Quote from livingmydream1
i'm working on a nursing care plan for a general surigcal patient (no specific surgery... just a post op patient). for the assignment i'm working on, i have to have 4 nursing diagnosis, 3 interventions for each diagnosis, rationale for each intervention and then give the relevance of the diagnosis i have selected.
in keeping with the abc's i have selected:
1) risk for ineffective airway clearance related to effects of anesthesia, immobility and incisional pain (without a patent airway nothing else matters which is why this is my number one priority)
2) risk for altered tissue perfussion related to active bleeding in surgery goal and interventions for this one has me a little stumped. i know i need to monitor vital signs, assess the surgical site for drainage, amount and type. what about the iv fluids? would that be included in this diagnosis or is that a whole new one altogether?
3) risk for alteration in level of consciousness related to the anesthesia and post operative immobilization (is this one i should be concerned with... is it a top priority?)
in keeping with maslow's hierarchy of needs, the patients physiological needs are a top priority. i'm thinking either pain control or risk for infection... am i thinking along the right lines?
thank you for any help/suggestions
some other assessment interventions for ineffective tissue perfusion might include capillary refill rates (peripheral) and loc (cerebral). there are many others as well which concentrate on assessing tissue perfusion in different body regions - research those and include what you believe to be most pertinent to your abc track.
i would cut the third diagnosis (risk for alteration in level of consciousness r/t anesthesia and post-op immobilization) and substitute risk for ineffective breathing (ab
) pattern r/t cns depression secondary to anesthesia administration or something like that - interventions to include monitoring breathing rate and depth, coughing and deep breathing/incentive spirometry.