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    13 Surgery (Perioperative Client) Nursing Care Plans

    By Matt Vera, RN-

    Mar 1, 2014

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    !r"ica# i$ter%e$tio$&ay be $ee'e' to 'ia"$o(e or c!re a ()eci*c 'i(ea(e )roce((,

    correct a 'e+or&ity, re(tore a +!$ctio$a# )roce(( or re'!ce te #e%e# o+ 'y(+!$ctio$

    .#to!" (!r"ery i( "e$era##y e#ecti%e or )re)#a$$e', )ote$tia##y #i+e-treate$i$"

    co$'itio$( ca$ ari(e, re/!iri$" e&er"e$cy i$ter%e$tio$ N!r(e( a%e a %ariety o+

    ro#e( a$' +!$ctio$( a((ociate' wit te )atie$t( (!r"ica# &a$a"e&e$t N!r(e(

    )ro%i'e care o+ a c#ie$t be+ore, '!ri$", a$' a+ter (!r"ica# o)eratio$, ti( i(co##ecti%e#y ca##e' a( erio)erati%e N!r(i$" t i( a ()ecia#ie' $!r(i$" area werei$

    a re"i(tere' $!r(e work( a( a tea& &e&ber o+ oter (!r"ica# ea#t care

    )ro+e((io$a#( .b(e$ce or #i&itatio$ o+ )reo)erati%e )re)aratio$ a$' teaci$"

    i$crea(e( te $ee' +or )o(to)erati%e (!))ort i$ a''itio$ to &a$a"i$" !$'er#yi$"

    &e'ica# co$'itio$(

    Nursing Care Plans

    ere are 13 )erio)erati%e $!r(i$" care )#a$( N

    1. Defcient Knowledge

    Nursing Diagnosis

    e*cie$t $ow#e'"e :reo)erati%e;

    May e related to

    reca##, i$+or&atio$ &i(i$ter)retatio$

    ?$+a&i#iarity wit i$+or&atio$ re(o!rce(

    Possily evidenced y

    tate&e$t o+ te )rob#e&>co$cer$(, &i(co$ce)tio$(

    Re/!e(t +or i$+or&atio$

    $a))ro)riate, e=a""erate' bea%ior( e", a"itate', a)atetic, o(ti#e

    $acc!rate +o##ow-tro!" o+ i$(tr!ctio$(>'e%e#o)&e$t o+ )re%e$tab#e

    co&)#icatio$(

    Desired !utco"es

    Verba#ie !$'er(ta$'i$" o+ 'i(ea(e )roce((>)erio)erati%e )roce(( a$')o(to)erati%e e=)ectatio$(

    orrect#y )er+or& $ece((ary )roce'!re( a$' e=)#ai$ rea(o$( +or te actio$(

    $itiate $ece((ary #i+e(ty#e ca$"e( a$' )artici)ate i$ treat&e$t re"i&e$

    http://nurseslabs.com/perioperative-nursing/http://nurseslabs.com/perioperative-nursing/http://nurseslabs.com/perioperative-nursing/http://nurseslabs.com/perioperative-nursing/
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    Nursing #nterventions $ationale

    .((e(( )atie$t( #e%e# o+ !$'er(ta$'i$"

    Faci#itate( )#a$$i$" o+ )reo)erati%e

    teaci$" )ro"ra&, i'e$ti*e( co$te$t

    $ee'(

    Re%iew ()eci*c )ato#o"y a$'

    a$tici)ate' (!r"ica# )roce'!re Veri+y tat

    a))ro)riate co$(e$t a( bee$ (i"$e'

    ro%i'e( k$ow#e'"e ba(e +ro& wic

    )atie$t ca$ &ake i$+or&e' tera)y

    coice( a$' co$(e$t +or )roce'!re, a$'

    )re(e$t( o))ort!$ity to c#ari+y

    &i(co$ce)tio$(

    ?(e re(o!rce teaci$" &ateria#(,

    a!'io%i(!a#( a( a%ai#ab#e

    )eci*ca##y 'e(i"$e' &ateria#( ca$

    +aci#itate te )atie$t( #ear$i$"

    Implement individualized preoperative teaching program:

    reo)erati%e or )o(to)erati%e )roce'!re(a$' e=)ectatio$(, !ri$ary a$' bowe#

    ca$"e(, 'ietary co$(i'eratio$(, acti%ity

    #e%e#(> tra$(+er(, re()iratory>

    car'io%a(c!#ar e=erci(e(@ a$tici)ate' V

    #i$e( a$' t!be( $a(o"a(tric :NA; t!be(,

    'rai$(, a$' cateter(

    $a$ce( )atie$t( !$'er(ta$'i$" or

    co$tro# a$' ca$ re#ie%e (tre(( re#ate' to

    te !$k$ow$ or !$e=)ecte'

    reo)erati%e i$(tr!ctio$(C ND ti&e,

    (ower or (ki$ )re)aratio$, wic ro!ti$e

    &e'icatio$( to take a$' o#',

    )ro)y#actic a$tibiotic(, ora$ticoa"!#a$t(, a$e(te(ia

    )re&e'icatio$

    e#)( re'!ce te )o((ibi#ity o+

    )o(to)erati%e co&)#icatio$( a$'

    )ro&ote( a ra)i' ret!r$ to $or&a# bo'y

    +!$ctio$ NoteC $ (o&e i$(ta$ce(, #i/!i'(a$' &e'icatio$( are a##owe' !) to 2 r

    be+ore (ce'!#e' )roce'!re

    $trao)erati%e )atie$t (a+etyC $ot cro((i$"

    #e"( '!ri$" )roce'!re( )er+or&e' !$'er

    #oca# or #i"t a$e(te(ia

    Re'!ce' ri(k o+ co&)#icatio$( or

    !$towar' o!tco&e(, (!c a( i$E!ry to te

    )ero$ea# a$' tibia# $er%e( wit

    )o(to)erati%e )ai$ i$ te ca#%e( a$' +eet

    =)ecte' or tra$(ie$t reactio$( #ow

    backace, #oca#ie' $!&b$e(( a$'

    re''e$i$" or (ki$ i$'e$tatio$(

    Mi$or eect( o+ i&&obi#iatio$ a$'

    )o(itio$i$" (o!#' re(o#%e i$ 24 r + tey

    )er(i(t, &e'ica# e%a#!atio$ i( re/!ire'

    $+or& )atie$t or D abo!t iti$erary,

    )y(icia$>D co&&!$icatio$(

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    Nursing #nterventions $ationale

    )re%e$ti$" co$+!(io$ a$' 'o!bt o%er

    )atie$t( we##-bei$"

    i(c!(( i$'i%i'!a# )o(to)erati%e )ai$

    &a$a"e&e$t )#a$ 'e$ti+y

    &i(co$ce)tio$( )atie$t &ay a%e a$'

    )ro%i'e a))ro)riate i$+or&atio$

    $crea(e( #ike#ioo' o+ (!cce((+!# )ai$

    &a$a"e&e$t o&e )atie$t( &ay e=)ect

    to be )ai$-+ree or +ear beco&i$" a''icte'

    to $arcotic a"e$t(

    ro%i'e o))ort!$ity to )ractice co!"i$",

    'ee)-breati$", a$' &!(c!#ar e=erci(e(

    $a$ce( #ear$i$" a$' co$ti$!atio$ o+

    acti%ity )o(to)erati%e#y

    %. &ear'niety

    Nursing Diagnosis

    Fear

    .$=iety

    May e related to

    it!atio$a# cri(i(@ !$+a&i#iarity wit e$%iro$&e$t

    a$"e i$ ea#t (tat!(@ treat o+ 'eat

    e)aratio$ +ro& !(!a# (!))ort (y(te&(

    Possily evidenced y

    $crea(e' te$(io$, a))ree$(io$, 'ecrea(e' (e#+-a((!ra$ce

    =)re((e' co$cer$ re"ar'i$" ca$"e(, +ear o+ co$(e/!e$ce(

    Facia# te$(io$, re(t#e(($e((, +oc!( o$ (e#+

    y&)atetic (ti&!#atio$

    Desired !utco"es

    .ck$ow#e'"e +ee#i$"( a$' i'e$ti+y ea#ty way( to 'ea# wit te&

    .))ear re#a=e', ab#e to re(t>(#ee) a))ro)riate#y

    Re)ort 'ecrea(e' +ear a$' a$=iety re'!ce' to a &a$a"eab#e #e%e#

    Nursing #nterventions $ationale

    ro%i'e )reo)erati%e e'!catio$, i$c#!'i$" a$ )ro%i'e rea((!ra$ce a$' a##e%iate

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    Nursing #nterventions $ationale

    %i(it wit DR )er(o$$e# be+ore (!r"ery

    we$ )o((ib#e i(c!(( a$tici)ate' ti$"(

    tat &ay co$cer$ )atie$tC &a(k(, #i"t(,

    V(, B c!, e#ectro'e(, bo%ie )a', +ee# o+o=y"e$ ca$$!#a or &a(k o$ $o(e or +ace,

    a!toc#a%e a$' (!ctio$ $oi(e(, ci#'

    cryi$"

    )atie$t( a$=iety, a( we## a( )ro%i'e

    i$+or&atio$ +or +or&!#ati$" i$trao)erati%e

    care .ck$ow#e'"e( tat +orei"$e$%iro$&e$t &ay be +ri"te$i$",

    a##e%iate( a((ociate' +ear(

    $+or& )atie$t or D o+ $!r(e(

    i$trao)erati%e a'%ocate ro#e

    e%e#o)( tr!(t a$' ra))ort, 'ecrea(i$"

    +ear o+ #o(( o+ co$tro# i$ a +orei"$

    e$%iro$&e$t

    'e$ti+y +ear #e%e#( tat &ay $ece((itate

    )o(t)o$e&e$t o+ (!r"ica# )roce'!re

    D%erwe#&i$" or )er(i(te$t +ear( re(!#t

    i$ e=ce((i%e (tre(( reactio$, )ote$tiati$"

    ri(k o+ a'%er(e reactio$ to )roce'!re

    a$'>or a$e(tetic a"e$t(

    Va#i'ate (o!rce o+ +ear ro%i'e acc!rate

    +act!a# i$+or&atio$

    'e$ti*catio$ o+ ()eci*c +ear e#)( )atie$t

    'ea# rea#i(tica##y wit it atie$t &ay a%e

    &i(i$ter)rete' )reo)erati%e i$+or&atio$

    or a%e &i(i$+or&atio$ re"ar'i$" (!r"ery

    Fear( re"ar'i$" )re%io!( e=)erie$ce( o+

    (e#+ or +a&i#y &ay be re(o#%e'

    Note e=)re((io$( o+ 'i(tre(( a$' +ee#i$"(

    o+ e#)#e(($e((, )reocc!)atio$ wit

    a$tici)ate' ca$"e or #o((, coke'

