---Ineffective breathing patteren related to anestesia pain and analgesic/sedative medications.
-Maintain O2 therapy as ordered to prevent hypoventilation. which can be an effect of analagesics, decreased LOC or an incision in the thorax causing painful respirations.
-Encourage deep breathing to expand the lungs
-Give analgesics carefully to promote deep breathing but avoid respiratory depression
-Maintain CPAP/BiPap to treat slee[ a[nea.
-Report respiratory depression to the anesthesioloist to obrain prompt treatment.
---Ineffective airway clearance related to obstruction, anesthesia medications and secretions.
- ensure that patient maintains a patent airway because airway obstruction may result when relaxed muscles allow the tongue to block the pharynx in patients with a decreased LOC
-Use jaw thrust method to manually open patients airway if a patient has snoring respirations and has not completely emerged from anesthesia.
---Ineffective airway clearance related to ineffective cough and secretion retention
-Monitor breath sounds
-Encourage deep breathing and coughing and use of incentive spirometer hourly while awake.
-Ensure the patients pain is relieved before activity.
-Encourage movement by turning every 2 hours and ambulating as able.
---Patient will maintain blood pressure, pulse, and urine output within normal limits at all times.
-Check dressing and incisions for color and amount of drainage to detect fluid
-Maintain IV fluids at ordered rate to replace lost fluids but avoid fluid overload.
-Monitor intake and output to detect imbalances.
---Disturbed sensory perception related to decreased LOC, amnesiac effects of anesthesia or spinal anesthesia.
-Verify patient data until patient data until patient is awake and can communicate to prevent errors.
-Maintain safety with side rails and extremities positioned in proper alignment and protected until patient is fully awake or extremity movement and sensation return following spinal anesthesia to prevent injury.-Secure and observe tubes, dressings, and IVs to prevent dislodgement.
-Provide orientation explanations as patient awakens and repeat them until amensiac anesthesia effects have resolved.
---Pain realted to tissue damage.
-The patient will report that pain is relieved at a satisfactory level within 15 to 30 minutes of the pain report.
-Monitor the patient for pain because pain may be the result from surgical procedure, movement, deep breathing anxiety, a full bladder, positioning during surgery, nasogastric tubes, catheters, IVs, ET tubes or prior medical conditions such as arthritis, cancer, or back pain.
-Give IV opiod analgesics promptly for their rapid onset.
-Begin PCA as ordered because it is started in PACU
-Reposition the patient, provide warmth and empty full bladder to help alleviate pain.
-Play music (nature sounds or classical) in the PACU, dim lights, and reduce room noise to help alleviate pain.
---Pain related to surgery, nausea, and vomiting.
-Explain pain relief interventions and set goals with patient for pain management.
-Assess pain using rating scale such as 0-10.
-Provide analgesics prn
-Provide antiemtics prn
-Position patient comfortably