1. Ineffective breathing pattern related to the depressant effects of medications and anesthetic agent.
Characterized by:
- Changes in the frequency and depth of breathing.
- Reduction in vital capacity.
- Apnea, cyanosis, noisy breathing (snoring).
- The decrease in oxygen saturation.
Outcomes:
- Saturation of more than 95%.
- Breathing regularly.
- No additional breath sounds.
- Airway is not blocked.
- Maintain airway by tilting the head, jaw hyperextension, oropharyngeal airflow.
- Auscultation of breath sounds, listen wheeze, Ronchi or noise after extubation.
- Observation frequency and depth of breathing, use of a respirator muscles, expansion of the thoracic cavity retraction or skin color nostril breathing and air flow.
- Place the client in the appropriate position, depending on the power of breathing, and the type of surgery.
- Observations refund function of respiratory muscles.
- Perform the movement as soon as possible on the client reactive.
- Perform suction mucus if required.
- Provide supplemental oxygen as needed.
- Review the breathing pattern, frequency and depth and saturation after a given action for 15 minutes.
- Collaboration for the provision of drugs to stimulate the movement of the respiratory muscles.
- Collaboration for the provision of respiratory assistive devices when needed.
2. Disturbed Thought Processes / Sensory Perception related to the effects of anesthesia, excessive sensory stimuli, physiological stress.
Characterized by:
- Disorientation to person, place time.
- Changes in response to stimulation.
- Failure of motor coordination.
Outcomes:
- Clients can be oriented to person, place and time.
- Clients can recognize limitations and seek sources of assistance as needed.
- Orient the continuous back after being out of the influence of anesthesia; stated that the operation had been completed.
- Talk to the client with a clear and normal voice without snapping, are fully aware of what was said. Minimize negative discussion within earshot of the client. Explain the procedure to be performed even if the client is not aware.
- Evaluation of sensation / movement of the extremities and the corresponding trachea.
- Use the pads on the edge of the bed, do binding if necessary.
- Maintain a calm and comfortable environment.
- Review the return of sensory ability and thought process before removal.
3. Acute pain related to disorders of the skin, tissue, and muscle integrity, musculoskeletal trauma, or the emergence of drainage channels.
Characterized by:
- Clients reported pain.
- Changes in muscle tone.
- Distraction / guarding behavior is active.
Outcomes:
- Clients seemed to relax.
- Clients do not shout.
- Review the intraoperative process; sizes, / location of the incision, changing channels, a substance used anesthetic agents.
- Evaluation of pain on a regular basis.
- Assess vital signs, note tachycardia, hypertension, and increased breathing, even if the client denies the existence of pain.
- Assess other possible inconveniences besides surgery procedures.
- Assess characteristics of pain.
- Encourage use of relaxation techniques, deep breathing exercises.
- Collaboration of analgesics.
5. Risk for fluid volume deficit related to loss of body fluids is not abnormal, changes in blood clotting ability.
Goal: Lack of fluid volume did not happen.
Outcomes:
- Vital signs are stable.
- Strong pulse palpation.
- Normal skin turgor.
- Mucous membranes moist.
- Appropriate expenditure of individual urine.
- Assess and record income and expenditure, and a review of the operation of intra records.
- Assess vital signs and peripheral circulation.
- Assess the appearance of nausea / vomiting, the patient's history.
- Assess the wound and bandage for signs of bleeding.
- Assess skin temperature and palpation of peripheral pulses.
- Collaboration for the administration of parenteral fluids, blood or plasma expanders as needed.
- Collaboration of antiemetics.
- Collaboration laboratory examination immediately post-surgery and compared with preoperatively.
Nursing Care Plan for Intraoperative Patient
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