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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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)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#


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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%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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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


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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)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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)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


$teracti%e co$'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



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


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'(

7/25/2019 13 Surgery

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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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&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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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



prevention.

Desired !utco"es

7/25/2019 13 Surgery

13/32

'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


.'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'(

7/25/2019 13 Surgery

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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


=)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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prevention.

Desired !utco"es

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


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

7/25/2019 13 Surgery

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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


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!$'(

7/25/2019 13 Surgery

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(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

7/25/2019 13 Surgery

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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


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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+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


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

$a!(ea

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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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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

7/25/2019 13 Surgery

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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


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

7/25/2019 13 Surgery

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$co!ra"e !(e o+ re#a=atio$ 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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)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$(


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

7/25/2019 13 Surgery

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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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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


$terr!)tio$ o+ KowC arteria#, %e$o!(

y)o%o#e&ia

Possily evidenced y



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


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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.((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$t re"i&e$


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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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

13 Surgery

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