ปัญหา 3ข้อวินิจฉัยการพยาบาล เสี่ยงต

Problem 3Nursing implications The risk of complications after surgery.O supporting information: a General anaesthetic, the patient saw types of Anesthesia. O: patients undergoing Modified radical mastectomy surgery.O: after surgery, the patient has nausea, vomiting coughing with phlegm. Objectives. No complications after the surgery.Evaluation criteria. -Patients with abnormal bleeding. Normal respiration can I remove phlegm out effectively. Body movement in the early days after the surgery-Vital sign is a regular basis 100 = P-60 times/minute R = 16-24 times/minute T = 36.4-37.5 degrees Celsius. BP = 90/60-120/80 mmHgNursing activities.1.Checke Vital sign before undergoing surgery to compare before and after cutting through the symptoms.2. after surgery back to Check Vital sign every 15 minutes 4 times every 30 min 2 once and for all for 1 hour until the Vital sign will be in regular basis due to surgery to lose blood. As a result, blood circulation disorders Pulse beats slow and saw through the press, which has GA anaesthetic breathing after surgery, the patient may have symptoms, breathing fast or use muscles to breathe, so they often sign CheckVital helps detect abnormalities of the blood circulation and respiration has (supani SOE na di Sayid, 2547 (2004): page 692-698)3. observe the appearance of pale skin, dry up, hot or cold, and the level of consciousness of a patient review surgical incisions that ooze blood or anything out of line supervision. Radivac drain plug into the bottle, already noticed blood inside the bottle if more than 200 cc., the cable Clamp per hour, I found a doctor to report observed, bleeding, and blood, and the substance is very irregular flow, which may be harmful to the patient, causing shock and blood loss from those exposed to it (60 pages-phut linchong 69: Moon)4. Observe complications from goverment anaesthetic nausea, vomiting, kidney shape Bowl preparation, bedside or near the patient, and the patient coughing to remove phlegm out effectively due to the Government General Anesthesis type sodium Guard will have an effect on respiration and circulation system. When a patient feels may cause nausea, vomiting, rapid breathing and a lot are Observe, so saliva reduces cholesterol complications very closely to prevent complications that can cause hazard to the patient include vomiting, choked into the lungs (supani. SOE Nadi Sayid, 2547 (2004): 692 pages)5. the patient breath deep and remove the phlegm out. Be careful not to let the patient choked Vomit into the lungsBecause of the surgery, causing obstruction of the trachea in the lungs and cause pain in some of the deep breathing, cough, which helps the lungs expand and the steam will help to get rid of phlegm that exist to prevent blockage in the windpipe (supani. SOE Nadi Sayid, 2547 (2004): page 681)6. encourage the patient with the movement after the surgery as soon as the patient is limbs after surgery are helping themselves to observe and take care not to sit for very long toes dangle.Because the surgery could cause inflammation of the vein, and the blood that has come on the ice contribute to the incidence of blocked circulation in the veins, it must provide the patient with the movement after surgery, to prevent the incidence of partitions in the veins and not to sit for very long because the foot dangle would make a comfy foot area of the blood.7. lift the wood blocking beds because of back surgery. The patient may also rarely feel good. Saluemot wooden raised bed barrier to starvation to prevent patients falling and potentially (supani. SOE Nadi Sayid, 696-698) page: 2547 (2004)8.ส่งเสริมการทำงานของ Radivacdrianโดยตรวจดูสายระบายของ Radivac drain ไม่ให้หักพับงอ หรืออุดตัน บีบรีดสายท่อระบายRadivacdrain ทุก 1-2 ชั่วโมง เนื่องจากการใส่ท่อระบายRadivac drain คือการระบายเลือดลสารคัดหลั่ง อาจมีตะกอน หรือลิ่มเลือดมาอุดตันสายทำให้เลือดและสายคัดหลั่งระบายออกมาไม่ได้การตรวจดูสายจะช่วยป้องกันไม่ให้ตะกอนหรือลิ่มเลือดมาอุดกั้นสายตรวจดูขวด Radivac drain หากเต็มให้เปลี่ยนขวดโดยยึดหลักปราศจากเชื้อ และclampสายท่อระบายทุกครั้ง เพื่อป้องกันการติดเชื้อและการของเลือดและสารคัดหลั่งขณะเปลี่ยนขวดดูแลให้ขวด Radivac drain เป็นสูญญากาศอยู่เสมอโดยดูที่ฝาขวดหากเป็นสูญญากาศฝาจะหด ถ้าไม่เป็นสูญญากาศฝาจะขยายตัวออก เนื่องจากเครื่อง Radivac drainไม่เป็นสูญญากาศจะไม่สามารถดูดเลือดและสารคัดหลั่งออกได้จัดวางขวด Radivac drain ให้อยู่ในระดับต่ำกว่าแผล เพื่อป้องกันการไหลย้อนกลับของเลือดและสารคัดหลั่ง แนะนำไม่ให้ผู้ป่วยออกแรงมากในข้างที่ใส่ Radivac drain ได้แก่ไม่ใช้แขนข้างที่ใส่ท่อ Radivac drainลากหรือดึงของหนักเพื่อป้องกันการหลุดของRadivac drain(ลินจง จันทร์พุฒ:หน้า 60-69)9. If a patient complains of pain a lot, every vein and mg 3 pill Morphin 6 hours according to the physician's treatment plan.Because if the patient has a large wound pain may cause symptoms of hyperthyroidism can cause shock and feel restless, Kanagawa. It's Morphin 3 mg pills, every vein 6 hours according to the physician's treatment plan is to relieve pain and prevent the symptoms feel restless and was exposed to very painful shock from WA.10. notice side effects of the drug if there are 3 mg Morphin experience side effects such as nausea, vomiting, pills 10 mg every 8 hours, Plasil, as medical treatment plan.To relieve nausea, vomiting (Levitating, melodious, 2554 (2011))Assessment.-Patients with abnormal bleeding. Normal respiration can I remove phlegm out. Body motion in 2 days after surgery with nausea, but not vomiting.-Vital sign value is P = 80 times/min R = 20 times/minute T = 36.8 degrees Celsius = 100 BP/70 mmHg.The problem of obstacles in implementing the plan-The patient is complaining of pain and so does not provide medication to all 3 vein 6 Morphin mg Plasil10 mg 8 hours and every hour, according to the doctor's treatment plan.To improve evaluation performance-Find out more about complications after surgery and symptoms within nested transaction from the Government hospital anaesthetic to make complete and valid.

