8 TAHBSO Nursing Care Plans

6
TAHBSO-NCP

Total abdominal hysterectomy bilateral salpingo oophorectomy (TAHBSO) is the removal of entire uterus, the ovaries, fallopian tubes and the cervix. TAHBSO is usually performed in the case of uterine and cervical cancer. This is the most common kind of hysterectomy. Removal of the ovaries eliminates the main source of the hormone estrogen, so menopause occurs immediately.

Postoperative Care

Main Article: TAHBSO Surgical Procedure and Perioperative Management

  1. Determines patient’s immediate response to surgical intervention.
  2. Monitor patient’s physiologic status.
  3. Assess patient’s pain level and administers appropriate pain relief measures.
  4. Maintains patient’s safety(airway, circulation, prevention of injury)
  5. Administer medication, fluid and blood component therapy, if prescribed.
  6. Assess patient’s readiness for transfer to in hospital unit or for discharge home based on institutional policy.

Nursing Care Plans

Here are the 9 TAHBSO nursing care plans:

Acute Pain

NDx: Acute pain secondary to surgical operation

Due to surgical procedure done that needs a surgical incision there will be presence of trauma in the area that signals an actual tissue damage and inflammation, this damage will cause an inflammation of the nerves when the nerves are affected, there will be the presence of pain.

AssessmentPlanningNursing
Interventions
RationaleEvaluation
Subjective:The patient may verbalized:“My wound hurts”Objective:

The patient manifested

  • irritability
  • impaired physical mobility
  • disturbed sleep pattern
  • facial mask
  • diaphoresis
  • restlessness
  • facial grimaces
Short term: After 4 hours of nursing interventions, the patient’s pain scale will decrease 10/10 to 5/10Long term: 

After 1 day of nursing interventions, patient’s pain will diminish and perform activities like side movement and leg bending

  1. Establish rapport
  2. Emphasize ordered diet
  3. Monitor vital signs
  4. Provide comfort measures
  5. Encourage deep breathing
  6. Provide safety measure
  7. Develop communicationreview procedures/expectations and tell client when treatment will hurt
  8. Administer analgesics as indicated to maximal dosage as needed
  1. To gain trust
  2. To encourage patient not to eat untolerated food
  3. To obtain baseline data
  4. To satisfy the confinement of patient
  5. To inhibit pain
  6. To prevent from injury
  7. To alter pain and diminish emotional stress
  8. To reduce concern of unknown and associated muscle tension & To maintain acceptable level of pain.
Short term:The patient’s pain scale decreased 10/10 to 5/10Long term:

The patient’s pain diminished and performed activities like side movements and leg bending

Hypothermia

Hypothermia is the sudden decrease of temperature. It is due to different factors such as exposure to cool environment, aging or medications. In a surgical procedure hypothermia occurs due to exposure to the cool environment in the OR. Anesthesia also affects body temperature. Inadequate clothing like the OR gown also contributes to heat loss.

AssessmentPlanningNursing
Interventions
RationaleEvaluation
The patient may manifest:

  • reduction in body temperature below normal range
  • shivering
  • cool skin
  • pallor
  • slow capillary refill
  • cyanotic nail beds
  • hypertension
  • tachycardia
Short term: After 3 hours of nursing interventions the patient will display core temperature within normal rangeLong term: 

After 1 day of nursing interventions the patient will demonstrate behaviors to monitor and promote normothermia

  1. Establish rapport
  2. Monitor  vital signs
  3. Remove wet clothing and prevent pooling of antiseptic solutions under client in OR
  4. Wrap in warm blanket
  5. Avoid use of heat clamps or hot water bottles
  6. Administer medications to prevent shivering
  7. Use hyperthermia blanket
  8. Administer fluids during rewarming
  9. Keep client quiet
  10. Provide well-balance high calorie diet
  11. Perform range-of-motion exercises, provide support hose, reposition, do cough/deep breathing exercises, avoid restrictive clothing
  12. Protect skin by repositioning, applying lotion and avoid direct contact with heating appliance or blanket
  13. Provide patent airway with humidified oxygen when used
  1. To gain trust
  2. To obtain baseline data
  3. These measures protect patient from heat loss
  4. To promote heat
  5. Surface rewarming can lead to rewarming  shock due to surface vasodilation
  6. To avoid increasing in temperature
  7. To warm patient
  8. To prevent hypovolemic shock
  9. To reduce potential for fibrillation in cold heart
  10. To replenish glycogen stores and nutritional balance
  11. To reduce circulatory stasis
  12. impaired circulation can result in severe tissue damage
  13. To provide heat
Short term: The patient displayed core temperature within normal rangeLong term:

The patient demonstrated behaviors to monitor and promote normothermia

Hyperthermia

Organisms release endotoxin which stimulates the release of pyrogens from the leukocytes resetting the body’s internal thermostat to febrile level then there will be activation of hypothalamus which will result to an increase in epinephrine and heparin, vasoconstriction of cutaneous vessels. Then heat will be produce as peripheral vasodilation results in skin flushing and skin which is warm to touch.

