Scribd
Upload
39 views2 pages

Cues Objective S Interventions Rationale Evaluatio N Subjective: Short Term Objectives: Independent: Short Term

The nurse will assess an 85-year-old patient scheduled for surgery to identify risks of hypothermia and develop a plan to maintain normal body temperature. Interventions include monitoring temperature before and during surgery, noting medications and body characteristics, and using warming techniques like blankets and fluids. Goals are for the patient to have normal temperature after 8 and 24 hours with behaviors showing appropriate temperature regulation.

Uploaded by

THERESA CLAIRE ENCINARES
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
39 views2 pages

Cues Objective S Interventions Rationale Evaluatio N Subjective: Short Term Objectives: Independent: Short Term

The nurse will assess an 85-year-old patient scheduled for surgery to identify risks of hypothermia and develop a plan to maintain normal body temperature. Interventions include monitoring temperature before and during surgery, noting medications and body characteristics, and using warming techniques like blankets and fluids. Goals are for the patient to have normal temperature after 8 and 24 hours with behaviors showing appropriate temperature regulation.

Uploaded by

THERESA CLAIRE ENCINARES
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

CUES OBJECTIVE INTERVENTIONS RATIONALE EVALUATIO

S N
Subjective: Short Term Independent: Short Term:
Objectives:
1. Ascertain the  This helps in  After 8
 After 8 identifying hours of
type of surgical
hours of elements of nursing
nursing procedure the risks. interventi
interventi on, the
client is having
on, the  Very thin, patient
patient 2. Note the client’s malnourished, displays
Objective: will be or dehydrated a core
body type and
able to individuals, as temperat
 Patient display age. well as the very ure within
is 85 core young or elderly normal
years temperat are more range.
old ure susceptible to
 Noted within perioperative Goal met.
BMI is normal hypothermia.
3. Note client’s
23 range.
 Albumi medication  Medications
n level including dome
regimen.
noted vasodilators,
as 3.3 antipsychotics,
g/dL and sedatives
can impair the
body’s ability to Long Term:
Long Term 4. Measure the regulate its
Objectives: temperature.  After 24
client’s
hours of
 After 24 temperature  For hypothermic nursing
hours of patients, core interventi
preoperatively,
nursing temperature can on, the
interventi and confirm that be monitored patient
on, the using a demonstr
continuous
patient temperature- ates
will be monitoring of sensitive behavior
able to pulmonary s for
temperature is
demonst artery catheter monitorin
rate occurring during or bladder g and
behavior catheter. maintaini
the procedure.
s for ng
monitorin Report a appropria
g and preoperative te body
maintaini temperat
temperature
ng ure.
appropri below the ideal
ate body Goal met.
range to the
temperat  Evidence
ure. surgical supports
commencement
team/anesthesio
of active
logist warming
preoperatively
and monitoring
Dependent:
it throughout the
Collaborative:
intraoperative
1. Implement
period.
preventive
warming
techniques
(e.g., blankets
from warmer in
holding area;
forced air
warming, warm
IV and irrigation
fluids) in the
operating room.

You might also like