    +ee#i$"(

    atie$t &ay a#rea'y be "rie%i$" +or te

    #o(( re)re(e$te' by te a$tici)ate'

    (!r"ica# )roce'!re, 'ia"$o(i( or

    )ro"$o(i( o+ i##$e((

    Te## )atie$t a$tici)ati$" #oca# or ()i$a#

    a$e(te(ia tat 'row(i$e(( a$' (#ee)

    occ!r(, tat &ore (e'atio$ &ay be

    re/!e(te' a$' wi## be "i%e$ i+ $ee'e',

    a$' tat (!r"ica# 'ra)e( wi## b#ock %iew o+

    te o)erati%e *e#'

    Re'!ce( co$cer$( tat )atie$t &ay G(eeH

    te )roce'!re

    $tro'!ce (ta at ti&e o+ tra$(+er to

    o)erati$" (!ite

    (tab#i(e( ra))ort a$' )(yco#o"ica#

    co&+ort

    o&)are (!r"ery (ce'!#e, )atie$t

    i'e$ti*catio$ ba$', cart, a$' (i"$e'

    o)erati%e co$(e$t +or (!r"ica# )roce'!re

    ro%i'e( +or )o(iti%e i'e$ti*catio$,

    re'!ci$" +ear tat wro$" )roce'!re &ay

    be 'o$e

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    Nursing #nterventions $ationale

    re%e$t !$$ece((ary bo'y e=)o(!re

    '!ri$" tra$(+er a$' i$ DR (!ite

    atie$t( are co$cer$e' abo!t #o(( o+

    'i"$ity a$' i$abi#ity to e=erci(e co$tro#

    Ai%e (i&)#e, co$ci(e 'irectio$( a$'

    e=)#a$atio$( to (e'ate' )atie$t Re%iew

    e$%iro$&e$ta# co$cer$( a( $ee'e'

    &)air&e$t o+ to!"t )roce((e( &ake(

    it 'iIc!#t +or )atie$t to !$'er(ta$'

    #e$"ty i$(tr!ctio$(

    o$tro# e=ter$a# (ti&!#i=tra$eo!( $oi(e( a$' co&&otio$ &ay

    acce#erate a$=iety

    Re+er to )a(tora# ()irit!a# care,

    )(yciatric $!r(e, c#i$ica# ()ecia#i(t,

    )(yciatric co!$(e#i$" i+ i$'icate'

    May be 'e(ire' or re/!ire' +or )atie$t to

    'ea# wit +ear, e()ecia##y co$cer$i$" #i+e-

    treate$i$" co$'itio$(, (erio!( a$'>or

    i"-ri(k )roce'!re(

    i(c!(( )o(t)o$e&e$t or ca$ce##atio$ o+(!r"ery wit )y(icia$, a$e(te(io#o"i(t,

    )atie$t, a$' +a&i#y a( a))ro)riate

    May be $ece((ary i+ o%erwe#&i$" +ear(

    are $ot re'!ce' or re(o#%e'

    Administer medications as indicated, e.g.:

    e'ati%e(, y)$otic(

    ?(e' to )ro&ote (#ee) te e%e$i$"

    be+ore (!r"ery@ &ay e$a$ce co)i$"

    abi#itie(

    V a$tia$=iety a"e$t(

    May be )ro%i'e' i$ te o!t)atie$t

    a'&itti$" or )reo)erati%e o#'i$" area to

    re'!ce $er%o!($e(( a$' )ro%i'e

    co&+ort NoteC Re()iratory 'e)re((io$

    a$'>or bra'ycar'ia &ay occ!r,

    $ece((itati$" )ro&)t i$ter%e$tio$

    3. $is* +or #n,ury

    Nursing Diagnosis

    erio)erati%e o(itio$i$", ri(k +or i$E!ry

    $is* +actors "ay include

    i(orie$tatio$@ (e$(ory>)erce)t!a# 'i(t!rba$ce( '!e to a$e(te(ia

    &&obi#iatio$@ &!(c!#o(ke#eta# i&)air&e$t(

    Dbe(ity>e&aciatio$@ e'e&a

    Possily evidenced y

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    Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

    the problem has not occurred and nursing interventions are directed at

    prevention.

    Desired !utco"es

    Be +ree o+ i$E!ry re#ate' to )erio)erati%e 'i(orie$tatio$

    Be +ree o+ !$towar' (ki$>ti((!e i$E!ry or ca$"e( #a(ti$" beyo$' 24J48 r

    +o##owi$" )roce'!re

    Re)ort re(o#!tio$ o+ #oca#ie' $!&b$e((, ti$"#i$", or ca$"e( i$ (e$(atio$

    re#ate' to )o(itio$i$" witi$ 24J48 r a( a))ro)riate

    Nursing #nterventions $ationale

    Note a$tici)ate' #e$"t o+ )roce'!re a$'c!(to&ary )o(itio$ Be aware o+ )ote$tia#

    co&)#icatio$(

    !)i$e )o(itio$ &ay ca!(e #ow back )ai$

    a$' (ki$ )re((!re at ee#(, e#bow(, or(acr!&@ #atera# ce(t )o(itio$ ca$ ca!(e

    (o!#'er a$' $eck )ai$, )#!( eye a$' ear

    i$E!ry o$ te )atie$t( 'ow$(i'e

    Re%iew )atie$t( i(tory, $oti$" a"e,

    wei"t, ei"t, $!tritio$a# (tat!(, )y(ica#

    #i&itatio$ a$' )ree=i(ti$" co$'itio$( tat

    &ay aect coice o+ )o(itio$ a$' (ki$ or

    ti((!e i$te"rity '!ri$" (!r"ery

    #'er#y )er(o$(, #ack o+ (!bc!ta$eo!(

    )a''i$", artriti(, 'iabete(, obe(ity,

    ab'o&i$a# (to&a, y'ratio$ (tat!( a$'

    te&)erat!re are (o&e +actor(

    tabi#ie bot )atie$t cart a$' DR tab#ewe$ tra$(+erri$" )atie$t to a$' +ro& DR

    tab#e, !(i$" a$ a'e/!ate $!&ber o+

    )er(o$$e# +or tra$(+er a$' (!))ort o+

    e=tre&itie(

    ?$(tabi#ie' cart or tab#e ca$ (e)arate,ca!(i$" )atie$t to +a## Bot (i'e rai#(

    &!(t be i$ te 'ow$ )o(itio$ +or

    care"i%er( to a((i(t )atie$t tra$(+er a$'

    )re%e$t #o(( o+ ba#a$ce

    .$tici)ate &o%e&e$t o+ e=tra$eo!( #i$e(

    a$' t!be( '!ri$" te tra$(+er a$' (ec!re

    or "!i'e te& i$to )o(itio$

    re%e$t( !$'!e te$(io$ a$' 'i(#ocatio$ o+

    V #i$e(, NA t!be(, cateter(, a$' ce(t

    t!be(@ &ai$tai$( "ra%ity 'rai$a"e we$

    a))ro)riate

    ec!re )atie$t o$ DR tab#e wit (a+ety

    be#t a( a))ro)riate, e=)#ai$i$" $ece((ity

    +or re(trai$t

    DR tab#e( a$' ar& boar'( are $arrow,

    )#aci$" )atie$t at ri(k +or i$E!ry,

    e()ecia##y '!ri$" +a(cic!#atio$ atie$t

    &ay beco&e re(i(ti%e or co&bati%e we$

    (e'ate' or e&er"i$" +ro& a$e(te(ia,

    +!rteri$" )ote$tia# +or i$E!ry

    rotect bo'y +ro& co$tact wit &eta# Re'!ce( ri(k o+ e#ectrica# i$E!ry

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    Nursing #nterventions $ationale

    )art( o+ te o)erati$" tab#e

    re)are e/!i)&e$t a$' )a''i$" +or

    re/!ire' )o(itio$, accor'i$" to o)erati%e

    )roce'!re a$' )atie$t( ()eci*c $ee'(

    ay ()ecia# atte$tio$ to )re((!re )oi$t( o+

    bo$y )ro&i$e$ce( ar&(, a$k#e( a$'

    $e!ro%a(c!#ar )re((!re )oi$t( brea(t(,

    k$ee(

    e)e$'i$" o$ i$'i%i'!a# )atie$t( (ie,

    wei"t, a$' )ree=i(ti$" co$'itio$(, e=tra

    )a''i$" &ateria#( &ay be re/!ire' to

    )rotect bo$y )ro&i$e$ce(, )re%e$t

    circ!#atory co&)ro&i(e a$' $er%e

    )re((!re, or a##ow +or o)ti&!& ce(t

    e=)a$(io$ +or %e$ti#atio$

    o(itio$ e=tre&itie( (o tey &ay be

    )erio'ica##y cecke' +or (a+ety,

    circ!#atio$, $er%e )re((!re, a$'

    a#i"$&e$t Mo$itor )eri)era# )!#(e(, (ki$co#or a$' te&)erat!re

    re%e$t( acci'e$ta# tra!&a, a$'(,

    *$"er(, a$' toe( co!#' i$a'%erte$t#y be

    (cra)e', )i$ce', or a&)!tate' by

    &o%i$" tab#e attac&e$t(@ )o(itio$a#

    )re((!re o+ bracia# )#e=!(, )ero$ea#, a$'

    !#$ar $er%e( ca$ ca!(e (erio!( )rob#e&(

    wit e=tre&itie(@ )ro#o$"e' )#a$tar

    Ke=io$ &ay re(!#t i$ +oot 'ro)

    #ace #e"( i$ (tirr!)( (i&!#ta$eo!(#y

    we$ #itoto&y )o(itio$ !(e', a'E!(ti$"

    (tirr!) ei"t to )atie$t( #e"(,

    &ai$tai$i$" (y&&etrica# )o(itio$ a'

    )o)#itea# ()ace a$' ee#( a$'>or +eet a(

    i$'icate'

    re%e$t( &!(c#e (trai$@ re'!ce( ri(k o+

    i) 'i(#ocatio$ i$ e#'er#y )atie$t(

    a''i$" e#)( )re%e$t )ero$ea# a$' tibia#

    $er%e 'a&a"e NoteC ro#o$"e'