Problem 3
nursing diagnoses Risk of complications after surgery
support O: Patient Anesthesia General Anesthesia Type
O: Patients underwent surgery Modified Radical mastectomy
O: After surgery, patients were nausea, vomiting, cough with phlegm purpose. No adverse postoperative evaluation criteria - patients without abnormal bleeding, breathing normally be coughing up phlegm out effectively. The body was in the first days after surgery -Vital sign within the normal P = 60-100 beats / min R = 16-24 beats / min, T = 36.4-37.5 ° C BP = 90 / 60-120. / 80 mmHg nursing activities 1.Checke Vital sign before the surgery. To compare symptoms before and after the cut 2. After back surgery to Check Vital sign every 15 minutes 4 times every 30 minutes to 2 hours until Vital sign and every one will be in the normal range. The surgery resulted in the loss of blood. As a result, blood flow is slow and irregular pulse, GA which has the effect of anesthesia, respiratory depression after surgery, the patient may have difficulty breathing fast. Or use their breathing muscles must CheckVital sign it because it allows them to detect abnormalities of the blood circulatory system. And breathing (Supanee Senadisai, 2547: pages 692-698) 3. Observe the appearance of the skin pale, dry, hot or cold, and level of consciousness of the patients examined with blood or other foreign matter that wound exudate charge Radivac drain. on the bottle carefully observed bleeding inside the bottle, if more than 200 cc. per hour Clamp put on hold if a doctor to observe hemorrhage and bleeding and vaginal flow is very unusual, which may be harmful to the patient. The shock from blood loss was (Linjong. Monday Decision: Home 60-69) 4.Observe to complications from anesthesia, nausea, vomiting Prepare emesis basin beside the bed or near the patient. And the patient coughing up phlegm out effectively because of sniffing guard General Anesthesis negative effect of respiratory depression and functioning of the circulatory system. When patients feel may cause nausea, vomiting, rapid breathing, increased secretions and saliva, so it must have complications Observe closely to prevent complications that may cause harm to the patient, including choking, vomiting into the lungs (Supanee. Senadisai, 2547: 692) 5. breathing deeply. And coughing up phlegm out Be careful not to choke patients Vomit into the lungs due to surgery cause of airway obstruction in some of the pain caused atelectasis and deep breathing can cause coughing, which helps the lungs fully extended. Eliminates phlegm and coughing are available. To prevent blockage in the pharynx (Supanee. Senadisai, 2547: 681) 6. Encourage the patient is moving soon after surgery. For patients to exercise their limbs after surgery include assistance in activities of daily living and take care not to sit and dangle your feet any longer due to the surgery. May cause inflammation of the veins and the blood clot that caused the island to the obstruction of the flow in the vein so that the patient is moving faster after surgery to prevent obstruction of the blood vessels. black And not to sit dangling feet long. It will have a blood clot in foot 7. Lift Barriers bed due to back surgery. Patients may also not a good feeling drowsy should be given one more barrier to prevent the patient out of bed and dangerous (Supanee. Senadisai, 2547: pages 696-698) 8. Promote the work. Radivacdrian by reviewing the drain line of Radivac drain not folded or rolled or clogged sewer line Radivacdrain squeeze every 1-2 hours because of drain Radivac drain is to drain blood and fluids may precipitate or blood clots. cord blood clots and the secretions out, not to monitor calls to help prevent blood clots from sediment or obstructive patrol Radivac drain if the bottle is full, change principle sterile bottle. Sewer line and clamp it. To prevent infection and blood and secretions while changing Radivac drain bottle to bottle and a vacuum is always by looking at the bottle if a vacuum cap is shrinking. If a vacuum cap to expand. Because Radivac drain a vacuum to suck the blood and secretions can not get that bottle out Radivac drain to a level below the wound. To prevent the backward flow of blood and secretions. The patient was advised not to put much effort in the Radivac drain pipes are not the arm and dragging or pulling heavy objects Radivac drain to prevent the loss of Radivac drain (Linjong Monday Listing page. 60-69) 9. If the patient complained of pain medication Morphin 3 mg intravenously every 6 hours, according to the medical treatment plan due. If the patient has pain can cause restlessness and may cause a shock it must be administered Morphin 3 mg intravenously every 6 hours, according to the medical treatment plan. For pain relief And to prevent the development of severe agitation and shock from the pain and side effects of medications 10. Observe if the duty Morphin 3 mg side effects, including nausea, vomiting, drug Plasil 10 mg every 8 hours, according to the medical treatment plan to relieve symptoms. nausea and vomiting (exquisitely cool melodic, 2554) assessment - the patient is not breathing, bleeding disorders can normally coughing up phlegm out. The body is in 2 days after surgery. Nausea But not vomiting -Vital sign the value is P = 80 beats / min, R = 20 beats / min, T = 36.8 ° C BP = 100/70 mmHg problems in the implementation of the plan - the patient did not complain of pain, so it does not provide. Drug Morphin 3 mg intravenously every 6 hours and Plasil10 mg every 8 hours, according to the medical treatment plan evaluation results to improve - learn more about the signs and symptoms of postoperative complications from anesthesia stacked placenta. To provide nursing care to fully and accurately.

