1. Breathing pattern, ineffective related to Neuromuscular, imbalance perceptual / cognitive.
Goal : normal breathing pattern / effective and free from signs of cyanosis or hypoxia .
Intervention :
- Maintain the patient's airway by tilting the head.
- Auscultation of breath sounds.
- Observation of the frequency and depth of breathing, the muscles use the respirator.
- Monitor vital signs continuously.
- Do the motion as soon as possible.
- Observation of the excess.
- Do suction mucus when necessary.
- Provide supplemental oxygen as needed.
- Give treatment as instructed.
2. Disturbed Sensory Perception : the process of thought related to chemical changes : the use of pharmaceutical drugs.
Goal : increasing the level of awareness
Intervention :
- Orient the patient back continuously after coming out of the influence of anesthesia.
- Talk with the patient in a clear voice and normal.
- Minimize negative discussion.
- Use the pads on the edge, do binding if necessary.
- Observations of the existence of hallucinations, depression and others.
- Maintain a calm and comfortable environment.
3. Fluid Volume Deficit, Risk for oral fluid intake restriction (process / medical procedure / nausea).
Goal : there is adequate fluid balance .
Intervention :
- Measure and record the input and output.
- Assess urinary spending, especially for the type of surgical procedure performed.
- Monitor vital signs.
- Note the emergence of nausea / vomiting, history of motion sickness.
- Check the pads, appliance drein at regular intervals , examine the wound for swelling.
- Give parenteral fluids, blood products and / or plasma expanders as directed. Level IV speed if necessary.
- Give back oral intake gradually as directed.
- Give antiemetics as needed.
4. Pain (acute) related to disorders of the skin, tissue, and muscle integrity.
Goal : pain has been controlled / eliminated, the client can rest and activity according to ability.
Intervention :
- Assess pain scale, intensity, and frequency.
- Evaluation of pain on a regular basis.
- Assess vital signs.
- Assess the cause of the discomfort that may be appropriate operating procedures.
- Put repositioning as directed.
- Encourage use of relaxation techniques.
- Give medicines as directed.
5. Impaired Skin Integrity related to the interrupt mechanism of the skin / tissue.
Goal : to improve the metabolic action shows.
Intervention :
- Review the functional capabilities and circumstances.
- Place the client in a particular position.
- Keep the body well-being functionally.
- Help or actions to perform range of motion exercises.
- Give skin care carefully.
- Monitor urine output.
6. Risk for infection related to an operating wounds and invasive procedures.
Goal : There are no signs and symptoms of infection
Intervention :
- Provide anti-septic and aseptic care, maintain good hand washing.
- Observations damaged skin area (stitches) attached regions invasive tool.
- Monitor the entire body on a regular basis, record the presence of fever, chills, and diaphoresis.
- Keep an eye or the number of visitors.
- Give antibiotics as indicated.
7. Disturbed Sleep Pattern related to the disease process, the effects of hospitalization, changes in the environment.
Goal : resting needs can be met
Intervention :
- Assess the client's ability and sleeping habits.
- Provide a comfortable bed with a few personal belongings. Example : pillows, bolsters.
- Suggest to light activity.
- Suggest to take action relaxation.
- Encourage the family to always accompany.
- Supervise and limit the number of visitors.
8. Knowledge deficit (learning need) regarding condition / situation, prognosis, treatment needs.
Goal : Declare, understanding of disease processes / pragnosis.
Intervention :
- Revisit surgery / special procedures performed and on future expectations.
- Discuss drug therapy , including the use of a prescription.
- Identification of specific activity limitations.
- Schedule an adequate period of rest.
- Emphasize the importance of further visits.
- Involve famous people in the teaching program. Provide written instructions / teaching materials.
- Repeat the importance of diet and fluid intake adequate nutrition.
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