    )o(itio$i$" i$ (tirr!)( &ay #ea' to

    co&)art&e$t (y$'ro&e i$ ca#+ &!(c#e(

    ro%i'e +ootboar' a$'>or e#e%ate 'ra)e(

    o toe( .%oi' a$' &o$itor )#ace&e$t o+

    e/!i)&e$t, i$(tr!&e$tatio$ o$ tr!$k a$'

    e=tre&itie( '!ri$" )roce'!re

    o$ti$!o!( )re((!re &ay ca!(e $e!ra#,

    circ!#atory, a$' (ki$ i$te"rity 'i(r!)tio$

    Re)o(itio$ (#ow#y at tra$(+er +ro& tab#e

    a$' i$ be' e()ecia##y a#ota$e-

    a$e(tetie' )atie$t

    Myocar'ia# 'e)re((a$t eect o+ %ario!(

    a"e$t( i$crea(e( ri(k o+ y)ote$(io$

    a$'>or bra'ycar'ia

    eter&i$e ()eci*c )o(to)erati%e

    )o(itio$i$" "!i'e#i$e(, e#e%atio$ o+ ea'

    o+ be' +o##owi$" ()i$a# a$e(te(ia, t!r$ to

    !$o)erate' (i'e +o##owi$"

    )$e!&o$ecto&y

    Re'!ce( ri(k o+ )o(to)erati%e

    co&)#icatio$(, e", ea'ace a((ociate'wit &i"ratio$ o+ ()i$a# a$e(te(ia, or

    #o(( o+ &a=i&a# re()iratory eort

    Reco&&e$' )o(itio$ ca$"e( to

    a$e(te(io#o"i(t a$'>or (!r"eo$ a(

    a))ro)riate

    #o(e atte$tio$ to )ro)er )o(itio$i$" ca$

    )re%e$t &!(c#e (trai$, $er%e 'a&a"e,

    circ!#atory co&)ro&i(e, a$' !$'!e

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    Nursing #nterventions $ationale

    )re((!re o$ (ki$ a$'>or bo$y

    )ro&i$e$ce( .#to!" te

    a$e(te(io#o"i(t i( re()o$(ib#e +or

    )o(itio$i$", te $!r(e &ay be ab#e to (eea$' a%e &ore ti&e to $ote )atie$t

    $ee'(, a$' )ro%i'e a((i(ta$ce

    -. $is* +or #n,ury

    $is* +actors "ay include

    $teracti%e co$'itio$( betwee$ i$'i%i'!a# a$' e$%iro$&e$t

    =ter$a# e$%iro$&e$t, e", )y(ica# 'e(i"$, (tr!ct!re o+ e$%iro$&e$t,

    e=)o(!re to e/!i)&e$t, i$(tr!&e$tatio$, )o(itio$i$", !(e o+ )ar&ace!tica#

    a"e$t(

    $ter$a# e$%iro$&e$t, e", ti((!e y)o=ia, ab$or&a# b#oo' )ro*#e>a#tere'

    c#otti$" +actor(, broke$ (ki$

    Possily evidenced y

    Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

    the problem has not occurred and nursing interventions are directed at

    prevention.

    Desired !utco"es

    'e$ti+y i$'i%i'!a# ri(k +actor(

    Mo'i+y e$%iro$&e$t a( i$'icate' to e$a$ce (a+ety a$' !(e re(o!rce(

    a))ro)riate#y

    Nursing #nterventions $ationale

    Re&o%e 'e$t!re(, )artia# )#ate( or

    bri'"e( )reo)erati%e#y )er )rotoco#

    $+or& a$e(te(io#o"i(t o+ )rob#e&( wit

    $at!ra# teet or #oo(e teet

    Forei"$ bo'ie( &ay be a()irate' '!ri$"

    e$'otracea# i$t!batio$ or e=t!batio$

    Re&o%e )ro(tetic(, oter 'e%ice(

    )reo)erati%e#y or a+ter i$'!ctio$,

    'e)e$'i$" o$ (e$(ory or )erce)t!a#

    a#teratio$( a$' &obi#ity i&)air&e$t

    o$tact #e$(e( &ay ca!(e cor$ea#

    abra(io$( wi#e !$'er a$e(te(ia@

    eye"#a((e( a$' eari$" ai'( are

    ob(tr!cti%e a$' &ay break@ owe%er,

    )atie$t( &ay +ee# &ore i$ co$tro# o+

    e$%iro$&e$t i+ eari$" a$' %i(!a# ai'(

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    Nursing #nterventions $ationale

    are #e+t o$ a( #o$" a( )o((ib#e .rti*cia#

    #i&b( &ay be 'a&a"e' a$' (ki$ i$te"rity

    i&)aire' i+ #e+t o$

    Re&o%e Eewe#ry )reo)erati%e#y or ta)e

    o%er a( a))ro)riate

    Meta#( co$'!ct e#ectrica# c!rre$t a$'

    )ro%i'e a$ e#ectroca!tery aar' $

    a''itio$, #o(( or 'a&a"e to )atie$t(

    )er(o$a# )ro)erty ca$ ea(i#y occ!r i$ te

    +orei"$ e$%iro$&e$t NoteC $ (o&e ca(e(

    e", artritic k$!ck#e(, it &ay $ot be

    )o((ib#e to re&o%e ri$"( wito!t c!tti$"

    te& o $ ti( (it!atio$, a))#yi$" ta)e

    o%er te ri$" &ay )re%e$t )atie$t +ro&

    Gcatci$"H ri$" a$' )re%e$t #o(( o+ (to$e

    or 'a&a"e to *$"er

    Veri+y )atie$t i'e$tity a$' (ce'!#e'

    o)erati%e )roce'!re by co&)ari$"

    )atie$t cart, ar& ba$', a$' (!r"ica#

    (ce'!#e Verba##y a(certai$ correct

    $a&e, )roce'!re, o)erati%e (ite, a$'

    )y(icia$

    .((!re( correct )atie$t, )roce'!re, a$'

    a))ro)riate e=tre&ity or (i'e

    oc!&e$t a##er"ie(, i$c#!'i$" ri(k +or

    a'%er(e reactio$ to #ate=, ta)e, a$' )re)

    (o#!tio$(

    Re'!ce( ri(k +or a##er"ic re()o$(e( tat

    &ay i&)air (ki$ i$te"rity or #ea' to #i+e-

    treate$i$" (y(te&ic reactio$(

    Ai%e (i&)#e a$' co$ci(e 'irectio$( to te

    (e'ate' )atie$t

    &)air&e$t o+ to!"t )roce(( &ake( it

    'iIc!#t +or )atie$t to !$'er(ta$' #e$"ty

    'irectio$(

    re%e$t )oo#i$" o+ )re) (o#!tio$( !$'er

    a$' aro!$' )atie$t

    .$ti(e)tic (o#!tio$( &ay ce&ica##y b!r$

    (ki$, a( we## a( co$'!ct e#ectricity

    .((i(t wit i$'!ctio$ a( $ee'e'C (ta$' by

    to a))#y cricoi' )re((!re '!ri$"

    i$t!batio$ or (tabi#ie )o(itio$ '!ri$"

    #!&bar )!$ct!re +or ()i$a# b#ock

    Faci#itate( (a+e a'&i$i(tratio$ o+

    a$e(te(ia

    .(certai$ e#ectrica# (a+ety o+ e/!i)&e$t

    !(e' i$ (!r"ica# )roce'!reC i$tact cor'(,

    "ro!$'(, &e'ica# e$"i$eeri$" %eri*catio$

    #abe#(

    Ma#+!$ctio$ o+ e/!i)&e$t ca$ occ!r

    '!ri$" te o)erati%e )roce'!re, ca!(i$"

    $ot o$#y 'e#ay( a$' !$$ece((ary

    a$e(te(ia b!t a#(o i$E!ry or 'eat, (ort

    circ!it(, +a!#ty "ro!$'(, #a(er

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    Nursing #nterventions $ationale

    &a#+!$ctio$(, or #a(er &i(a#i"$&e$t

    erio'ic e#ectrica# (a+ety ceck( are

    i&)erati%e +or a## DR e/!i)&e$t

    #ace 'i()er(i%e e#ectro'e e#ectroca!tery

    )a' o%er "reate(t a%ai#ab#e &!(c#e

    &a((, e$(!ri$" it( co$tact

    ro%i'e( a "ro!$' +or &a=i&!&

    co$'!cti%ity to )re%e$t e#ectrica# b!r$(

    o$*r& a$' 'oc!&e$t correct ()o$"e,

    i$(tr!&e$t, $ee'#e, a$' b#a'e co!$t(

    Forei"$ bo'ie( re&ai$i$" i$ bo'y ca%itie(

    at c#o(!re $ot o$#y ca!(e i$Ka&&atio$,

    i$+ectio$, )er+oratio$, a$' ab(ce((

    +or&atio$, 'i(a(tro!( co&)#icatio$( tat

    #ea' to 'eat

    Veri+y cre'e$tia#( o+ #a(er o)erator( +or

    ()eci*c wa%e#e$"t #a(er re/!ire' +or

    )artic!#ar )roce'!re

    Beca!(e o+ te )ote$tia# aar'( o+ #a(er,

    )y(icia$ a$' e/!i)&e$t o)erator( &!(tbe certi*e' i$ te !(e a$' (a+ety

    re/!ire&e$t( o+ ()eci*c wa%e#e$"t #a(er

    a$' )roce'!re, o)e$, e$'o(co)ic,

    ab'o&i$a#, #ary$"ea#, i$tra!teri$e

    o$*r& )re(e$ce o+ *re e=ti$"!i(er(

    a$' wet *re (&oteri$" &ateria#( we$

    #a(er( are !(e' i$trao)erati%e#y

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    Nursing #nterventions $ationale

    Mo$itor i$take a$' o!t)!t LD '!ri$"

    )roce'!re .(certai$ tat i$+!(io$ )!&)(

    are +!$ctio$i$" acc!rate#y

    ote$tia# +or K!i' %o#!&e 'e*cit or e=ce((

    e=i(t(, aecti$" (a+ety o+ a$e(te(ia,

    or"a$ +!$ctio$, a$' )atie$t we##-bei$"

    .'&i$i(ter V K!i'(, b#oo', b#oo'

    co&)o$e$t(, a$' &e'icatio$( a(

    i$'icate'

    e#)( &ai$tai$ o&eo(ta(i( a$'

    a'e/!ate #e%e# o+ (e'atio$ a$'>or &!(c#e

    re#a=atio$ to )ro'!ce o)ti&a# (!r"ica#

    o!tco&e

    o##ect b#oo' i$trao)erati%e#y a(

    a))ro)riate

    B#oo' #o(t i$trao)erati%e#y &ay be

    co##ecte', *#tere', a$' rei$+!(e' eiter

    i$trao)erati%e#y or )o(to)erati%e#y NoteC

    .#ter$ati%e#y re' b#oo' ce## RB

    )ro'!ctio$ &ay be i$crea(e' by te

    a'&i$i(tratio$ o+ e)oeti$ D, re'!ci$"

    te $ee' +or b#oo' tra$(+!(io$ weter

    a!to#o"o!( or 'o$ate'

    .'&i$i(ter a$taci'(, 2b#ocker,

    )reo)erati%e#y a( i$'icate'

    Ne!tra#ie( "a(tric aci'ity a$' &ay

    re'!ce ri(k o+ a()iratio$ or (e%erity o+

    )$e!&o$ia (o!#' a()iratio$ occ!r,

    e()ecia##y i$ obe(e or )re"$a$t )atie$t(

    i$ wo& tere i( a$ 85 ri(k o+ &orta#ity

    wit a()iratio$

    co$ta&i$a$t(, e$%iro$&e$ta# e=)o(!re, i$%a(i%e

    )roce'!re(

    Possily evidenced y

    Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

    the problem has not occurred and nursing interventions are directed at

    prevention.

