About
Surgical removal of the spleen usually due to trauma, history of blood disorders, or ruptured spleen.
Assess
Abdomen, bowels sounds, incision ( redness, drainage, bleeding, bruising), vital signs, pulse oximetry, pain levels, lung sounds
Complications
Pneumonia, atelectasis, abscess, blood clots, infection
Diagnosis
- Acute pain related to actual tissue damage
- Risk for infection related to surgical procedure
- Deficient knowledge related to post surgical treatment regimen
- Impaired skin integrity related to surgical intervention.
Goals
- The client will understand pre-, intra-, and post-operative instructions.
- The client will remain free from post-operative complications.
- The client will have incision closed, well approximated without evidence of bruising or bleeding.
- The client will perform coughing and deep breathing exercises at least ten times an hour while awake.
Interventions
- Monitor vital signs every 15 minutes X 2, 30 minutes X2, one hour X2, than every 4 hours ( may have different guidelines for each clinical agency).
- Monitor for signs and symptoms of infection.
- Assess lung sounds, pulse oximetry, bowel sounds, circulation frequently.
- Implement incentive spirometry pre-operatively.
- Encourage to do IS post-operatively at least ten times an hour.
- Teach abdominal splinting.
- Apply elastic compression stockings and/or sequential compression device as ordered.
- Maintain NPO prior to surgery and start with clear liquids after surgery.
- Encourage early ambulation to avoid complications.
- Teach client signs and symptoms requiring immediate follow-up by a health care provider.
- Monitor for signs/ symptoms of complications.
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