AssessmentPlanningNursing
Interventions
RationaleEvaluation
S The patient may manifest:

  • headache

O The patient may manifest:

  • increase in body temperature above normal range
  • flushed skin, warm to touch
  • tachycardia
  • seizures or  convulsions
Short term: After 4 hours of nursing interventions the patient will maintain core temperature within normal rangeLong term: 

After 1 day of nursing interventions the patient will be free from complications such as irreversible brain damage and acute renal failure

  1. Establish rapport
  2. Monitor  vital signs
  3. Monitor body temperature every 4 hours or more often if indicated
  4. Loosen patient’s clothingand remove blankets
  5. Apply ice bags to axilla or groin and do TSB
  6. Administer antipyretic as ordered
  7. Observe patient for confusion or disorientation
  8. Determine patient’s preference for liquids
  9. Keep liquids at bedside and within reach
  10. Monitor intake and output accurately
  11. Administer I.V fluid as ordered
  12. Give patient oresol
  13. Provide supplement oxygen
  14. Maintain bed rest
  15. Provide high-caloric diet, tube feedings or parenteral nutrition
  1. To gain trust
  2. To obtain baseline data
  3. To evaluate effectiveness of interventions
  4. To promote heat loss through radiation and conduction
  5. To promote heat loss through evaporation
  6. To reduce fever
  7. Changes LOC may result from tissue hypoxia
  8. Offering patient liquids he prefers promotes adequate hydration
  9. To allow patient easy access
  10. To identify changes and progress of the treatment
  11. These measure prevents excessive loss of water, sodium chloride and potassium
  12. To replace loss fluid and electrolytes
  13. To offset increase oxygen demands and consumption
  14. To reduce metabolic demands
  15. To meet increased metabolic demands
Short term: The patient maintained core temperature within normal rangeLong term: 

The patient was free from complications such as irreversible brain damage and acute renal failure

Anxiety

Due to upcoming surgical procedure patients are usually experiencing anxiety. The brain signals our body part to initiate responses such as fatigue, nausea and abdominal pain.

AssessmentPlanningNursing
Interventions
RationaleEvaluation
S The patient may manifest:

  • concerns due to change in life event
  • fear
  • nausea
  • abdominal pain
  • fatigue
  • sleep disturbance
  • urinary hesitancy

O The patient may manifest:

  • poor eye contact
  • extraneous movement
  • restlessness
  • irritability
  • anorexia
  • insomnia
  • impaired attention
  • Trembling, hand tremors
Short term: After 3 hours of nursing interventions the patient will verbalized awareness of feelings of anxietyLong term: 

After 1 day of nursing interventions the patient will appear relaxed and report anxiety is reduced to a manageable level

  1. Establish rapport
  2. Monitor  vital signs
  3. Listen attentively; allow patient to express feelings verbally
  4. Identify and reduce as many environment stressors
  5. Provide accurate information about the situation
  6. Provide comfort measures like back rub and soft music
  7. Use cognitive therapy
  8. Refer patient to professional mental health resources
  1. To gain trust
  2. To obtain baseline data
  3. To allow patient to identify anxious behaviors and discover source of anxiety
  4. Anxiety commonly results from lack of trust in the environment
  5. Helps the patient what is reality based
  6. To decrease autonomic response to anxiety
  7. To correct faulty catastrophic interpretations of physical symptoms
  8. To provide ongoing mental health assistance
Short term:The patient verbalized awareness of feelings of anxietyLong term:

The patient appeared relaxed and reported that anxiety was reduced to a manageable level

Fatigue

Due to poor physical condition after surgical procedure, body insist demands of nutrition and oxygen that results to fatigue

AssessmentPlanningNursing
Interventions
RationaleEvaluation
  • Pale skin
  • Impaired physical mobility
  • Irritability
  • Weakness
  • Pain= 5/10
  • Activity intolerance
  • Stress
Short term: After 4 hours of nursing intervention, the patient will demonstrate an increase energy output with presence of fatigueLong term: 

After 3 day of nursing intervention, the patient will perform activities of daily living and participate in desired activities at level of ability

  1. Establish rapport
  2. Monitor vital signs
  3. Evaluate the need for individual assistance and discuss lifestyle changes imposed by fatigue state
  4. Establish realistic activity goals with client
  5. Instruct client in ways to monitor responses to activity and significant signs and symptoms
  1. To gain trust
  2. To obtain maintenance data
  3. To determine degree of fatigue
  4. Enhance commitment in promoting optimal outcomes
  5. To indicate the need to alter activity level
Short term: The patient demonstrated increase energy output without presence of fatigueLong term: 

The patient performed activities of daily living and participate in desired activities at level of activities

Sexual Dysfunction

NDx: Sexual Dysfunction related to altered body structure and function

Dysfunction of the female reproductive system can produce depression and even anxiety. The patient experiences this due to deficient knowledge about the dysfunction and the decrease in sexual desire.