    Desired !utco"es

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    'e$ti+y i$'i%i'!a# ri(k +actor( a$' i$ter%e$tio$( to re'!ce )ote$tia# +or

    i$+ectio$

    Mai$tai$ (a+e a(e)tic e$%iro$&e$t

    Nursing #nterventions $ationale

    .'ere to +aci#ity i$+ectio$ co$tro#,

    (teri#iatio$, a$' a(e)tic )o#icie( a$'

    )roce'!re(

    (tab#i(e' &eca$i(&( 'e(i"$e' to

    )re%e$t i$+ectio$

    Veri+y (teri#ity o+ a## &a$!+act!rer( ite&(

    re)acka"e' ite&( &ay a))ear to be

    (teri#e@ owe%er, eac ite& &!(t be

    (cr!ti$ie' +or &a$!+act!rer( (tate&e$t

    o+ (teri#ity, break( i$ )acka"i$",

    e$%iro$&e$ta# eect o$ )acka"e, a$'

    'e#i%ery tec$i/!e( acka"e (teri#iatio$

    a$' e=)iratio$ 'ate(, #ot>(eria# $!&ber(

    &!(t be 'oc!&e$te' o$ i&)#a$t ite&(

    +or +!rter +o##ow-!) i+ $ece((ary

    Re%iew #aboratory (t!'ie( +or )o((ibi#ity

    o+ (y(te&ic i$+ectio$(

    $crea(e' B co!$t &ay i$'icate

    o$"oi$" i$+ectio$, wic te o)erati%e

    )roce'!re wi## a##e%iate a))e$'iciti(,

    ab(ce((, i$Ka&&atio$ +ro& tra!&a@ or

    )re(e$ce o+ (y(te&ic or or"a$ i$+ectio$,

    wic &ay co$trai$'icate or i&)act

    (!r"ica# )roce'!re a$'>or a$e(te(ia

    )$e!&o$ia, ki'$ey i$+ectio$

    Veri+y tat )reo)erati%e (ki$, %a"i$a#, a$'

    bowe# c#ea$(i$" )roce'!re( a%e bee$

    'o$e a( $ee'e' 'e)e$'i$" o$ ()eci*c

    (!r"ica# )roce'!re

    #ea$(i$" re'!ce( bacteria# co!$t( o$ te

    (ki$, %a"i$a# &!co(a, a$' a#i&e$tary

    tract

    re)are o)erati%e (ite accor'i$" to

    ()eci*c )roce'!re(

    Mi$i&ie( bacteria# co!$t( at o)erati%e

    (ite

    =a&i$e (ki$ +or break( or irritatio$,

    (i"$( o+ i$+ectio$

    i(r!)tio$( o+ (ki$ i$te"rity at or $ear te

    o)erati%e (ite are (o!rce( o+co$ta&i$atio$ to te wo!$' are+!#

    (a%i$" or c#i))i$" i( i&)erati%e to

    )re%e$t abra(io$( a$' $ick( i$ te (ki$

    Mai$tai$ 'e)e$'e$t "ra%ity 'rai$a"e o+

    i$'we##i$" cateter(, t!be(, a$'>or

    )o(iti%e )re((!re o+ )are$tera# or

    re%e$t( (ta(i( a$' reK!= o+ bo'y K!i'(

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    Nursing #nterventions $ationale

    irri"atio$ #i$e(

    'e$ti+y break( i$ a(e)tic tec$i/!e a$'

    re(o#%e i&&e'iate#y o$ occ!rre$ce

    o$ta&i$atio$ by e$%iro$&e$ta# or

    )er(o$$e# co$tact re$'er( te (teri#e *e#'

    !$(teri#e, tereby i$crea(i$" te ri(k o+

    i$+ectio$

    o$tai$ co$ta&i$ate' K!i'( a$'

    &ateria#( i$ ()eci*c (ite i$ o)erati$"

    roo& (!ite, a$' 'i()o(e o+ accor'i$" to

    o()ita# )rotoco#

    o$tai$&e$t o+ b#oo' a$' bo'y K!i'(,

    ti((!e, a$' &ateria#( i$ co$tact wit a$

    i$+ecte' wo!$' atie$t wi## )re%e$t

    ()rea' o+ i$+ectio$ to e$%iro$&e$t a$'>or

    oter )atie$t( or )er(o$$e#

    .))#y (teri#e 're((i$"re%e$t( e$%iro$&e$ta# co$ta&i$atio$ o+

    +re( wo!$'

    ro%i'e co)io!( wo!$' irri"atio$, e",

    (a#i$e, water, a$tibiotic, or a$ti(e)tic

    May be !(e' i$trao)erati%e#y to re'!ce

    bacteria# co!$t( at te (ite a$' c#ea$(e

    te wo!$' o+ 'ebri(, e", bo$e, i(ce&ic

    ti((!e, bowe# co$ta&i$a$t(, to=i$(

    Dbtai$ ()eci&e$( +or c!#t!re( or Ara&

    (tai$

    &&e'iate i'e$ti*catio$ o+ ty)e o+

    i$+ecti%e or"a$i(& by Ara& (tai$ a##ow(

    )ro&)t treat&e$t, wi#e &ore ()eci*c

    i'e$ti*catio$ by c!#t!re( ca$ be obtai$e'

    i$ o!r( or 'ay(

    .'&i$i(ter a$tibiotic( a( i$'icate'May be "i%e$ )ro)y#actica##y +or

    (!()ecte' i$+ectio$ or co$ta&i$atio$

    /. $is* +or ltered 0ody e"perature

    Nursing Diagnosis

    Ri(k +or .#tere' Bo'y Te&)erat!re

    $is* +actors "ay include

    =)o(!re to coo# e$%iro$&e$t

    ?(e o+ &e'icatio$(, a$e(tetic a"e$t(

    =tre&e( o+ a"e, wei"t@ 'ey'ratio$

    Possily evidenced y

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    Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

    the problem has not occurred and nursing interventions are directed at

    prevention.

    Desired !utco"es

    Mai$tai$ bo'y te&)erat!re witi$ $or&a# ra$"e

    Nursing #nterventions $ationale

    Note )reo)erati%e te&)erat!re

    ?(e' a( ba(e#i$e +or &o$itori$"

    i$trao)erati%e te&)erat!re reo)erati%e

    te&)erat!re e#e%atio$( are i$'icati%e o+

    'i(ea(e )roce((C a))e$'iciti(, ab(ce((, or

    (y(te&ic 'i(ea(e re/!iri$" treat&e$t

    )reo)erati%e#y, )erio)erati%e#y, a$'

    )o((ib#y )o(to)erati%e#y NoteC ect( o+

    a"i$" o$ y)ota#a&!( &ay 'ecrea(e

    +e%er re()o$(e to i$+ectio$

    .((e(( e$%iro$&e$ta# te&)erat!re a$'

    &o'i+y a( $ee'e'C )ro%i'i$" war&i$"

    a$' coo#i$" b#a$ket(, i$crea(i$" roo&

    te&)erat!re

    May a((i(t i$ &ai$tai$i$" or (tabi#ii$"

    )atie$t( te&)erat!re

    o%er (ki$ area( o!t(i'e o+ o)erati%e

    *e#'

    eat #o((e( wi## occ!r a( (ki$ #e"(, ar&(,

    ea' i( e=)o(e' to coo# e$%iro$&e$t

    ro%i'e coo#i$" &ea(!re( +or )atie$t wit

    )reo)erati%e te&)erat!re e#e%atio$(

    oo# irri"atio$( a$' e=)o(!re o+ (ki$(!r+ace( to air &ay be re/!ire' to

    'ecrea(e te&)erat!re

    Note ra)i' te&)erat!re e#e%atio$ or

    )er(i(te$t i" +e%er a$' treat )ro&)t#y

    )er )rotoco#

    Ma#i"$a$t y)erter&ia &!(t be

    reco"$ie' a$' treate' )ro&)t#y to a%oi'

    (erio!( co&)#icatio$( a$'>or 'eat

    $crea(e a&bie$t roo& te&)erat!re e",

    to 78OF or 80OF at co$c#!(io$ o+

    )roce'!re

    e#)( #i&it )atie$t eat #o(( we$ 'ra)e(

    are re&o%e' a$' )atie$t i( )re)are' +or

    tra$(+er

    .))#y war&i$" b#a$ket( at e&er"e$ce

    +ro& a$e(te(ia

    $a#atio$ a$e(tetic( 'e)re(( te

    y)ota#a&!(, re(!#ti$" i$ )oor bo'y

    te&)erat!re re"!#atio$

    Mo$itor te&)erat!re tro!"o!t

    i$trao)erati%e )a(e

    o$ti$!o!( war& or coo# !&i'i*e'

    i$a#atio$ a$e(tetic( are !(e' to

    &ai$tai$ !&i'ity a$' te&)erat!re

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    Nursing #nterventions $ationale

    ba#a$ce witi$ te traceobro$cia# tree

    Te&)erat!re e#e%atio$ a$' +e%er &ay

    i$'icate a'%er(e re()o$(e to

    a$e(te(ia NoteC ?(e o+ atro)i$e or(co)o#a&i$e &ay +!rter i$crea(e

    te&)erat!re

    ro%i'e ice' (a#i$e a( i$'icate'

    co"$iti%e i&)air&e$t

    ecrea(e' #!$" e=)a$(io$, e$er"y

    Traceobro$cia# ob(tr!ctio$

    Possily evidenced y

    a$"e( i$ re()iratory rate a$' 'e)t

    Re'!ce' %ita# ca)acity, a)$ea, cya$o(i(, $oi(y re()iratio$(

    Desired !utco"es

    (tab#i( a $or&a#>eecti%e re()iratory )atter$ +ree o+ cya$o(i( or oter (i"$(

    o+ y)o=ia

    Nursing #nterventions $ationale

    Mai$tai$ )atie$t airway by ea' ti#t, Eaw

    y)ere=te$(io$, ora# )ary$"ea# airwayre%e$t( airway ob(tr!ctio$

    .!(c!#tate breat (o!$'(

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    Nursing #nterventions $ationale

