The nurse establishes a postoperative nursing diagnosis of Ineffective thermoregulation for the 63-year-old client in the immediate postoperative period after back surgery under general anesthesia
Which nursing intervention is most likely to be suitable for this client? 1. Apply warming blankets to stop the shivering.
2. Encourage ankle and foot exercises frequently.
3. Use a cooling mat to lower the body temperature.
4. Assist with coughing and deep breathing exercises.
1
1. After surgery, clients are more likely to be hypothermic than febrile unless the client went to surgery with an infection. To warm the client, the nurse applies warm blankets or a warming device to eliminate shivering because shivering consumes massive amounts of oxygen in skeletal muscle. If the client has respiratory or cardiovascular problems, shivering potentially aggravates the problem significantly. If warming blankets are ineffective in stopping shivering, the nurse administers a small dose of meperidine (Demerol) IV. In the past providers used meperidine for pain management, but it fell out of favor because it breaks down into an active metabolite; now it is used in low doses to halt postoperative shivering.
2. In the immediate postoperative period, the nurse can encourage ankle and foot exercises after resolving the priority issues; shivering has a higher priority than the ankle and foot exercises because shivering is directly related to the nursing diagnosis and is more likely to cause a life-threatening event in the immediate postoperative period than venous pooling would.
3. The nurse applies a cooling mat in the PACU to the client with an elevated body temperature from infection or from malignant hyperthermia to save the client's life and vital organs. Shivering is much more common than malignant hyperthermia, which has a very high fatality rate, and most clients die from malignant hyperthermia in the operating room.
4. Coughing and deep breathing is indirectly related to thermoregulation and thus is not the priority.
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