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Anesthesia

The patient reported worsening headache and difficulty breathing after a cesarean section under regional anesthesia. The plan was to elevate the head of the bed to improve breathing, encourage deep breathing exercises, and provide a calm environment and comfort measures to relieve symptoms within 6-8 hours without pharmacological intervention.

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JAMES ROD MARINDUQUE
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38 views2 pages

Anesthesia

The patient reported worsening headache and difficulty breathing after a cesarean section under regional anesthesia. The plan was to elevate the head of the bed to improve breathing, encourage deep breathing exercises, and provide a calm environment and comfort measures to relieve symptoms within 6-8 hours without pharmacological intervention.

Uploaded by

JAMES ROD MARINDUQUE
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
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVAL

Subjective Data: Impaired After 6-8 Independent -The


"My headache is comfort related Hours of - elevate the - elevation of mainta
coming back to headache and intervention the head of the bed the bed effectiv
really bad, and I ineffective patient will be facilitates breathi
feel like I can’t breathing able to feel respiratory pattern
catch my pattern as relieved and the function by use evidenc
breath." as manifested by patient will of gravity relaxed
verbalized by the regional maintain the breathi
the patient anesthesia normal - encourage - to promote normal
breathing. deep breathing chest expansion depth
Objective Data: exercise absenc
 Pulse 115 dyspne
 BP 160/94 -provide comfort - to promote feel co
 Temp 37.2 measures, quiet non after n
 Resp Rate environment pharmacological an head
28 and calm management
 Deep activities
tendon
reflex (DTR)
3+no clonus
 Lung exam
is limited
due to noise
level in
room, but
some
crackles can
be heard at
the bases
 O2
Saturation
95% on
room air.

"Ms. Morrison is a 27-year-old G3P3 who is post-op from a repeat cesarean at 38


weeks for pre-eclampsia. She had regional anesthesia and just came from the OR
about 10 minutes ago." She verbalized "My headache is coming back really bad, and I
feel like I can’t catch my breath." Pulse 115 BP 160/94 Temp 37.2 Resp Rate 28 Deep
tendon reflex (DTR) 3+, no clonus Lung exam is limited due to noise level in room,
but some crackles can be heard at the bases O2 Saturation 95% on room air.

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