    (i#e$ce reKect( )artia#-to-tota#

    #ary$"o()a(&

    Db(er%e re()iratory rate a$' 'e)t, ce(t

    e=)a$(io$, !(e o+ acce((ory &!(c#e(,

    retractio$ or Kari$" o+ $o(tri#(, (ki$ co#or@

    $ote airKow

    .(certai$( eecti%e$e(( o+ re()iratio$(i&&e'iate#y (o correcti%e &ea(!re( ca$

    be i$itiate'

    Mo$itor %ita# (i"$( co$ti$!o!(#y$crea(e' re()iratio$(, tacycar'ia,

    a$'>or bra'ycar'ia (!""e(t( y)o=ia

    o(itio$ )atie$t a))ro)riate#y, 'e)e$'i$"

    o$ re()iratory eort a$' ty)e o+ (!r"ery

    ea' e#e%atio$ a$' #e+t #atera# i&(

    )o(itio$ )re%e$t( a()iratio$ o+ (ecretio$(

    or %o&it!(@ e$a$ce( %e$ti#atio$ to #ower

    #obe( a$' re#ie%e( )re((!re o$ 'ia)ra"&

    Db(er%e +or ret!r$ o+ &!(c#e +!$ctio$,

    e()ecia##y re()iratory

    .+ter a'&i$i(tratio$ o+ i$trao)erati%e

    &!(c#e re#a=a$t(, ret!r$ o+ &!(c#e

    +!$ctio$ occ!r( *r(t to te 'ia)ra"&,

    i$terco(ta#(, a$' #ary$=@ +o##owe' by #ar"e

    &!(c#e "ro!)(, $eck, (o!#'er(, a$'

    ab'o&i$a# &!(c#e(@ te$ by &i'(ie

    &!(c#e(, to$"!e, )ary$=, e=te$(or(, a$'

    Ke=or(@ a$' *$a##y by eye(, &o!t, +ace,

    a$' *$"er(

    $itiate G(tir-!)H t!r$, co!", 'ee)

    breate re"i&e$ a( (oo$ a( )atie$t i(

    reacti%e a$' co$ti$!e i$ te

    )o(to)erati%e )erio'

    .cti%e 'ee) %e$ti#atio$ i$Kate( a#%eo#i,break( !) (ecretio$(, i$crea(e(

    D2tra$(+er, a$' re&o%e( a$e(tetic

    "a(e(@ co!"i$" e$a$ce( re&o%a# o+

    (ecretio$( +ro& te )!#&o$ary

    (y(te& NoteC Re()iratory &!(c#e(

    weake$ a$' atro)y wit a"e, )o((ib#y

    a&)eri$" e#'er#y )atie$t( abi#ity to

    co!" or 'ee)-breate eecti%e#y

    Db(er%e +or e=ce((i%e (o&$o#e$ce Narcotic-i$'!ce' re()iratory 'e)re((io$

    or )re(e$ce o+ &!(c#e re#a=a$t( i$ te

    bo'y &ay be cyc#ica# i$ rec!rre$ce,

    creati$" (i$e-wa%e )atter$ o+ 'e)re((io$

    a$' re-e&er"e$ce +ro& a$e(te(ia $

    a''itio$, tio)e$ta# (o'i!& e$tota# i(

    ab(orbe' i$ te +atty ti((!e(, a$', a(

    circ!#atio$ i&)ro%e(, it &ay be

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    Nursing #nterventions $ationale

    re'i(trib!te' tro!"o!t te

    b#oo'(trea&

    #e%ate ea' o+ be' a( a))ro)riate Aeto!t o+ be' a( (oo$ a( )o((ib#e

    ro&ote( &a=i&a# e=)a$(io$ o+ #!$"(,

    'ecrea(i$" ri(k o+ )!#&o$ary

    co&)#icatio$(

    !ctio$ a( $ece((ary.irway ob(tr!ctio$ ca$ occ!r beca!(e o+

    b#oo' or &!c!( i$ troat or tracea

    .'&i$i(ter (!))#e&e$ta# D2a( i$'icate'

    Ma=i&ie( o=y"e$ +or !)take to bi$' wit

    b i$ )#ace o+ a$e(tetic "a(e( to

    e$a$ce re&o%a# o+ i$a#atio$ a"e$t(

    .'&i$i(ter V &e'icatio$(C $a#o=o$e

    Narca$ or 'o=a)ra& o)ra&

    Narca$ re%er(e( $arcotic-i$'!ce' ce$tra#

    $er%o!( (y(te& N 'e)re((io$ a$'o)ra& (ti&!#ate( re()iratory &!(c#e(

    Te eect( o+ bot 'r!"( are cyc#ic i$

    $at!re a$' re()iratory 'e)re((io$ &ay

    ret!r$

    ro%i'e a$' &ai$tai$ %e$ti#ator

    a((i(ta$ce

    e)e$'i$" o$ ca!(e o+ re()iratory

    'e)re((io$ or ty)e o+ (!r"ery

    )!#&o$ary, e=te$(i%e ab'o&i$a#,

    car'iac, e$'otracea# t!be T &ay be

    #e+t i$ )#ace a$' &eca$ica# %e$ti#atio$

    &ai$tai$e' +or a ti&e

    .((i(t wit !(e o+ re()iratory ai'(C

    i$ce$ti%e ()iro&eter

    Ma=i&a# re()iratory eort( re'!ce

    )ote$tia# +or ate#ecta(i( a$' i$+ectio$

    5. ltered Sensory'4oug4t Perception

    Nursing Diagnosis

    .#tere' e$(ory erce)tio$

    .#tere' To!"t erce)tio$

    May e related to

    e&ica# a#teratio$C !(e o+ )ar&ace!tica# a"e$t(, y)o=ia

    Tera)e!tica##y re(tricte' e$%iro$&e$t(@ e=ce((i%e (e$(ory (ti&!#i

    y(io#o"ica# (tre((

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    Possily evidenced y

    i(orie$tatio$ to )er(o$, )#ace, ti&e@ ca$"e i$ !(!a# re()o$(e to (ti&!#i@

    i&)aire' abi#ity to co$ce$trate, rea(o$, &ake 'eci(io$(

    Motor i$coor'i$atio$

    Desired !utco"es

    Re"ai$ !(!a# #e%e# o+ co$(cio!($e((>&e$tatio$

    Reco"$ie #i&itatio$( a$' (eek a((i(ta$ce a( $ece((ary

    Nursing #nterventions $ationale

    Reorie$t )atie$t co$ti$!o!(#y we$

    e&er"i$" +ro& a$e(te(ia@ co$*r& tat

    (!r"ery i( co&)#ete'

    .( )atie$t re"ai$( co$(cio!($e((, (!))ort

    a$' a((!ra$ce wi## e#) a##e%iate a$=iety

    )eak i$ $or&a#, c#ear %oice wito!t

    (o!ti$", bei$" aware o+ wat yo! are

    (ayi$" Mi$i&ie 'i(c!((io$ o+ $e"ati%e(

    witi$ )atie$t( eari$" =)#ai$

    )roce'!re(, e%e$ i+ )atie$t 'oe( $ot

    (ee& aware

    Te $!r(e ca$$ot te## we$ )atie$t i(

    aware, b!t it i( to!"t tat te (e$(e o+

    eari$" ret!r$( be+ore )atie$t a))ear(

    +!##y awake, (o it i( i&)orta$t $ot to (ay

    ti$"( tat &ay be &i(i$ter)rete'

    ro%i'i$" i$+or&atio$ e#)( )atie$t

    )re(er%e 'i"$ity a$' )re)are +or acti%ity

    %a#!ate (e$(atio$ a$'>or &o%e&e$t o+

    e=tre&itie( a$' tr!$k a( a))ro)riate

    Ret!r$ o+ +!$ctio$ +o##owi$" #oca# or ()i$a#

    $er%e b#ock( 'e)e$'( o$ ty)e or a&o!$t

    o+ a"e$t !(e' a$' '!ratio$ o+ )roce'!re

    ?(e be'rai# )a''i$", re(trai$t( a(

    $ece((ary

    ro%i'e( +or )atie$t (a+ety '!ri$"

    e&er"e$ce (tate re%e$t( i$E!ry to ea'

    a$' e=tre&itie( i+ )atie$t beco&e(

    co&bati%e wi#e 'i(orie$te'

    ec!re )are$tera# #i$e(, T t!be,

    cateter(, i+ )re(e$t, a$' ceck +or

    )ate$cy

    i(orie$te' )atie$t &ay )!## o$ #i$e( a$'

    'rai$a"e (y(te&(, 'i(co$$ecti$" or

    ki$ki$" te&

    Mai$tai$ /!iet, ca#& e$%iro$&e$t

    =ter$a# (ti&!#i, (!c a( $oi(e, #i"t(,to!c, &ay ca!(e )(ycic aberratio$(

    we$ 'i((ociati%e a$e(tetic( keta&i$e

    a%e bee$ a'&i$i(tere'

    $%e(ti"ate ca$"e( i$ (e$(ori!& o$+!(io$, e()ecia##y i$ e#'er#y )atie$t(,

    &ay reKect 'r!" i$teractio$(, y)o=ia,

    a$=iety, )ai$, e#ectro#yte i&ba#a$ce(, or

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    Nursing #nterventions $ationale

    +ear

    Db(er%e +or a##!ci$atio$(, 'e#!(io$(,

    'e)re((io$, or a$ e=cite' (tate

    May 'e%e#o) +o##owi$" tra!&a a$'

    i$'icate 'e#iri!&, or &ay reKect

    G(!$'ow$er( (y$'ro&eH i$ e#'er#y

    )atie$t $ )atie$t wo a( !(e' a#coo#

    to e=ce((, &ay (!""e(t i&)e$'i$"

    'e#iri!& tre&e$(

    Rea((e(( (e$(ory or &otor +!$ctio$ a$'

    co"$itio$ toro!"#y be+ore 'i(car"e, a(

    i$'icate'

    .&b!#atory (!r"ica# )atie$t &!(t be ab#e

    to care +or (e#+ wit te e#) o+ D i+

    a%ai#ab#e to )re%e$t )er(o$a# i$E!ry a+ter

    'i(car"e

    %a#!ate $ee' +or e=te$'e' (tay i$

    )o(to)erati%e reco%ery area or $ee' +ora''itio$a# $!r(i$" care be+ore 'i(car"e

    a( a))ro)riate

    i(orie$tatio$ &ay )er(i(t, a$' D &ay$ot be ab#e to )rotect te )atie$t at

    o&e

    6. $is* +or &luid 7olu"e Defcit

    $is* +actors "ay include

    Re(trictio$ o+ ora# i$take 'i(ea(e )roce((>&e'ica# )roce'!re>)re(e$ce o+

    $a!(ea

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    Nursing #nterventions $ationale

