(^486) Medical-Surgical Nursing Demystified
- low–molecular weight heparin
- warfarin
NURSING DIAGNOSES
- Decreased cardiac output
- Ineffective cardiopulmonary tissue perfusion
- Ineffective peripheral tissue perfusion
- Impaired physical mobility
NURSING INTERVENTIONS
- Monitor vital signs for changes.
- Check blood pressure lying down and sitting up for orthostatic change.
- Monitor cardiovascular status for cardiac rhythm, heart sounds, peripheral
pulses, capillary refill, and pulse deficit. - Assess for peripheral edema.
- Ask patient about calf pain or tenderness.
- Monitor intravenous site for signs of infiltration.
- Encourage ambulation and leg exercises to prevent development of DVT.
- Monitor proper use of elastic stockings or sequential compression devices
postoperatively.
Respiratory Complications
Patients with preexisting respiratory disorders, obesity, or thoracic or upper abdom-
inal surgical procedures are at greater risk of developing respiratory complications
postoperatively.WHAT WENT WRONG?
After surgery, patients are not as mobile. This lack of physical activity leads to
diminished chest wall and diaphragmatic movement, resulting in a decreased
amount of air exchange. Alveolar sacs can collapse, leading to areas of atelectasis.6