and manifestations of absence of exhaustion
  • • Recover mobility before surgery
  • • Demonstrate healing of surgical incision: approximate limits and without drainage, redness or hardening
  • • Experience a timely resolution of pain; will go to oral analgesics in (date) and will no longer require analgesics at (date)
  • • Comply with all the criteria for hospital discharge on the date on which the period programmed for specific surgery is met

NIC Interventions

  • Support in self -care: Help another to carry out the activities of daily life
  • Infection control: decrease in the acquisition and transmission of infectious agents
  • Nausea control: prevention and relief of nausea
  • Wound care: prevention of wound complications and help for cure
  • Wound care: Closed drainage: Maintenance of a pressure drain system at the wound site
  • Incision site care: cleaning, surveillance and promotion of healing a closed wound by suture, clips or staples
  • Bed Care: Improvement of comfort and safety, as well as prevention of complications of a patient who cannot get out of bed
  • Promotion of exercise: Facilitation of usual physical activity to maintain or increase the degree of physical and health
  • Energy management: Regulation of energy use to treat or prevent fatigue and optimize operation
  • Nutrition management: Help with or provision of a balanced diet in food and liquids
  • Liquid management: promotion of water balance and the prevention of complications resulting from abnormal or undesirable water concentrations
  • Vomiting management: prevention and mitigation of vomiting
  • Pain management: relief or pain elimination until an acceptable level of well -being for the patient
  • Exercise therapy: Desembling: Promotion and Patient Help to walk, in order to maintain or reestablish the voluntary and autonomous functions of the organism during the treatment and recovery of the disease or injury
  • Surveillance: Collection, interpretation and synthesis of patient data, continuously and with an end, to make clinical decisions
  • Surveillance of vital signs: Collection and analysis of cardiovascular and respiratory data, as well as body temperature, to determine and prevent complications

Note : The following nursing activities are general because the nursing diagnosis is not specific; It does not determine any particular surgery and includes many different nursing labels (see previous use suggestions). For more specific nursing activities, refer to nursing activities corresponding to nursing diagnoses intolerance to activity, fatigue, nausea, deterioration of physical mobility, deterioration of skin integrity, pain, risk of nutritional imbalance: lower intake than the needs and deficit of self -care.

Valuations

  • • Monitor the nature and location of pain
  • • Evaluate patient skills to perform self -care (for example, consider mobility, sedation and level of consciousness)
  • • (NIC) Surveillance:
    • Select the appropriate patient indicators for continuous surveillance, based on the patient’s condition
    • Establish the frequency of data collection and interpretation, as indicated by the patient’s status
    • Monitor the neurological state
    • Monitor vital signs, as required
    • Monitor the signs and symptoms of the imbalance of liquids and electrolytes
    • Monitor tissue perfusion, as required

Nursing Activities

  • Monitor the presence of infections, as required
  • Monitor nutritional status, as required
  • Monitor the gastrointestinal function, as required
  • Monitor the elimination patterns, as required
  • Monitor bleeding trends in high -risk patients
  • Observe the type and quantity of drainage of probes and holes, and notify the doctor if there are important changes
  • • (NIC) Energy management:
    • Monitor the cardiorespiratory response to activity (tachycardia, other arrhythmias, dyspnea, diaphoresis, paleness, hemodynamic pressures, and respiratory rate)
    • Monitor and record the patient’s sleep pattern, as well as the amount of hours that sleep
  • • (NIC) Nutrition Management: Determine the patient’s food preferences
  • • (NIC) Wound care: Examine the wound in each bandage change
    • Patient education
  • • (NIC) Incision site care: teach the patient to reduce the pressure at the incision site

Collaboration activities

  • • (NIC) Nutrition management: Determine (in collaboration with the nutritionist, as required), the number of calories and the type of nutrients necessary to meet the nutritional requirements
  • • (NIC) Surveillance:
    • Analyze the doctor’s orders together with the patient’s status to guarantee their safety
    • Obtain the consultation of the appropriate health specialist to initiate a new treatment, or modify existing treatments

Others

  • • Make sure the patient receives adequate analgesia
  • • Consider cultural influences in pain responses
  • • Reduce or eliminate factors that precipitate or increase experienced pain (fear, fatigue, monotony and lack of knowledge)
  • • Provide help until the patient is completely capable of performing self -care
  • • Motivate independence, but intervene when the patient is not able to perform the activities
  • • Compare your current state with your previous state to detect any improvement or deterioration in the patient’s condition
  • • Administer IV therapy at the point of care, as required
  • • (NIC) Energy management:
    • Determine what and how much activity is necessary to increase resistance
    • Use passive and active exercises with movement rank to release the voltage of the muscles
    • Avoid care activities during scheduled rest periods
  • • (NIC) Wound care:
    • Provide care to the site of the incision, as required
    • Strengthen the bandage, as required
    • Change the bandage according to the amount of liquid and drainage
    • Change position avoiding pressure on the wound, as required

At home

  • • (NIC) Energy management: instruct the patient and/or the closest people about self -care techniques that reduce oxygen consumption (for example, highway and locomotion techniques to carry out the activities of daily life )
  • • (NIC) Incision site care:
    • Instruct the patient about incision care during bathroom or shower
    • Teach the patient and family the care of the incision, including the signs and symptoms of infection

Babies and Children

  • • To use distractions to reduce pain

Older people

  • • Monitor changes in patient’s basal temperature; Older people can present an abnormal body temperature
  • • Keep the patient well covered, use hot blankets and not manage cold liquids