    Mea(!re a$' recor' LD i$c#!'i$" t!be(

    a$' 'rai$( a#c!#ate !ri$e ()eci*c

    "ra%ity a( a))ro)riate Re%iewi$trao)erati%e recor'

    .cc!rate 'oc!&e$tatio$ e#)( i'e$ti+y

    K!i' #o((e( or re)#ace&e$t $ee'( a$'

    i$K!e$ce( coice o+ i$ter%e$tio$( NoteC

    .bi#ity to co$ce$trate !ri$e 'ec#i$e( wita"e, i$crea(i$" re$a# #o((e( 'e()ite

    "e$era# K!i' 'e*cit

    .((e(( !ri$ary o!t)!t ()eci*ca##y +or ty)e

    o+ o)erati%e )roce'!re 'o$e

    May be 'ecrea(e' or ab(e$t a+ter

    )roce'!re( o$ te "e$ito!ri$ary (y(te&

    a$'>or a'Eace$t (tr!ct!re( !retero)#a(ty,

    !retero#itoto&y, ab'o&i$a# or %a"i$a#

    y(terecto&y, i$'icati$" &a#+!$ctio$ or

    ob(tr!ctio$ o+ te !ri$ary (y(te&

    ro%i'e %oi'i$" a((i(ta$ce &ea(!re( a(

    $ee'e'C )ri%acy, (itti$" )o(itio$, r!$$i$"

    water i$ (i$k, )o!ri$" war& water o%er

    )eri$e!&

    ro&ote( re#a=atio$ o+ )eri$ea# &!(c#e(

    a$' &ay +aci#itate %oi'i$" eort(

    Mo$itor %ita# (i"$( $oti$" ca$"e( i$

    b#oo' )re((!re, eart rate a$' ryt&,

    a$' re()iratio$( a#c!#ate )!#(e

    )re((!re

    y)ote$(io$, tacycar'ia, i$crea(e'

    re()iratio$( &ay i$'icate K!i' 'e*cit

    'ey'ratio$ a$'>or y)o%o#e&ia

    .#to!" a 'ro) i$ b#oo' )re((!re i(

    "e$era##y a #ate (i"$ o+ K!i' 'e*cit

    e&orra"ic #o((, wi'e$i$" o+ te )!#(e

    )re((!re &ay occ!r ear#y, +o##owe' by$arrowi$" a( b#ee'i$" co$ti$!e( a$'

    (y(to#ic B be"i$( to +a##

    Note )re(e$ce o+ $a!(ea a$'>or %o&iti$"

    o&e$, obe(e )atie$t(, a$' to(e )ro$e

    to &otio$ (ick$e(( a%e a i"er ri(k o+

    )o(to)erati%e $a!(ea a$'>or %o&iti$" $

    a''itio$, te #o$"er te '!ratio$ o+

    a$e(te(ia, te "reater te ri(k +or

    $a!(ea NoteC Na!(ea occ!rri$" '!ri$"

    *r(t 12J24 r )o(to)erati%e#y i(

    +re/!e$t#y re#ate' to a$e(te(iai$c#!'i$" re"io$a# a$e(te(ia Na!(ea

    )er(i(ti$" &ore ta$ 3 'ay(

    )o(to)erati%e#y &ay be re#ate' to te

    coice o+ $arcotic +or )ai$ co$tro# or

    oter 'r!" tera)y

    $()ect 're((i$"(, 'rai$a"e 'e%ice( at =ce((i%e b#ee'i$" ca$ #ea' to

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    Nursing #nterventions $ationale

    re"!#ar i$ter%a#( .((e(( wo!$' +or

    (we##i$"

    y)o%o#e&ia a$'>or circ!#atory co##a)(e

    or #ow

    ct co&bi$e' wit !$re)#ace' K!i'

    #o((e( i$trao)erati%e#y wi## +!rter

    )ote$tiate 'e*cit

    18. cute Pain

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    May e related to

    i(r!)tio$ o+ (ki$, ti((!e, a$' &!(c#e i$te"rity@ &!(c!#o(ke#eta#>bo$e tra!&a

    re(e$ce o+ t!be( a$' 'rai$(

    Possily evidenced y

    Re)ort( o+ )ai$

    .#teratio$ i$ &!(c#e to$e@ +acia# &a(k o+ )ai$

    i(tractio$>"!ar'i$">)rotecti%e bea%ior(

    e#+-+oc!(i$"@ $arrowe' +oc!(

    .!to$o&ic re()o$(e(

    Desired !utco"es

    Re)ort )ai$ re#ie%e'>co$tro##e'

    .))ear re#a=e', ab#e to re(t>(#ee) a$' )artici)ate i$ acti%itie( a))ro)riate#y

    Nursing #nterventions $ationale

    Note )atie$t( a"e, wei"t, coe=i(ti$"

    &e'ica# or )(yco#o"ica# co$'itio$(,

    i'io(y$cratic (e$(iti%ity to a$a#"e(ic(,

    a$' i$trao)erati%e co!r(e

    .))roac to )o(to)erati%e )ai$

    &a$a"e&e$t i( ba(e' o$ &!#ti)#e

    %ariab#e +actor(

    Re%iew i$trao)erati%e or reco%ery roo&

    recor' +or ty)e o+ a$e(te(ia a$'

    &e'icatio$( )re%io!(#y a'&i$i(tere'

    re(e$ce o+ $arcotic( a$' 'ro)eri'o# i$

    (y(te& )ote$tiate( $arcotic a$a#"e(ia,

    werea( )atie$t( a$e(tetie' wit

    F#!ota$e a$' tra$e a%e $o re(i'!a#

    a$a#"e(ic eect( $ a''itio$,

    i$trao)erati%e #oca#> re"io$a# b#ock( a%e

    %aryi$" '!ratio$, e", 1J2 r +or

    re"io$a#( or !) to 2J6 r +or #oca#(

    %a#!ate )ai$ re"!#ar#y e%ery 2 r(

    $oti$" caracteri(tic(, #ocatio$, a$'i$te$(ity 0J10 (ca#e &)a(ie

    )atie$t( re()o$(ibi#ity +or re)orti$" )ai$>

    re#ie+ o+ )ai$ co&)#ete#y

    ro%i'e( i$+or&atio$ abo!t $ee' +or or

    eecti%e$e(( o+ i$ter%e$tio$( NoteC t&ay $ot a#way( be )o((ib#e to e#i&i$ate

    )ai$@ owe%er, a$a#"e(ic( (o!#' re'!ce

    )ai$ to a to#erab#e #e%e# . +ro$ta# a$'>or

    occi)ita# ea'ace &ay 'e%e#o) 24J72 r

    +o##owi$" ()i$a# a$e(te(ia, $ece((itati$"

    rec!&be$t )o(itio$, i$crea(e' K!i'

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    Nursing #nterventions $ationale

    i$take, a$' $oti*catio$ o+ te

    a$e(te(io#o"i(t

    Note )re(e$ce o+ a$=iety or +ear, a$'

    re#ate wit $at!re o+ a$' )re)aratio$ +or

    )roce'!re

    o$cer$ abo!t te !$k$ow$ e",

    o!tco&e o+ a bio)(y a$'>or i$a'e/!ate

    )re)aratio$ e", e&er"e$cy

    a))e$'ecto&y ca$ ei"te$ )atie$t(

    )erce)tio$ o+ )ai$

    .((e(( %ita# (i"$(, $oti$" tacycar'ia,

    y)erte$(io$, a$' i$crea(e' re()iratio$,

    e%e$ i+ )atie$t 'e$ie( )ai$

    a$"e( i$ te(e %ita# (i"$( o+te$

    i$'icate ac!te )ai$ a$' 'i(co&+ort NoteC

    o&e )atie$t( &ay a%e a (#i"t#y

    #owere' B, wic ret!r$( to $or&a#

    ra$"e a+ter )ai$ re#ie+ i( acie%e'

    .((e(( ca!(e( o+ )o((ib#e 'i(co&+ort

    oter ta$ o)erati%e )roce'!re

    i(co&+ort ca$ be ca!(e' or a""ra%ate'by )re(e$ce o+ $o$-)ate$t i$'we##i$"

    cateter(, NA t!be, )are$tera# #i$e(

    b#a''er )ai$, "a(tric K!i' a$' "a(

    acc!&!#atio$, a$' i$*#tratio$ o+ V K!i'(

    or &e'icatio$(

    ro%i'e i$+or&atio$ abo!t tra$(itory

    $at!re o+ 'i(co&+ort, a( a))ro)riate

    ?$'er(ta$'i$" te ca!(e o+ te

    'i(co&+ort e", (ore &!(c#e( +ro&

    a'&i$i(tratio$ o+ (!cci$y#co#i$e &ay

    )er(i(t !) to 48 r )o(to)erati%e#y@ (i$!(

    ea'ace a((ociate' wit $itro!( o=i'e

    a$' (ore troat '!e to i$t!batio$ are

    tra$(itory )ro%i'e( e&otio$a#

    rea((!ra$ce NoteC are(te(ia o+ bo'y

    )art( (!""e(t $er%e i$E!ry y&)to&(

    &ay #a(t o!r( or &o$t( a$' re/!ire

    a''itio$a# e%a#!atio$

    Re)o(itio$ a( i$'icate'C (e&i-Fow#er(@

    #atera# i&(

    May re#ie%e )ai$ a$' e$a$ce circ!#atio$

    e&i-Fow#er( )o(itio$ re#ie%e( ab'o&i$a#

    &!(c#e te$(io$ a$' artritic back &!(c#ete$(io$, werea( #atera# i&( wi## re#ie%e

    'or(a# )re((!re(

    ro%i'e a''itio$a# co&+ort &ea(!re(C

    backr!b, eat or co#' a))#icatio$(

    &)ro%e( circ!#atio$, re'!ce( &!(c#e

    te$(io$ a$' a$=iety a((ociate' wit )ai$

    $a$ce( (e$(e o+ we##-bei$"

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    Nursing #nterventions $ationale

    $co!ra"e !(e o+ re#a=atio$ tec$i/!e(C

    'ee)-breati$" e=erci(e(, "!i'e'

    i&a"ery, %i(!a#iatio$, &!(ic

    Re#ie%e( &!(c#e a$' e&otio$a# te$(io$@

    e$a$ce( (e$(e o+ co$tro# a$' &ay

    i&)ro%e co)i$" abi#itie(

    ro%i'e re"!#ar ora# care, occa(io$a# ice

    ci)( or (i)( o+ K!i'( a( to#erate'

