PREOPERATIVE PERIOD Cues/Evidences Objective cues: Vital signs: T = 35.

5.20C PR = 162 bpm, strong and regular RR = 38 cpm, regular, with sternal retractions Nursing Diagnosis Risk for injury related to developmental age Objectives Within our care, the patient will remain free from injury as evidenced by: Vital signs within normal range Absence of crying and restlessness Refrain from extreme movements Provision of sufficient restraints Provision of safety measures Interventions Ongoing Assessment - Assess vital signs. Independent - Identify individual risk factors, e.g., airway patency, therapeutic use of potentially toxic medications, invasive lines/procedures, exposure to latex products, impaired neurological status, seizure activity, exposure to safety hazards, immobility/use of restraints, presence of fractures, malnutrition, fluid deficit/excess. - Handle infant/child gently. Provides opportunity to modify environment/ eliminate factors that place child at risk. Rationale Evaluation After our care, the patient remained free from injury as evidenced by: -MET Vital signs within normal range Absence of crying and restlessness Refrain from extreme movements Skin/tissues are more fragile and at greater risk for damage. Permits monitoring of patients well-being, allows for timely intervention. Preventing injuries and complications is a prime responsibility of parents and caregivers. Provision of sufficient restraints Provision of safety measures

To obtain baseline data.

Intense crying
and restlessness noted Extreme movements Insufficient restraints High OR bed level

- PROVIDE APPROPRIATE LEVEL OF SUPERVISION. - Initiate safety precautions as individually appropriate, e.g., bed in low position, padded side rails, infection precautions, medications in childproof containers, etc.

- Have age-appropriate equipment available, e.g., properly sized BP cuffs, IV catheters, airway adjuncts, and oxygen mask/hood; suction equipment, ventilator bag, lowflow IV pump, warming devices. - Monitor medication administration closely, especially dosage measurements and conversions. Use pediatric concentrations of medications when available. - Ascertain recurrent exposure to latex gloves, catheters/tubing, etc. Note history of allergies, eczema. Collaborative Refer to community education programs and resources as indicated.

Prevents treatment-related injuries and ensures availability of life-saving equipment.

Provides for effective therapeutic management, prevents overdose, and reduces risk for toxic reactions.

Repeat exposure increases risk of developing sensitivity/adverse reaction to latex products.

Can provide additional opportunities for improving parenting skills, obtaining necessary equipment.

Cues/Evidences

Nursing

Objectives

Interventions

Rationale

Evaluation

Diagnosis Objective cues: Vital signs: T = 35.20C PR = 162 bpm, strong and regular RR = 38 cpm, regular, with sternal retractions Intense crying and restlessness noted Extreme movements Facial grimacing noted Diaphoresis noted Irritable Altered comfort: Severe pain related to invasive procedure: IVF therapy Within our care, the patients level of pain is reduced as evidenced by: Vital signs within normal range Absence of intense crying and restlessness Refrain from extreme movements Absence of diaphoresis and facial grimacing Less irritable Independent - Perform routine comprehensive pain assessment, including location, characteristics, onset/duration, frequency, quality, severity (using 010 scale, facial expressions, or color scale). - Investigate changes in frequency of pain. - Observe for guarding, rigidity, and restlessness. Assessment of children involves observational skills and may require enlisting the aid of parent/caregiver to clarify cues and verbalizations. May signal worsening of condition or development of complications. Nonverbal expressions may signal pain or changes in pain severity. Ongoing Assessment - Assess vital signs. To obtain baseline data. Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain. After our care, the patients level of pain is reduced as evidenced by: -MET Vital signs within normal range Absence of crying and restlessness Refrain from extreme movements Absence of diaphoresis and facial grimacing Less irritable

- Monitor heart rate, blood pressure (BP) (using correctly sized cuff), and respiratory rate, noting age-appropriate normals/variations.

Changes in autonomic responses may indicate increased pain before child verbalizes. Note: Autonomic responses change with acute pain not chronic pain.

- Note location/ type of

invasive procedure, injuries/trauma. - Provide comfort measures, e.g., repositioning, back rub, use of heat/cold.

Influences degree/severity of pain manifestations. Nonpharmacological pain management promotes relaxation, may reduce level of pain and enhance coping. Helps reduce fatigue and enhances coping ability.

Collaborative Encourage rest periods. Dependent ADMINISTER ANALGESIC MEDICATIONS AS INDICATED.

A REGULAR SCHEDULE MAY BE REQUIRED TO MANAGE PAIN EFFECTIVELY. AS CONDITION RESOLVES, ADVANCING TO A PRN SCHEDULE MAY BE SUFFICIENT.

Cues/Evidences

Nursing Diagnosis Risk for fluid volume deficit related to NPO status and of extreme age

Objectives Within our care, the patient will maintain fluid volume at functional level as evidenced by: Vital signs within normal range urine output of 30cc/hr blood values maintained within normal range pinkish skin and nail beds color palpable pulses of good quality, normal skin turgor and warm to touch skin well hydrated moist mucous membranes good capillary refill

Interventions Independent Asses and monitor vital signs.

Rationale

Evaluation After our care, the patient maintained fluid volume at functional level as evidenced by: -MET Vital signs within normal range urine output of 30cc/hr blood values maintained within normal range pinkish skin and nail beds color palpable pulses of good quality, normal skin turgor and warm to touch skin well hydrated moist mucous membranes good capillary refill

Objective cues: Vital signs: T = 35.20C PR = 162 bpm, strong and regular RR = 38 cpm, regular, with sternal retractions On NPO status 3 months old Skin pinkish to pale in color Good skin turgor

Monitoring can provide reference that vital signs are altered due to fluid loss/fluid deficit. Hypotension, tachycardia, increased respirations may indicate fluid deficit, e.g., dehydration/hypovolemi a. Although a drop in blood pressure is generally a late sign of fluid deficit (hemorrhagic loss), widening of the pulse pressure may occur early, followed by narrowing as bleeding continues and systolic BP begins to fall. Accurate documentation helps identify fluid losses/ replacement needs and influences choice of interventions. Cool/clammy skin, weak pulses indicate decreased peripheral circulation and need for additional fluid replacement. This will provide caregivers the baseline

Noting changes in blood pressure, heart rate and rhythm, and respirations. Calculate pulse pressure.

Skin and lips

slightly dry Slightly moist mucous membranes Capillary refill of less than 2 secs. CBC: Hg: Hct:

Measure and record I&O (including tubes and drains). Calculate urine specific gravity as appropriate.

Monitor skin temperature, palpate peripheral pulses.

Assess for causative or precipitating factor like hemorrhage or drainage from wounds/fistulas, or

suction device.

Asses for dry mucous membranes, poor turgor, Assessing will give the and thirst. caregiver the idea that patient is experiencing dehydration. Dependent Administer parenteral fluids, blood products (including autologous collection), and/or plasma expanders as indicated. Increase IV rate if needed.

data so that they may/can be guided for the level of intervention to be provided.

COLLABORATIVE Monitor laboratory studies, e.g., Hb/Hct, electrolytes. Compare preoperative and postoperative blood studies.

Replaces documented fluid loss. Timely replacement of circulating volume decreases potential for complications of deficit, e.g., electrolyte imbalance, dehydration, cardiovascular collapse. Note: Increased volume may be required initially to support circulating volume/prevent hypotension because of decreased vasomotor tone following Fluothane administration. Indicators of hydration/circulating volume. Preoperative anemia and/or low Hct combined with unreplaced fluid losses intraoperatively will further potentiate deficit.