postoperative Phase
Nursing Process Postoperative Pt.:
-Assessment
*Airway patency
*Monitoring vital signs and ROS upon arrival
*Respiratory status; Quality, depth, rate, and sound.
*Breath sounds
*Assess pain level using VAS
*Assess appearance skin color, skin temperature
*Observed for bleeding, type and integrity of dressing, and drains.
*Assess mental status and level of consciousness, speech, and
orientation
*Assess for complications
Neurologic
Delirium
Stroke
*Urinary
acute urine retention
*Functional
Weakness
Fatigue
Functional decline
*Respiratory
Atelectasis
Pneumonia
Pulmonary embolism
Aspiration
*Cardiovascular
Shock
Thrombophlebitis
*Gastrointestinal
Constipation
Paralytic ileus
Bowel obstruction
*Wound
Infection
Dehiscence
Evisceration
Delayed healing
Hemorrhage
Hematoma
-Diagnosis
Based on the assessment data, major nursingdiagnoses may include the following:
•Risk for ineffective airway clearance related todepressed respiratory function, pain, and bed rest
•Acute pain related to surgical incision
•Decreased cardiac output related to shock or hemorrhage
•Impaired skin integrity related to surgical incision and drains
•Risk for imbalanced body temperature related to surgical environment and anesthetic agents
•Activity intolerance related to generalized weakness secondary to surgery
•Risk for imbalanced nutrition, less than body requirements related to decreased intake and increased need for nutrients secondary to surgery
•Risk for constipation related to effects of medications,surgery, dietary change, and immobility
•Risk for urinary retention related to anesthetic agents
•Risk for injury related to surgical procedure or anesthetic agents
•Anxiety related to surgical procedure
•Risk for ineffective management of therapeutic
•regimen related to insufficient knowledge about wound care, dietary restrictions, activity
•recommendations, medications, follow-up care, or signs and symptoms of complications
•Risk for ineffective airway clearance related todepressed respiratory function, pain, and bed rest
•Acute pain related to surgical incision
•Decreased cardiac output related to shock or hemorrhage
•Impaired skin integrity related to surgical incision and drains
•Risk for imbalanced body temperature related to surgical environment and anesthetic agents
•Activity intolerance related to generalized weakness secondary to surgery
•Risk for imbalanced nutrition, less than body requirements related to decreased intake and increased need for nutrients secondary to surgery
•Risk for constipation related to effects of medications,surgery, dietary change, and immobility
•Risk for urinary retention related to anesthetic agents
•Risk for injury related to surgical procedure or anesthetic agents
•Anxiety related to surgical procedure
•Risk for ineffective management of therapeutic
•regimen related to insufficient knowledge about wound care, dietary restrictions, activity
•recommendations, medications, follow-up care, or signs and symptoms of complications
-Collaborative Problems/ Potential Complications
*Deep vein
thrombosis
*Bleeding/ Hematoma
*Infection
*Wound dehiscence or
evisceration
-intervention
*respiratory
*cardiac (hypotension + shock +Hemorrhage+hypertention +Dysrhythmias)
*Relieving Pain And Anxiety
*Controlling Nausea And Vomiting
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