Assessment S: Ø O: Patient manifests: >irritability >poor eye contact >focus on self >increased tension >increased PR, RR >impaired attention >urinary

urgency >perspiration

Nursing Diagnosis Anxiety r/t procedure and outcome

Scientific Explanation




EXPECTED OUTCOME Short Term: After 1 hour of NI, the pt. shall be able to understand the procedure and show signs of comfort

Because of Short Term: knowledge deficit, After 1 hour of NI, the client may the pt. will be able show anxiety to understand the because of procedure and unfamiliarity and show signs of outcome of the comfort procedure Long Term:

>assess the clients >for baseline data level of anxiety by listening and observing >acknowledge anxiety >to identify feelings or fear >provide accurate information about the situation

Long Term: >helps client identify what is reality based After 5 hours of NI, After 5 hours of NI, the pt. shall show >stay with the patient >to make him/her the pt. will show decreased or no feel that he is not decreased or no manifestations of alone manifestations of anxiety as anxiety as evidenced by calmly >may interfere with discussing his or her >note defense evidenced by calmly discussing mechanism being used the client ability to apprehension and cope his or her ventilating feeling apprehension and regarding the ventilating feeling procedure and >give sedatives or regarding the diagnosis. >to allay anxiety report to the health procedure and team of the client’s diagnosis. anxiety

Assessment S: Ø

Nursing Diagnosis

Scientific Explanation Anesthesia artificially induces a state of partial or total loss of sensation. Anesthetic agents affect the different systems of the body, including the respiratory system. Anesthesia interferes with the normal movement of mucus up and out of the bronchial tree causing pooling of secretions. A major complication of surgery may include aspiration of the retained secretions

OBJECTIVES Short term: After 4hours of NI, the pt will demonstrate absence of symptoms of respiratory distress

NURSING INTERVENTIONS -Assess rate and depth of respiration



Ineffective breathing pattern O: >Shortness of r/t anesthetic breath drugs secondary to surgical >difficulty of operation breathing >nasal flaring > chest retractions :>tachycardia >respiratory grunting >use of accessory muscles for breathing

-Provides baseline Short term: data Pt shall demonstrate absence of -Auscultate lung -The base of the symptoms of sounds at least every lungs are at least respiratory distress 4 hours for the first 48 likely to be hours postoperatively ventilated Long term: therefore lung patient shall have Long term: After 3 sounds may be days of NI, the distinguished over demonstrated behaviors that may patient will the bases prevent the demonstrate formation of retained behaviors that may -Encourage or assist -These actions patient to turn side to mobilize secretions in the prevent the formation secretions lungs of retained secretions side every 2 hours in the lungs -Encourage the patient -Deep breathing to do deep breathing keeps the alveoli exercises a minimum from collapsing of 10 times everyday -Encourage coughing every hour -This cleans the bronchial tree of secretions -Encourage ambulation as tolerated -Breathing effectiveness and mobilization of secretions are

enhanced by position change and an upright position








Self care deficit r/t For client’s O: pt may mobility musculoskeletal manifest: impairment trauma, further movements and >increased induce further dependence for injury. Patients self- care after ORIF, movement without >poor hygiene assistance can induce alteration >use of assisted in the fixation devices in moving plates and can alter alignment >hostility and fixation of the bones. Activities >irritable like self- care can be compromised thus compromising the patients hygiene.

>assess the degree of >for comparison Short Term: deficit and baseline data After 4 hours of NI, patient will patient will >assist patient in self- >for prevention of demonstrate demonstrate care like the use of straining understanding of understanding of bed bath acceptance of acceptance of situation and the >reinforce use of situation and the need for assistance. assistive devices with >to assist patient need for assistance. collaboration with the in doing self- care Long Term: acitivites Long Term: therapist patient will After 8 months of NI, >educate patient and >to empower the demonstrate prepatient will SO for importance of patient and SO injury dependence in demonstrate prehygiene meeting self care injury dependence in needs >provide positive meeting self care reinforcement in client > to empower the needs patient efforts