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SURGICAL INTERVENTION Surgery may be needed to diagnose or cure a specific disease process, correct a structural deformity, restore a functional process, or reduce the level of dysfunction/pain. Although surgery is generally elective or preplanned, potentially life-threatening conditions can arise, requiring emergency intervention. Absence or limitation of preoperative preparation and teaching increases the need for postoperative support in addition to managing underlying medical conditions. CARE SETTING May be inpatient on a surgical unit or outpatient/short-stay in an ambulatory surgical setting. RELATED CONCERNS Alcohol: acute withdrawal Cancer Diabetes mellitus/Diabetic ketoacidosis Fluid and electrolyte imbalances Hemothorax/Pneumothorax Metabolic acidosis Metabolic alkalosis Peritonitis Pneumonia, microbial Psychosocial aspects of care Respiratory acidosis Respiratory alkalosis Sepsis/Septicemia Thrombophlebitis: DVT Total nutritional support Also refer to plan of care for specific surgical procedure performed. Patient Assessment Database Data depends on the duration/severity of underlying problem and involvement of other body systems. Refer to specific plans of care for data and diagnostic studies relevant to the procedure and additional nursing diagnoses. CIRCULATION May report: History of cardiac problems, heart failure (HF), pulmonary edema, peripheral vascular disease, or vascular stasis (increases risk of thrombus formation) May exhibit: Changes in heart rate (sympathetic stimulation) EGO INTEGRITY May report: Feelings of anxiety, fear, anger, apathy Multiple stress factors, e.g., financial, relationship, lifestyle May exhibit: Restlessness, increased tension/irritability Sympathetic stimulation, e.g., changes in heart rate (HR), respiratory rate ELIMINATION May report: History of kidney/bladder conditions; use of diuretics/laxatives FOOD/FLUID May report: Pancreatic insufficiency/DM (predisposing to hypoglycemia/ketoacidosis) Use of diuretics May exhibit: Malnutrition (including obesity) Dry mucous membranes (limited intake/nothing-by-mouth [NPO] period preoperatively)
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RESPIRATION May report: Infections, chronic conditions/cough, smoking May exhibit: Changes in respiratory rate (sympathetic stimulation) SAFETY May report: Allergies or sensitivities to medications, food, tape, latex, and solution(s) Immune deficiencies (increases risk of systemic infections and delayed healing) Presence of cancer/recent cancer therapy Family history of malignant hyperthermia/reaction to anesthesia, autoimmune diseases History of hepatic disease (affects drug detoxification and may alter coagulation) History of blood transfusion(s)/transfusion reaction May exhibit: Presence of existing infectious process; fever TEACHING/LEARNING May report: Use of medications such as anticoagulants, steroids, antibiotics, antihypertensives, cardiotonic glycosides, antidysrhythmics, bronchodilators, diuretics, decongestants,
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