AssessmentPlanningNursing
Interventions
RationaleEvaluation
S The patient may verbalized:

  • -problem such as loss of sexual desire
  • - inability to achieved desired satisfaction
  • -conflicts involving values

O the patient manifested:

  • alteration in relationship with SO
  • Change of interest in self and others
Short term: After 4 hours of nursing interventions the patient will identify stressors in lifestyle that may contribute to the dysfunctionLong term: 

After 3 day of nursing interventions the patients will verbalize understanding of individual reasons for sexual problems

  1. Establish rapport
  2. Monitor vital signs
  3. Obtain sexual history including usual patterns of functioning and level of desires
  4. Be alert to comments of client
  5. identify current stressors in individual situations
  6. Avoid making value judgments
  7. Establish therapeutic nurse-client relationship
  8. Provide ways to obtain privacy
  1. To gain trust
  2. To obtain maintenance data
  3. To maximize communication and understanding
  4. Sexual concerns are often disguised as humor, sarcasm, or offhand remarks
  5. These factors may be producing enough anxiety to cause depression
  6. They do not help the client
  7. To promote treatment and facilitate sharing of sensitive information
  8. To allow sexual expression for individual between partners without embarrassment
Short term: The patient identified stressors in lifestyle that contributes to the dysfunctionLong term: 

The patient verbalized understanding of individual reasons for sexual problems

Risk for Infection

NDx: Risk for infection secondary to surgical incision

The skin considered as the first line of defense against any foreign organism when surgical procedure impaired the skin, possible entry of microorganism therefore may cause infection

AssessmentPlanningNursing
Interventions
RationaleEvaluation
  • Weakness
  • Pallor-with dry and intact dressing on the area.
  • Pain over the incision
  • Irritability
  • Presence of intact dressing
  • Impaired physical mobility
  • Diaphoresis
  • Fever
  • Seizures
Short term: After 4 hours of nursing interventions, the patient shall identify and demonstrate intervention to prevent infectionLong term: After 1 day of nursing interventions, the patient will not have infection
  1. Establish rapport
  2. Monitor V.S.
  3. Note signs and symptoms of sepsis
  4. Provide wound healing such as cleaning of wound
  5. Provide care, change dressing as needed
  6. Encourage increase intake of Vitamin C
  7. Encourage deep breathing exercise
  1. To gain trust
  2. To obtain baseline data
  3. To reduce complication and monitor for infection
  4. To reduce risk for infection
  5. To promote healing to the incision
  6. To prevent infection to increase immune resistance
  7. To increase healing of wound
Short term:The patient identified and demonstrated interventions to prevent risk of infectionLong term:The patient does not experience infection

Risk for Deficient Fluid Volume

Decrease intravascular, interstitial, or intracellular fluid refers to dehydration. Fluid volume deficit or hypovolemia occurs from a loss of body fluid or the shift of fluids into the third space or reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria and increased perspiration. It also occurs to patient who underwent surgery. In an operation the patient is losing too much body fluid through blood loss that can lead to deficient fluid.

AssessmentPlanningNursing
Interventions
RationaleEvaluation
  • thirst
  • weakness
  • decrease urine output
  • sudden weight loss
  • decrease skin turgor
  • dry mucous membranes
  • sunken eyeballs
  • change in mental state
Short term: After 4 hours of nursing interventions the patient will identify risk factors and appropriate interventionsLong term: After 3 day of nursing interventions the patients will demonstrate behaviors or lifestyle changes to prevent development of fluid volume deficit
  1. Establish rapport
  2. Monitor vital signs
  3. Encourage increase oral fluid intake
  4. Provide supplemental fluids as ordered
  5. Monitor intake and output
  6. Provide safety measures
  7. Encourage the use of oresol
  1. To gain trust
  2. To obtain maintenance data
  3. To replace lost fluids
  4. Prevents peak in fluid level
  5. To ensure accurate picture of fluid status
  6. Confusion can lead to accidents
  7. To replace loss electrolyte.
Short term:The patient identified risk factors and appropriate interventionsLong term:The patient demonstrated behaviors or lifestyle changes to prevent development of fluid volume deficit

6 COMMENTS

  1. very good..!!! as a nursing student, you helped me a lot. it answered my question. very good very good!!!! thank you thank you.

Leave a Reply