    Re'!ce( 'i(co&+ort a((ociate' wit 'ry

    &!co!( &e&bra$e( '!e to a$e(tetic

    a"e$t(, ora# re(trictio$(

    oc!&e$t eecti%e$e(( a$' (i'e a$'>or

    a'%er(e eect( o+ a$a#"e(ia

    Re()iratio$( &ay 'ecrea(e o$

    a'&i$i(tratio$ o+ $arcotic, a$' (y$er"i(tic

    eect( wit a$e(tetic a"e$t( &ay occ!r

    NoteC Mi"ratio$ o+ e)i'!ra# a$a#"e(ia

    towar' ea' ce)a#a' 'i!(io$ &ay

    ca!(e re()iratory 'e)re((io$ or e=ce((i%e

    (e'atio$

    Administer medications as indicated:

    .$a#"e(ic( V a+ter re%iewi$" a$e(te(ia

    recor' +or co$trai$'icatio$( a$'>or

    )re(e$ce o+ a"e$t( tat &ay )ote$tiate

    a$a#"e(ia@ )ro%i'e aro!$'-te-c#ocka$a#"e(ia wit i$ter&itte$t re(c!e 'o(e(@

    .$a#"e(ic( "i%e$ V reac te )ai$

    ce$ter( i&&e'iate#y, )ro%i'i$" &ore

    eecti%e re#ie+ wit (&a## 'o(e( o+

    &e'icatio$ M a'&i$i(tratio$ take(

    #o$"er, a$' it( eecti%e$e(( 'e)e$'( o$

    ab(or)tio$ rate( a$' circ!#atio$ NoteC

    Narcotic 'o(a"e (o!#' be re'!ce' by

    o$e-+o!rt to o$e-tir' a+ter !(e o+

    +e$ta$y# $$o%ar or 'ro)eri'o# $a)(i$e

    to )re%e$t )ro+o!$' tra$/!i#iatio$ '!ri$"

    *r(t 10 r )o(to)erati%e#y !rre$t

    re(earc (!))ort( $ee' to a'&i$i(ter

    a$a#"e(ic( aro!$' te c#ock i$itia##y to

    )re%e$t rater ta$ &ere#y treat )ai$

    atie$t-co$tro##e' a$a#"e(ia .

    ?(e o+ . $ece((itate( 'etai#e' )atie$t

    i$(tr!ctio$ . &!(t be &o$itore'

    c#o(e#y b!t i( co$(i'ere' %ery eecti%e i$

    &a$a"i$" ac!te )o(to)erati%e )ai$ wit(&a##er a&o!$t( o+ $arcotic a$'

    i$crea(e' )atie$t (ati(+actio$

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    Nursing #nterventions $ationale

    )ai$ NoteC o$ti$!o!( e)i'!ra# i$+!(io$(

    &ay be !(e' +or 1J5 'ay( +o##owi$"

    )roce'!re( tat are k$ow$ to ca!(e

    (e%ere )ai$ certai$ ty)e( o+ toracic orab'o&i$a# (!r"ery

    N.(C a()iri$, 'iK!$i(a# o#obi',

    $a)ro=e$ .$a)ro=

    ?(e+!# +or &i#' to &o'erate )ai$ or a(

    a'E!$ct( to o)ioi' tera)y we$ )ai$ i(

    &o'erate to (e%ere .##ow( +or a #ower

    'o(a"e o+ $arcotic(, re'!ci$" )ote$tia#

    +or (i'e eect(

    Mo$itor !(e a$'>or eecti%e$e(( o+

    tra$(c!ta$eo!( e#ectrica# $er%e

    (ti&!#atio$ TN

    TN &ay be !(e+!# i$ re'!ci$" )ai$ a$'

    a&o!$t o+ &e'icatio$ re/!ire'

    )o(to)erati%e#y

    11. #"paired S*in'issue #ntegrity

    May e related to

    Meca$ica# i$terr!)tio$ o+ (ki$>ti((!e(

    .#tere' circ!#atio$, eect( o+ &e'icatio$@ acc!&!#atio$ o+ 'rai$a"e@ a#tere'

    &etabo#ic (tate

    Possily evidenced y

    i(r!)tio$ o+ (ki$ (!r+ace>#ayer( a$' ti((!e(

    Desired !utco"es

    .cie%e ti&e#y wo!$' ea#i$"

    e&o$(trate bea%ior(>tec$i/!e( to )ro&ote ea#i$" a$' to )re%e$t

    co&)#icatio$(

    Nursing #nterventions $ationale

    Rei$+orce i$itia# 're((i$" a$' ca$"e a(

    i$'icate' ?(e (trict a(e)tic tec$i/!e(

    rotect( wo!$' +ro& &eca$ica# i$E!ry

    a$' co$ta&i$atio$ re%e$t(

    acc!&!#atio$ o+ K!i'( tat &ay ca!(e

    e=coriatio$

    Ae$t#y re&o%e ta)e i$ 'irectio$ o+ air

    "rowt a$' 're((i$"( we$ ca$"i$"

    Re'!ce( ri(k o+ (ki$ tra!&a a$'

    'i(r!)tio$ o+ wo!$'

    .))#y (ki$ (ea#a$t( or barrier( be+ore Re'!ce( )ote$tia# +or (ki$ tra!&a a$'>or

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    Nursing #nterventions $ationale

    ta)e i+ $ee'e' ?(e y)oa##er"e$ic ta)e

    or Mo$t"o&ery (tra)( or e#a(tic $etti$"

    +or 're((i$"( re/!iri$" +re/!e$t ca$"i$"

    abra(io$( a$' )ro%i'e( a''itio$a#

    )rotectio$ +or 'e#icate (ki$ or ti((!e(

    eck te$(io$ o+ 're((i$"( .))#y ta)e at

    ce$ter o+ i$ci(io$ to o!ter &ar"i$ o+

    're((i$" .%oi' wra))i$" ta)e aro!$'

    e=tre&ity

    a$ i&)air or occ#!'e circ!#atio$ to

    wo!$' a$' to 'i(ta# )ortio$ o+ e=tre&ity

    $()ect wo!$' re"!#ar#y, $oti$"

    caracteri(tic( a$' i$te"rity Note

    )atie$t( at ri(k +or 'e#aye' ea#i$"

    )re(e$ce o+ cro$ic ob(tr!cti%e

    )!#&o$ary 'i(ea(eD, a$e&ia,

    obe(ity or &a#$!tritio$, M, e&ato&a

    +or&atio$, %o&iti$", TD a#coo#

    wit'rawa#@ !(e o+ (teroi' tera)y@

    a'%a$ce' a"e

    ar#y reco"$itio$ o+ 'e#aye' ea#i$" or

    'e%e#o)i$" co&)#icatio$( &ay )re%e$t a

    &ore (erio!( (it!atio$ o!$'( &ay ea#

    &ore (#ow#y i$ )atie$t( wit co&orbi'ity,

    or te e#'er#y i$ wo& re'!ce' car'iaco!t)!t 'ecrea(e( ca)i##ary b#oo' Kow

    .((e(( a&o!$t( a$' caracteri(tic( o+

    'rai$a"e

    ecrea(i$" 'rai$a"e (!""e(t( e%o#!tio$

    o+ ea#i$" )roce((, werea( co$ti$!e'

    'rai$a"e or )re(e$ce o+ b#oo'y or

    o'ori+ero!( e=!'ate (!""e(t(

    co&)#icatio$( e", *(t!#a +or&atio$,

    e&orra"e, i$+ectio$

    Mai$tai$ )ate$cy o+ 'rai$a"e t!be(@

    a))#y co##ectio$ ba" o%er 'rai$( a$'

    i$ci(io$( i$ )re(e$ce o+ co)io!( or ca!(tic

    'rai$a"e

    Faci#itate( a))ro=i&atio$ o+ wo!$'

    e'"e(@ re'!ce( ri(k o+ i$+ectio$ a$'

    ce&ica# i$E!ry to (ki$ a$' ti((!e(

    #e%ate o)erati%e area a( a))ro)riate

    ro&ote( %e$o!( ret!r$ a$' #i&it( e'e&a

    +or&atio$ NoteC #e%atio$ i$ )re(e$ce o+

    %e$o!( i$(!Icie$cy &ay be 'etri&e$ta#

    )#i$t ab'o&i$a# a$' ce(t i$ci(io$( or

    area wit )i##ow or )a' '!ri$" co!"i$"

    or &o%e&e$t

    /!a#ie( )re((!re o$ te wo!$',

    &i$i&ii$" ri(k o+ 'ei(ce$ce or r!)t!re

    a!tio$ )atie$t $ot to to!c wo!$' re%e$t( co$ta&i$atio$ o+ wo!$'

    #ea$(e (ki$ (!r+ace i+ $ee'e' wit

    'i#!te' y'ro"e$ )ero=i'e (o#!tio$, or

    r!$$i$" water a$' &i#' (oa) a+ter

    Re'!ce( (ki$ co$ta&i$a$t(@ ai'( i$

    re&o%a# o+ 'rai$a"e or e=!'ate

    http://nurseslabs.com/5-chronic-obstructive-pulmonary-disease-copd-nursing-care-plans/http://nurseslabs.com/5-chronic-obstructive-pulmonary-disease-copd-nursing-care-plans/http://nurseslabs.com/5-chronic-obstructive-pulmonary-disease-copd-nursing-care-plans/http://nurseslabs.com/5-chronic-obstructive-pulmonary-disease-copd-nursing-care-plans/
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    Nursing #nterventions $ationale

    i$ci(io$ i( (ea#e'

    .))#y ice i+ a))ro)riate

    Re'!ce( e'e&a +or&atio$ tat &ay

    ca!(e !$'!e )re((!re o$ i$ci(io$ '!ri$"

    i$itia# )o(to)erati%e )erio'

    ?(e ab'o&i$a# bi$'er i+ i$'icate'ro%i'e( a''itio$a# (!))ort +or i"-ri(k

    i$ci(io$( obe(e )atie$t

    rri"ate wo!$'@ a((i(t wit 'ebri'e&e$t

    a( $ee'e'

    Re&o%e( i$+ectio!( e=!'ate or $ecrotic

    ti((!e to )ro&ote ea#i$"

    Mo$itor or &ai$tai$ 're((i$"(C y'ro"e#,

    %ac!!& 're((i$"

    May be !(e' to a(te$ ea#i$" i$ #ar"e,

    'rai$i$" wo!$'> *(t!#a, to i$crea(e

    )atie$t co&+ort, a$' to re'!ce +re/!e$cy

    o+ 're((i$" ca$"e( .#(o a##ow( 'rai$a"eto be &ea(!re' &ore acc!rate#y a$'

    a$a#ye' +or ) a$' e#ectro#yte co$te$t

    a( a))ro)riate

    1%. $is* +or ltered issue Per+usion

    $is* +actors "ay include

    $terr!)tio$ o+ KowC arteria#, %e$o!(

    y)o%o#e&ia

    Possily evidenced y

    Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as

    the problem has not occurred and nursing interventions are directed at

    prevention.

