Question

2. Choose TWO potential postoperative problems from different physiological areas (i.e. respiratory, circulatory, etc.) List the clinical signs, preventive interventions, and a nursing diagnosis for that problem.

Answer 1

Nursing Diagnosis

• Risk for ineffective airway clearance related to depressed respiratory function,pain and bed rest.

Clinical signs

• Decreased breath sounds.over the affected area.
• Crackles
• Cough
• Hypostatic pulmonary congestion.

Preventive interventions and timely recognition of signs and symptoms help avert pulmonary complications.Strategies to prevent respiratory complications include

• Use of an incentive spirometer and deep breathing and coughing excercises.Crackles indicate static pulmonary secretions that need to be mobilized by coughing and deep breathing excercises.To clear secretions and prevent pneumonia,the nurse encourages the patient to turn frequently and take deep breaths atleast every 2 hours.Coughing is also encouraged to dislodge mucus plug.
• Early ambulation increases metabolism and pulmonary aeration and in general,improves all body functions.The patient is encouraged to be out of bed as soon as possible.

Decreased cardiac output related to shock and haemorrhage.

The primary clinical complications are hypotension,shock,haemorrhage,hypertension and dysryhthmias.

Theclassic signs of hypotension are pallor,cool moist skin,rapid breathing,Cyanosis of the lips ,rapid weak and thready pulse,narrowing pulse pressure ,low BP and concentrated urine.

Incase of haemorrhage patient becomes apprehensive,restlessness and thirsty,skin is cold ,moist and pale,pulse rate increases,temperature falls ,respirations are rapid and deep.

Preventive interventions include

• Venous stasis from dehydration,immobility and pressure on leg veins during surgery put the patient at risk for deep vein thrombosis.Leg excercises and frequent position changes are initiated early in the postoperative period to stimulate circulation .Patients should avoid positions that compromise venous return ,such as raising the beds knee gatch,placing a pillow under knees ,sitting for long periods and dangling the legs with pressure at the back of the knees .Venous return is promoted by elastic compression stockings and early ambulation .Early ambulation has a significant effect on recovery and the prevention of complications .Postoperative activity orders are checked before the patient is assisted to get out of bed.Sitting up at the edge of bed for a few minutes maybe all that the patient who has undergone a major surgical procedure can tolerate at first.