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Patient Symptoms May exhibit: Increased tension Apprehension Expressed concern regarding condition Restlessness Facial tension Focus

on self Irritable

Nursing Diagnosis & Intervention Anxiety r/t fear of the unknown

Dependent Management Medical:

Expected Outcome After nursing intervention, patient will: Acknowledge feelings and identify healthy ways to deal with them. Report decreased fear and anxiety reduced to a manageable level.

Complication Management s

1. Compare surgery 1. Serve as a schedule, chart, witness in patient signing the identification consent of band and the patient signed with the operative physician consent. 2. Provide 2. Assist preoperative anesthesiol education. ogist. Discuss anticipated Pharmacologic: things that may frighten/concer 1. Administer n patient and medication significant s as others. Then indicated. assess level of 2. Administer understanding. supplement 3. Tell patient al oxygen anticipating as local/spinal indicated/n anesthesia that eeded. drowsiness occurs.

Respiratory Depression

Proper positioning; Emergency drugs and equipment should be prepared.

4. Instruct patient exercises that will benefit the patient postoperatively . 5. Introduce staff at time of transfer to operating suite. 6. Prevent unnecessary body exposure during transfer and in OR suite. 7. Give simple, concise directions/expla nations to sedated patient. 8. Control of external stimuli.

Patient Symptoms Vital signs taken as follows: PR-116 bpm RR- 29 bpm BP190/100 mmHg

Nursing Diagnosis & Intervention Risk for bleeding related to invasive surgical procedure. Independent: Monitor/docu-ment trends in heart rate and BP, especially noting hypertension. Be aware of specific systolic/diastolic limits defined for patient.

Dependent Management Medical: Administer supplemental oxygen, as indicated. Monitor cardiac output and other functional parameters as appropriate.

Expected Outcome

Complication s


Maximal oxygenation can be achieve which can reduce cardiac workload. Response to therapeutic interventions and identifying need for more aggressive/emerg ency care were evaluated properly.

Hypotension due to decrease in circulatory volume Hemorrhagic shock

Positioning and emergency drugs should be prepared. Control external haemorrhage by elevating the limb and by direct firm pressure with a clean pad

Have emergency equipment/medicat Maintain IV ions available. access as indicated.

Administration of emergency drugs needed during surgery were given promptly. Blood and fluid loss were restored/maintain ed for adequate circulating volume and enhanced oxygen-carrying capacity. Electrolytes, antidysrhythmics, and other heart medications may be required on a short-term or long-term basis to maximize cardiac contractility/outp ut.

Changes in level of consciousNess

over the bleeding site. Give oxygen in a high inspired concentration by face mask. Intubate patients who are unconscious Keep environment in a conducive manner and an immediate replacement of blood is needed.

Administer IV fluids/blood transfusions as needed.

Hypothermia due to decreased perfusion and evaporation of sweat

Pharma: Administer electrolytes and medications as indicated, e.g., electrolyte solutions/potassium, antidysrhythmics, beta-blockers.

Patient Symptoms

Nursing Diagnosis and Interventions Ineffective tissue perfusion related to vasoconstriction of blood vessels

Dependent Management Medical

Expected Outcome



Pulse rate= 116 bpm Respiratory rate= 29 cpm

Provide supplemental oxygen as prescribed.

Increases oxygen supply to the myocardium

Blood clot

Blood thinning medications such as warfarin (Coumadin).

Blood pressure = 190/100 mmHg

Independent Inspect for pallor, cyanosis, mottling and cool or clammy skin. Note strength of peripheral pulses. Monitor respirations. Monitor intake, noting changes in urine output.

Obtain a 12lead ECG monitoring. Pharmacologi c Administer antiplatelet agents such as aspirin, abciximab (ReoPro), eptifibatide (Integrilin) and clopidogrel (Plavix) as ordered.

Determine arrhythmias.

Aspirin reduces coronary reocclusion after Percutaneous Transluminal Coronary Angioplasty(PT CA). IV antiplatelet drugs such as ReoPro and Integrilin are used as adjuncts to PTCA to decrease complication of platelet clumping within stent when placed. Low dose heparin is given

Anticoagulants such as heparin/enoxap

arin (Lovenox)

during PTCA and may be given prophylactically in high risk client to reduce risk of thrombophlebiti s.