    Desired !utco"es

    e&o$(trate a'e/!ate )er+!(io$ e%i'e$ce' by (tab#e %ita# (i"$(, )eri)era#

    )!#(e( )re(e$t a$' (tro$"@ (ki$ war&>'ry@ !(!a# &e$tatio$ a$' i$'i%i'!a##y

    a))ro)riate !ri$ary o!t)!t

    Nursing #nterventions $ationale

    a$"e )o(itio$ (#ow#y i$itia##y

    Va(oco$(trictor &eca$i(&( are

    'e)re((e' a$' /!ick &o%e&e$t &ay #ea'

    to orto(tatic y)ote$(io$, e()ecia##y i$

    te ear#y )o(to)erati%e )erio'

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    Nursing #nterventions $ationale

    .((i(t wit ra$"e-o+-&otio$ RDM

    e=erci(e(, i$c#!'i$" acti%e a$k#e a$' #e"

    e=erci(e(

    ti&!#ate( )eri)era# circ!#atio$@ ai'( i$

    )re%e$ti$" %e$o!( (ta(i( to re'!ce ri(k o+

    tro&b!( +or&atio$

    $co!ra"e a$' a((i(t wit ear#y

    a&b!#atio$

    $a$ce( circ!#atio$ a$' ret!r$ o+ $or&a#

    or"a$ +!$ctio$

    .%oi' !(e o+ k$ee "atc a$'>or )i##ow

    !$'er k$ee( a!tio$ )atie$t a"ai$(t

    cro((i$" #e"( or (itti$" wit #e"(

    'e)e$'e$t +or )ro#o$"e' )erio'

    re%e$t( (ta(i( o+ %e$o!( circ!#atio$ a$'

    re'!ce( ri(k o+ tro&bo)#ebiti(

    .((e(( #ower e=tre&itie( +or eryte&a,

    e'e&a, ca#+ te$'er$e(( )o(iti%eo&a$( (i"$

    irc!#atio$ &ay be re(tricte' by (o&e

    )o(itio$( !(e' '!ri$" (!r"ery, wi#e

    a$e(tetic( a$' 'ecrea(e' acti%ity a#ter

    %a(o&otor to$e, )ote$tiati$" %a(c!#ar)oo#i$" a$' i$crea(i$" ri(k( o+ tro&b!(

    +or&atio$

    Mo$itor %ita# (i"$(C )a#)ate )eri)era#

    )!#(e(@ $ote (ki$ te&)erat!re> co#or a$'

    ca)i##ary re*## %a#!ate !ri$ary

    o!t)!t>ti&e o+ %oi'i$" oc!&e$t

    'y(ryt&ia(

    $'icator( o+ a'e/!acy o+ circ!#ati$"

    %o#!&e a$' ti((!e )er+!(io$ or or"a$

    +!$ctio$ ect( o+ &e'icatio$( or

    e#ectro#yte i&ba#a$ce( &ay create

    'y(ryt&ia(, i&)airi$" car'iac o!t)!t

    a$' ti((!e )er+!(io$

    $%e(ti"ate ca$"e( i$ &e$tatio$ or

    +ai#!re to acie%e !(!a# &e$ta# (tate

    May reKect a $!&ber o+ )rob#e&( (!c a(i$a'e/!ate c#eara$ce o+ a$e(tetic

    a"e$t, o%er(e'atio$ )ai$ &e'icatio$,

    y)o%e$ti#atio$, y)o%o#e&ia, or

    i$trao)erati%e co&)#icatio$( e&bo#i

    .'&i$i(ter V K!i'( or b#oo' )ro'!ct( a(

    $ee'e'

    Mai$tai$( circ!#ati$" %o#!&e@ (!))ort(

    )er+!(io$

    .))#y a$tie&bo#itic o(e a( i$'icate'

    ro&ote( %e$o!( ret!r$ a$' )re%e$t(

    %e$o!( (ta(i( o+ #e"( to re'!ce ri(k o+

    tro&bo(i(

    13. Defcient Knowledge

    May e related to

    #ack o+ reca##, i$+or&atio$ &i(i$ter)retatio$

    ?$+a&i#iarity wit i$+or&atio$ re(o!rce(

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    o"$iti%e #i&itatio$

    Possily evidenced y

    P!e(tio$(>re/!e(t +or i$+or&atio$@ (tate&e$t o+ &i(co$ce)tio$

    $acc!rate +o##ow-tro!" o+ i$(tr!ctio$(>'e%e#o)&e$t o+ )re%e$tab#eco&)#icatio$(

    Desired !utco"es

    Verba#ie !$'er(ta$'i$" o+ co$'itio$, eect( o+ )roce'!re a$' )ote$tia#

    co&)#icatio$(

    Verba#ie !$'er(ta$'i$" o+ tera)e!tic $ee'(

    orrect#y )er+or& $ece((ary )roce'!re( a$' e=)#ai$ rea(o$( +or actio$(

    $itiate $ece((ary #i+e(ty#e ca$"e( a$' )artici)ate i$ treat&e$t re"i&e$

    Nursing #nterventions $ationale

    Re%iew ()eci*c (!r"ery )er+or&e' a$'

    )roce'!re 'o$e a$' +!t!re e=)ectatio$(

    ro%i'e( k$ow#e'"e ba(e +ro& wic

    )atie$t ca$ &ake i$+or&e' coice(

    Re%iew a$' a%e )atie$t or D

    'e&o$(trate 're((i$" or wo!$' a$' t!be

    care we$ i$'icate' 'e$ti+y (o!rce +or

    (!))#ie(

    ro&ote( co&)ete$t (e#+-care a$'

    e$a$ce( i$'e)e$'e$ce

    Re%iew a%oi'a$ce o+ e$%iro$&e$ta# ri(k

    +actor(C e=)o(!re to crow'( or )er(o$(

    wit i$+ectio$(

    Re'!ce( )ote$tia# +or ac/!ire' i$+ectio$(

    i(c!(( 'r!" tera)y, i$c#!'i$" !(e o+

    )re(cribe' a$' DT a$a#"e(ic(

    $a$ce( coo)eratio$ wit re"i&e$@

    re'!ce( ri(k o+ a'%er(e reactio$( a$'>or

    !$towar' eect(

    'e$ti+y ()eci*c acti%ity #i&itatio$( re%e$t( !$'!e (trai$ o$ o)erati%e (ite

    Reco&&e$' )#a$$e' or )ro"re((i%e

    e=erci(e

    ro&ote( ret!r$ o+ $or&a# +!$ctio$ a$'

    e$a$ce( +ee#i$"( o+ "e$era# we##-bei$"

    ce'!#e a'e/!ate re(t )erio'(re%e$t( +ati"!e a$' co$(er%e( e$er"y

    +or ea#i$"

    Re%iew i&)orta$ce o+ $!tritio!( 'iet a$'

    a'e/!ate K!i' i$take

    ro%i'e( e#e&e$t( $ece((ary +or ti((!e

    re"e$eratio$ or ea#i$" a$' (!))ort o+

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    Nursing #nterventions $ationale

    ti((!e )er+!(io$ a$' or"a$ +!$ctio$

    $co!ra"e ce((atio$ o+ (&oki$"

    &oki$" i$crea(e( ri(k o+ )!#&o$ary

    i$+ectio$(, ca!(e( %a(oco$(trictio$, a$'

    re'!ce( o=y"e$-bi$'i$" ca)acity o+

    b#oo', aecti$" ce##!#ar )er+!(io$ a$'

    )ote$tia##y i&)airi$" ea#i$"

    'e$ti+y (i"$ a$' (y&)to&( re/!iri$"

    &e'ica# e%a#!atio$, e", $a!(ea a$'>or

    %o&iti$"@ 'iIc!#ty %oi'i$"@ +e%er,

    co$ti$!e' or o'ori+ero!( wo!$' 'rai$a"e@

    i$ci(io$a# (we##i$", eryte&a, or

    (e)aratio$ o+ e'"e(@ !$re(o#%e' or

    ca$"e( i$ caracteri(tic( o+ )ai$

    ar#y reco"$itio$ a$' treat&e$t o+

    'e%e#o)i$" co&)#icatio$( i#e!(, !ri$ary

    rete$tio$, i$+ectio$, 'e#aye' ea#i$" &ay

    )re%e$t )ro"re((io$ to &ore (erio!( or

    #i+e-treate$i$" (it!atio$

    tre(( $ece((ity o+ +o##ow-!) %i(it( wit

    )ro%i'er(, i$c#!'i$" tera)i(t(,

    #aboratory

    Mo$itor( )ro"re(( o+ ea#i$" a$'

    e%a#!ate( eecti%e$e(( o+ re"i&e$

    $c#!'e D i$ teaci$" )ro"ra& or

    'i(car"e )#a$$i$" ro%i'e writte$

    i$(tr!ctio$( a$'>or teaci$" &ateria#(

    $(tr!ct i$ !(e o+ a$' arra$"e +or ()ecia#

    e/!i)&e$t

    ro%i'e( a''itio$a# re(o!rce( +or

    re+ere$ce a+ter 'i(car"e ro&ote(

    eecti%e (e#+-care

    'e$ti+y a%ai#ab#e re(o!rce(C o&e care(er%ice(, %i(iti$" $!r(e, o!t)atie$t

    tera)y, co$tact )o$e $!&ber +or

    /!e(tio$(

    $a$ce( (!))ort +or )atie$t '!ri$"reco%ery )erio' a$' )ro%i'e( a''itio$a#

    e%a#!atio$ o+ o$"oi$" $ee'( a$' $ew

    co$cer$(

    !t4er Possile Nursing Care Plans

    Fati"!eQi$crea(e' e$er"y re/!ire&e$t( to )er+or& acti%itie( o+ 'ai#y #i%i$",

    (tate( o+ 'i(co&+ort

    $+ectio$, ri(k +orQbroke$ (ki$, tra!&atie' ti((!e(, (ta(i( o+ bo'y K!i'(@

    )re(e$ce o+ )ato"e$(>co$ta&i$a$t(, e$%iro$&e$ta# e=)o(!re, i$%a(i%e)roce'!re(

    e#+-are 'e*cit>o&e Mai$te$a$ce Ma$a"e&e$t, i&)aire'Q'ecrea(e'

    (tre$"t>e$'!ra$ce, )ai$>'i(co&+ort, !$+a&i#iarity wit $ei"boroo'

    re(o!rce(, i$a'e/!ate (!))ort (y(te&(

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    Re+er a#(o to a))ro)riate )#a$( o+ care re"ar'i$" !$'er#yi$" co$'itio$>()eci*c

    (!r"ica# )roce'!re +or a''itio$a# co$(i'eratio$(

    See lso