The problem 3
nursing diagnoses. The risk of complications after surgery
data supporting O: patient anesthesia type General Anesthesia
O: patients undergoing surgery Modified. Radical mastectomy
O: after the operation, patients have nausea and vomiting cough with phlegm

.The purpose, no complications after surgery
evaluation criteria.
- patients with no bleeding. Normal breathing, can make the CIA sputum out effectively. The movement of the body in the first day after the drivers operation
.- Vital sign normal P = 60-100 times / minute R = 16-24 times / minute T = 36.4-37.5 C
BP = 90 / 60-120 / 80 mmHg

1.Checke nursing activities. Vital sign before surgery. To compare the symptoms before and after passing the cut
2.After the operation back to Check Vital sign every 15 minutes 4 times. Every 30 minutes 2 times and every 1 hours until Vital sign are within normal range. Surgery is due to blood loss. Due to the slow pulse, blood circulation disorders.GA which is able to press the breathing after surgery, patients may have shortness of breath. Or use the muscle can help breathing must CheckVital sign often because it allows the detected abnormalities ของระบบไหลเวียนเลือด. And breathing (สุปาณี. Sena, disk?2547: page 692-698)
3.To observe the characteristics of the skin, pale, dry up, hot or cold, and level of consciousness of patients to see the wound that blood or alien ooze out of line. Radivac drain.