COLLEGE OF NURSING SILLIMAN UNIVERSITY Dumaguete City

NURSING CARE PLAN

INTRAOPERATIVE Phase

CUES/EVIDENCES Objective: - was induction of anesthesia by 2:50 pm - RASAB - Anesthetist: Dr. Joven A. Occea - Vital signs: - Capillary refill: <3 secs - O2 sat: - Surgical procedure: cystectomy

NURSING DIAGNOSIS Risk for Ineffective breathing pattern related to decreased lung expansion secondary to induction and effects of general anesthesia

OBJECTIVES At the end of the intraoperative stage, the client will maintain a normal breathing pattern, as evidenced by: a. Maintain vital signs within normal range: HR= 60-100 bpm RR= 15-20 cpm BP= 110-140/ 6090 mmHg

INTERVENTIONS Independent: a. Monitor vital signs every 5 mins. throughout the entire operation -

RATIONALE

EVALUATION

b. Capillary refill: <3 seconds

b. Monitor the respiratory pattern for rate, depth and rhythm every 5 minutes. Assess presence of cyanosis, restlessness, and use of accessory muscles, monitor oxygen saturation level c. Position patient appropriately, depending on respiratory effort and type of surgery. d. Elevate head of bed as appropriate to surgical procedure.

c. Absence of skin pallor, and cyanosis

d. Maintained normal O2 saturation level: 95- 100%

By the end, of the intraoperative stage, the client maintained a normal breathing pattern, as evidenced To provide by: comparative MET: baseline data and to a. Absence of pallor, and cyanosis develop appropriate b. O2 sat ranges from 95-100% plan of care. Increased PARTIALLY MET: respiration and a. Vital Signs especially BP, RR, and PR shows varied pulse rate suggests changes, as shown in this table: hypoxia - during operation: 2:55 3:30 4:05 4:50 Ascertains PR=72 PR= 70 PR=67 PR=65 effectiveness of RR=21 RR=17 RR=17 RR=17 respirations BP=103/65 BP=97/56 BP=108/50 BP=148/86 immediately so O2=97 O2=99 O2=100 O2=100 corrective measures 3:00 3:35 4:10 4:55 can be initiated PR=70 PR=72 PR=67 PR=67 RR=21 RR=17 RR=18 RR=19 BP=96/55 BP=97/56 BP=108/50 BP=147/83 O2= 97 O2=99 O2=100 O2=100 3:05 3:40 4:15 5:00 To enhance PR=97 PR=96 PR=70 PR=67 favorable air RR=21 RR=16 RR=15 RR=16 passage. BP=116/71 BP=99/57 BP=120/74 BP=144/85 O2=95% O2=99 O2=100 O2=100 3:10 3:45 4:20 PR=90 PR=67 PR=74 RR=20 RR=15 RR=19 Promotes maximal

Dependent: e. Administer supplemental O2 as indicated. O2 at 4 L/min.

expansion of lungs, decreasing risk of pulmonary complications.

f.

Provide/maintain ventilator assistance. -

Maximizes oxygen for uptake to bind with hemoglobin in place of anesthetic gases to enhance removal of inhalation agent Depending on cause of respiratory depression or type of surgery, endotracheal tube may be left in place and mechanical ventilation maintained for a time.

BP=107/58 O2=95% 3:15 PR=72 RR=15 BP=97/55 O2=99 3:20 PR=74 RR=17 BP=97/55 O2=99 3:25 PR=74 RR=17 BP=94/53 O2=99

BP=99/58 O2=99 3:50 PR=68 RR=14 BP=100/60 O2=99 3:55 PR=65 RR=15 BP=102/61 O2=100 4:00 PR=67 RR=15 BP=109/69 O2=100%

BP=125/85 O2=100 4:25 PR=65 RR=16 BP=124/86 O2=100 4:30 PR=67 RR=17 BP=133/79 O2=100% 4:45 PR=73 RR=156 BP=139/86 O2=100

NOT MET: a. capillary refill not checked