Question

A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restrain are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care?

Answer 1

The most critical outcome to include in the plan of care for the post-appendectomy, ventilated patient is the maintenance of a patent airway. Soft wrist restraints are used to prevent self-extubation, and their use must be evaluated regularly. The healthcare team should remain vigilant for any signs of respiratory complications.

Step-by-step explanation:

The most important outcome for a nurse to include in the plan of care for a client who has had an emergency appendectomy and is being mechanically ventilated with soft wrist restraints to prevent self-extubation is maintaining a patent airway. Ensuring that the airway stays clear is critical, as it impacts the client's ability to receive adequate oxygenation and ventilation. The team should continuously monitor the patient's respiratory status and readiness to wean from the ventilator, ensuring that equipment for resuscitation is immediately available should the patient exhibit signs of respiratory distress or airway obstruction. This includes being prepared to perform procedures like the Heimlich maneuver if aspiration occurs.

Soft wrist restraints are in place to prevent self-extubation, which could lead to a potentially life-threatening situation. The nurse must regularly assess the need for restraints and ensure that they are not interfering with circulation or causing injury. Additionally, the healthcare team, including the surgeon, nurse, and anesthesia professional, should consistently review any issues that may arise during the recovery process, such as potential for airway obstruction, aspiration risks, and the gradual emergence from anesthesia.