N C P for Perioperative Pts.

P RE OP ER AT IVE ASSESSMENT SUBJECTIVE: Natatakot akong magpaopera! as verbalized by the patient. OBJECTIVE: y Restlessness y Narrowed focus y Voice quivering y Hand tremors y Facial flushing y Observed:  Feelings of  adequacy  apprehensi on

DIAGNOSIS

PLANNING

Anxiety related to actual/ perceived threat to death as manifested by increased tension.

After 4 hours of  nursing intervention before the settled operation, the patient will appear relaxed and report anxiety is reduced to a manageable level as manifested by decreased tension.

N CP

INTERVENTION y

y

y

y

y

Monitor vital signs.

Observe behaviors.

Be aware of  defense mechanisms being used. Provide accurate information about the situation. Establish a therapeutic relationship, conveying empathy and unconditional positive reward.

RATIONALE y

y

y

y

y

To identify physical responses associated with both medical and emotional conditions. This can point to the clients level of anxiety. Interferes the ability to deal with problem. Helps the client to identify what is reality based. To avoid a contagious effect/ transmission of anxiety.

EVALUATION Goal met as evidenced by patient appear relaxed and report anxiety is reduced to a manageable level as manifested by decreased tension after 4 hours of  nursing intervention.

I NT RA OP ER AT IVE ASSESSMENT y

Tachypnea

y

Decreased

y

y

y

respiratory depth/ vital capacity Decreased inspiratory/ expiratory pressure Decreased minute ventilation C yanotic

DIAGNOSIS Ineffective breathing pattern related to decreased lung expansion (pain and muscle weakness) secondary to surgery as manifested by decreased respiratory depth/ vital capacity.

PLANNING The

patient will establish a normal/ effective respiratory pattern as evidenced by absence of  cyanosis and other signs and symptoms of hypoxia after the surgery.

N CP

INTERVENTION y

Administer oxygen at lowest concentration indicated and prescribed respiratory medications. pulse oximetry, as indicated.

RATIONALE y

For

management of underlying pulmonary condition, respiratory distress, or cyanosis.

y

Monitor

y

To

y

Stress

y

To

importance of  good posture and effective use of  accessory muscles.

verify maintainance / improvement in oxygen saturation. maximize respiratory effort.

EVALUATION Goal met as manifested by patient established a normal/ effective respiratory pattern as evidenced by absence of cyanosis and other signs and symptoms of hypoxia after the surgery.

P OS TO PE RA TI VE ASSESSMENT

DIAGNOSIS

SUBJECTIVE: Hindi ako masyadong makagalaw dahil masakit pa ang sugat ng operasyon ko. As verbalized by the patient.

Impaired physical mobility related to pain/discomfort secondary to surgical operation as manifested by limited range of  motion.

OBJECTIVE: y Limited range of motion y Difficulty turning y Slowed movement y Postural instability y Gait changes

PLANNING After 12 hours of  nursing intervention, the patient will maintain position of function and skin integrity as evidenced by absence of  contractures, footdrop, decubitus, and so forth.

NC P

INTERVENTION y

y

y

y

y

Observe

movement when client is unaware of  observation. Instruct in the use of side rails, overhead trapeze, and roller pads. Administer medications prior to activity as needed for pain relief. Support affected body parts/joints using pillows/ rolls, foot supports/ shoes, air mattress, water bed, and so forth. Encourage adequate intake of fluids/ nutritious foods.

RATIONALE y

y

To

note any in congruencies with reports of  abilities. For position changes and transfers.

y

Permits

maximal effort/ involvement in activity.

y

Maintains

position of  function and reduce risk of  pressure ulcers.

y

Promotes

wellbeing and maximizes energy production.

EVALUATION Goal met as manifested by the patient maintains position of function and skin integrity as evidenced by absence of  contractures, foot drop, decubitus, and so forth after 12 hours of nursing intervention.