A quantifiable tool that assists the post op nurse in determining level of unintentional sedation due to opioid medications
What is the POSS?
The only person that should push the button on a PCA.
Who is the patient
This diagnosis may be related to the following factors: mechanical interruption of the skin/tissues; altered circulation; or accumulation of drainage.
What is Impaired Skin Integrity?
Postoperative complications of the gastrointestinal system that may result from manipulation of the abdominal organs and the effects of some anesthetic agents. Symptoms include abdominal distention, discomfort, vomiting, and absence of bowel sounds.
What is paralytic ileus?
May be prescribed for the purpose of reducing postoperative complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE). (Two medications)
What are low molecular weight or low dose heparin and Coumadin (warfarin)?
Results from prolonged anesthesia exposure, which causes all muscles to become relaxed. Is treated by tilting the head back ond thrusting the jaw forward.
What is hypopharyngeal obstruction?
Vital signs are monitored and documented in this time frame.
What is every 15 minutes?
This class of drug should be prescribed along with an opioid to combat a common side effect.
What is a stool softener.
This NANDA diagnosis is used to describe the potential for a post-surgical complication that causes bladder distention and pain which may result from the effects of anesthetic agents, as well as anticholinergic and opioid medications.
What is Risk for Urinary Retention?
Pallor, cool skin, rapid breathing, cyanosis, weak, thready pulse and narrowing pulse pressure.
What are signs of hypovolemic shock?
This diagnosis may be related to depressed respiratory function, the use of opioid medications and anesthetic agents. Nursing interventions include deep breathing and coughing, and instructing the client on the use of an incentive spirometer.
What is Risk for Ineffective Airway Clearance?
The patient is turned to one side to promote mouth drainage and prevent aspiration
What is the priority intervention when a patient is nauseated?
The most critical assessment to perform after surgery for a patient that underwent general anesthesia, moderate sedation, or has received sedative or opioid drugs?
What is a respiratory assessment?
This diagnosis relates to a patient's ability to manage wound care; adhere to dietary restrictions; participate in activity recommendations; use medications appropriately;obtain follow up care; and recognize signs and symptoms of complications.
What is Risk for Ineffective Therapeutic Regimen Management?