Nurse's Pocket Guide

Risk Factors
Disorientation; sensory/perceptual disturbances due to
anesthesia
Immobilization, muscle weakness; [preexisting musculoskeletal
conditions]
Obesity; emaciation; edema
[Elderly]
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as
the problem has not occurred and nursing interventions are
directed at prevention.
Desired Outcomes/Evaluation
Criteria—Client Will:
• Be free of injury related to perioperative disorientation.
• Be free of untoward skin and tissue injury or changes lasting
beyond 24 to 48 hours post-procedure.
• Report resolution of localized numbness, tingling, or changes
in sensation related to positioning within 24 to 48 hours, as
appropriate.
Actions/Interventions
NURSING PRIORITY NO.1.To identify individual risk factors/needs:
• Review client’s history, noting age, weight/height, nutritional
status, physical limitations/preexisting conditions (e.g., elderly
person with arthritis; extremes of weight; diabetes/other conditions
affecting peripheral vascular health; nutrition/hydration
impairments, etc.). Affects choice of perioperative positioning
and affects skin/tissue integrity during surgery.
• Evaluate/document client’s preoperative reports of neurologic,
sensory, or motor deficits for comparative baseline of
perioperative/postoperative sensations.
• Note anticipated length of procedure and customary position
to increase awareness of potential postoperative complications
(e.g., supine position may cause low back pain and
skin pressure at heels/elbows/sacrum; lateral chest position
can cause shoulder and neck pain, or eye and ear injury on
the client’s downside).
• Assess the individual’s responses to preoperative sedation/
medication, noting level of sedation and/or adverse effects (e.g.,
drop in BP) and report to surgeon, as indicated.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 419
risk for perioperative positioning INJURY