13 surgery
TRANSCRIPT
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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