Question

Need 3 nursing diagnoses for 3 interventions, 3 interventions are

1. Pain assesment

2. Raise head bed

3. Intsruct deep breath

The nurse is assessing a 72 year old client at 1430 after a minor outpatient surgical procedure. What diagnosis and resulting intervention would support the data? You describe the data and diagnosis that would support the intervention listed. Example: Intervention: Cover with warm blanket. 0830 Pre-op assessments: Oral Temp 97.9 F, Pulse 78, BP100/80, SpO2 96%, Oriented X 4, Resp 16 1430 Post-op assessments: Oral Temp 97.1 F, Pulse 68, BP 112/78, Spo2 96%, somnolent, Resp 12 Nursing Diagnosis: Risk for hypothermia r/t age sensitivity and loss through conduction AEB 0.8 degree F change from baseline.
Know that respirations have dropped, pulse is decreased, BP small change and is somnolent post op.

Answer 1

1.Pain

Acute pain related to surgical procedure as evidenced by incision secondary to disease condition

2.Raise head bed

Risk for decreased cardiac output related to age,medication, disease as evidenced by decreased pulse

Altered cardiac output related to post operative state as evidenced by decreased blood pressure

3.Instruct deep breath

Ineffective breathing pattern related to surgery as evidenced by decreases respiratory rate