Medical Surgical Nursing

by providing rest periods and

assisting with activities.

3. Change position every 2 h.

4. Assist with paracentesis or

thoracentesis.

a. Explain procedure

and its purpose to

patient.

b. Have patient void

before paracentesis.

c. Support and maintain

position during

procedure.

d. Record both the

amount and the

character of fluid

aspirated.

e. Observe for evidence

of coughing,

increasing dyspnea,

or pulse rate.

expansion

2. Reduces metabolic and

oxygen requirements

3. Promotes expansion and

oxygenation of all areas of

the lungs

4. Paracentesis and

thoracentesis (performed to

remove fluid from the

abdominal and thoracic

cavities, respectively) may

be frightening to the patient.

a. Helps obtain patient's

cooperation with

procedures

b. Prevents inadvertent

bladder injury

c. Prevents inadvertent

organ or tissue injury

d. Provides record of

fluid removed and

indication of severity

of limitation of lung

expansion by fluid

e. Indicates irritation of

the pleural space and

evidence of

pneumothorax or

hemothorax.

shortness of breath

 Reports increased strength

and sense of well-being

 Exhibits normal

respiratory rate (12–

18/min) with no

adventitious sounds

 Exhibits full thoracic

excursion without shallow

respirations

 Exhibits normal arterial

blood gases

 Exhibits adequate oxygen

saturation by pulse

oximetry

 Experiences absence of

confusion or cyanosis

Collaborative Problem: Gastrointestinal bleeding and hemorrhage

Goal: Absence of episodes of gastrointestinal bleeding and hemorrhage

1. Assess patient for evidence

of gastrointestinal bleeding

or hemorrhage. If bleeding

does occur:

a. Monitor vital signs

1. Allows early detection of

signs and symptoms of

bleeding and hemorrhage

2. Minimizes increases in intra-

abdominal pressure that

10. Assess patient for

evidence of

gastrointestinal bleeding

or hemorrhage. If bleeding

does occur: