Nursing Care Plans

Nursing Care Plans1. Deficient Knowledge

Nursing Diagnosis

Deficient Knowledge [Preoperative]

May be related to

Lack of exposure/recall, information misinterpretation

Unfamiliarity with information resources

Possibly evidenced by

Statement of the problem/concerns, misconceptions

Request for information

Inappropriate, exaggerated behaviors (e.g., agitated,

apathetic, hostile)

Inaccurate follow-through of instructions/development of

preventable complications

Desired Outcomes

Verbalize understanding of disease process/perioperative

process and postoperative expectations.

Correctly perform necessary procedures and explain reasons

for the actions.

Initiate necessary lifestyle changes and participate in

treatment regimen.

Nursing Interventions Rationale

Assess patient’s level of understanding. Facilitates planning of preoperative


teaching program, identifies content needs.

Review specific pathology and anticipated

surgical procedure. Verify that appropriate

consent has been signed.

Provides knowledge base from which

patient can make informed therapy choices

and consent for procedure, and presents

opportunity to clarify misconceptions.

Use resource teaching materials,

audiovisuals as available.

Specifically designed materials can

facilitate the patient’s learning.

Implement individualized preoperative teaching program:

Preoperative or postoperative procedures

and expectations, urinary and bowel

changes, dietary considerations, activity

levels/ transfers, respiratory/

cardiovascular exercises; anticipated IV

lines and tubes (nasogastric [NG] tubes,

drains, and catheters).

Enhances patient’s understanding or

control and can relieve stress related to the

unknown or unexpected.

Preoperative instructions: NPO time,

shower or skin preparation, which routine

medications to take and hold, prophylactic

antibiotics, or anticoagulants, anesthesia

premedication.

Helps reduce the possibility of

postoperative complications and promotes

a rapid return to normal body

function. Note: In some instances, liquids

and medications are allowed up to 2 hr


before scheduled procedure.

Intraoperative patient safety: not crossing

legs during procedures performed under

local or light anesthesia.

Reduced risk of complications or untoward

outcomes, such as injury to the peroneal

and tibial nerves with postoperative pain in

the calves and feet.

Expected or transient reactions (low

backache, localized numbness and

reddening or skin indentations).

Minor effects of immobilization and

positioning should resolve in 24 hr. If they

persist, medical evaluation is required.

Inform patient or SO about itinerary,

physician/SO communications.

Logistical information about operating

room (OR) schedule and locations

(recovery room, postoperative room

assignment), as well as where and when

the surgeon will communicate with SO

relieves stress and mis-communications,

preventing confusion and doubt over

patient’s well-being.

Discuss individual postoperative pain

management plan. Identify misconceptions

patient may have and provide appropriate

information.

Increases likelihood of successful pain

management. Some patients may expect to

be pain-free or fear becoming addicted to

narcotic agents.


Provide opportunity to practice coughing,

deep-breathing, and muscular exercises.

Enhances learning and continuation of

activity postoperatively.

2. Fear/Anxiety

Nursing Diagnosis

Fear

Anxiety

May be related to

Situational crisis; unfamiliarity with environment

Change in health status; threat of death

Separation from usual support systems


Increased tension, apprehension, decreased self-assurance

Expressed concern regarding changes, fear of consequences

Facial tension, restlessness, focus on self

Sympathetic stimulation

Desired Outcomes

Acknowledge feelings and identify healthy ways to deal with

them.

Appear relaxed, able to rest/sleep appropriately.

Report decreased fear and anxiety reduced to a manageable

level.


Provide preoperative education, including

visit with OR personnel before surgery

when possible. Discuss anticipated things

that may concern patient: masks, lights,

IVs, BP cuff, electrodes, bovie pad, feel of

oxygen cannula or mask on nose or face,

autoclave and suction noises, child crying.

Can provide reassurance and alleviate

patient’s anxiety, as well as provide

information for formulating intraoperative

care. Acknowledges that foreign

environment may be frightening, alleviates

associated fears.

Inform patient or SO of nurse’s

intraoperative advocate role.

Develops trust and rapport, decreasing fear

of loss of control in a foreign environment.

Identify fear levels that may necessitate

postponement of surgical procedure.

Overwhelming or persistent fears result in

excessive stress reaction, potentiating risk

of adverse reaction to procedure and/or

anesthetic agents.

Validate source of fear. Provide accurate

factual information.

Identification of specific fear helps patient

deal realistically with it. Patient may have

misinterpreted preoperative information or

have misinformation regarding surgery.

Fears regarding previous experiences of

self or family may be resolved.

Note expressions of distress and feelings Patient may already be grieving for the


of helplessness, preoccupation with

anticipated change or loss, choked

feelings.

loss represented by the anticipated surgical

procedure, diagnosis or prognosis of

illness.

Tell patient anticipating local or spinal

anesthesia that drowsiness and sleep

occurs, that more sedation may be

requested and will be given if needed, and

that surgical drapes will block view of the

operative field.

Reduces concerns that patient may “see”

the procedure.

Introduce staff at time of transfer to

operating suite.

Establishes rapport and psychological

comfort.

Compare surgery schedule, patient

identification band, chart, and signed

operative consent for surgical procedure.

Provides for positive identification,

reducing fear that wrong procedure may be

done.

Prevent unnecessary body exposure during

transfer and in OR suite.

Patients are concerned about loss of

dignity and inability to exercise control.

Give simple, concise directions and

explanations to sedated patient. Review

environmental concerns as needed.

Impairment of thought processes makes it

difficult for patient to understand lengthy

instructions.


Control external stimuli. Extraneous noises and commotion may

accelerate anxiety.

Refer to pastoral spiritual care, psychiatric

nurse, clinical specialist, psychiatric

counseling if indicated.

May be desired or required for patient to

deal with fear, especially concerning life-

threatening conditions, serious and/or

high-risk procedures.

Discuss postponement or cancellation of

surgery with physician, anesthesiologist,

patient, and family as appropriate.

May be necessary if overwhelming fears

are not reduced or resolved.

Administer medications as indicated, e.g.:

Sedatives, hypnotics Used to promote sleep the evening before

surgery; may enhance coping abilities.

IV antianxiety agents. May be provided in the outpatient

admitting or preoperative holding area to

reduce nervousness and provide

comfort. Note: Respiratory depression

and/or bradycardia may occur,

necessitating prompt intervention.

3. Risk for Injury

Nursing Diagnosis

Perioperative Positioning, risk for injury

Risk factors may include

Disorientation; sensory/perceptual disturbances due to

anesthesia

Immobilization; musculoskeletal impairments

Obesity/emaciation; edema


Not applicable. 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

Be free of injury related to perioperative disorientation.

Be free of untoward skin/tissue injury or changes lasting

beyond 24–48 hr following procedure.

Report resolution of localized numbness, tingling, or changes

in sensation related to positioning within 24–48 hr as

appropriate.


Note anticipated length of procedure and

customary position. Be aware of potential

complications.

Supine position may cause low back pain

and skin pressure at heels, elbows, or

sacrum; lateral chest position can cause

shoulder and neck pain, plus eye and ear

injury on the patient’s downside.


Review patient’s history, noting age,

weight, height, nutritional status, physical

limitation and preexisting conditions that

may affect choice of position and skin or

tissue integrity during surgery.

Elderly persons, lack of subcutaneous

padding, arthritis, diabetes, obesity,

abdominal stoma, hydration status and

temperature are some factors.

Stabilize both patient cart and OR table

when transferring patient to and from OR

table, using an adequate number of

personnel for transfer and support of

extremities.

Unstabilized cart or table can separate,

causing patient to fall. Both side rails must

be in the down position for caregiver(s) to

assist patient transfer and prevent loss of

balance.

Anticipate movement of extraneous lines

and tubes during the transfer and secure or

guide them into position.

Prevents undue tension and dislocation of

IV lines, NG tubes, catheters, and chest

tubes; maintains gravity drainage when

appropriate.

Secure patient on OR table with safety belt

as appropriate, explaining necessity for

restraint.

OR tables and arm boards are narrow,

placing patient at risk for injury, especially

during fasciculation. Patient may become

resistive or combative when sedated or

emerging from anesthesia, furthering

potential for injury.

Protect body from contact with metal parts Reduces risk of electrical injury.


of the operating table.

Prepare equipment and padding for

required position, according to operative

procedure and patient’s specific needs. Pay

special attention to pressure points of bony

prominences (arms, ankles) and

neurovascular pressure points (breasts,

knees).

Depending on individual patient’s size,

weight, and preexisting conditions, extra

padding materials may be required to

protect bony prominences, prevent

circulatory compromise and nerve

pressure, or allow for optimum chest

expansion for ventilation.

Position extremities so they may be

periodically checked for safety,

circulation, nerve pressure, and alignment.

Monitor peripheral pulses, skin color and

temperature.

Prevents accidental trauma, hands, fingers,

and toes could inadvertently be scraped,

pinched, or amputated by moving table

attachments; positional pressure of

brachial plexus, peroneal, and ulnar nerves

can cause serious problems with

extremities; prolonged plantar flexion may

result in foot drop.

Place legs in stirrups simultaneously (when

lithotomy position used), adjusting stirrup

height to patient’s legs, maintaining

symmetrical position. Pad popliteal space

and heels and/or feet as indicated.

Prevents muscle strain; reduces risk of hip

dislocation in elderly patients. Padding

helps prevent peroneal and tibial nerve

damage. Note: Prolonged positioning in

stirrups may lead to compartment


syndrome in calf muscles.

Provide footboard and/or elevate drapes

off toes. Avoid and monitor placement of

equipment, instrumentation on trunk and

extremities during procedure.

Continuous pressure may cause neural,

circulatory, and skin integrity disruption.

Reposition slowly at transfer from table

and in bed (especially halothane-

anesthetized patient).

Myocardial depressant effect of various

agents increases risk of hypotension and/or

bradycardia.

Determine specific postoperative

positioning guidelines, elevation of head of

bed following spinal anesthesia, turn to

unoperated side following

pneumonectomy.

Reduces risk of postoperative

complications, e.g., headache associated

with migration of spinal anesthesia, or loss

of maximal respiratory effort.

Recommend position changes to

anesthesiologist and/or surgeon as

appropriate.

Close attention to proper positioning can

prevent muscle strain, nerve damage,

circulatory compromise, and undue

pressure on skin and/or bony prominences.

Although the anesthesiologist is

responsible for positioning, the nurse may

be able to see and have more time to note

patient needs, and provide assistance.

4. Risk for Injury


Interactive conditions between individual and environment

External environment, e.g., physical design, structure of

environment, exposure to equipment, instrumentation,

positioning, use of pharmaceutical agents

Internal environment, e.g., tissue hypoxia, abnormal blood

profile/altered clotting factors, broken skin





Desired Outcomes

Identify individual risk factors.

Modify environment as indicated to enhance safety and use

resources appropriately.


Remove dentures, partial plates or bridges

preoperatively per protocol. Inform

anesthesiologist of problems with natural

teeth or loose teeth.

Foreign bodies may be aspirated during

endotracheal intubation or extubation.

Remove prosthetics, other devices Contact lenses may cause corneal


preoperatively or after induction,

depending on sensory or perceptual

alterations and mobility impairment.

abrasions while under anesthesia;

eyeglasses and hearing aids are obstructive

and may break; however, patients may feel

more in control of environment if hearing

and visual aids are left on as long as

possible. Artificial limbs may be damaged

and skin integrity impaired if left on.

Remove jewelry preoperatively or tape

over as appropriate.

Metals conduct electrical current and

provide an electrocautery hazard. In

addition, loss or damage to patient’s

personal property can easily occur in the

foreign environment. Note: In some cases

(e.g., arthritic knuckles), it may not be

possible to remove rings without cutting

them off. In this situation, applying tape

over the ring may prevent patient from

“catching” ring and prevent loss of stone

or damage to finger.

Verify patient identity and scheduled

operative procedure by comparing patient

chart, arm band, and surgical schedule.

Verbally ascertain correct name,

Assures correct patient, procedure, and

appropriate extremity or side.


procedure, operative site, and physician.

Document allergies, including risk for

adverse reaction to latex, tape, and prep

solutions.

Reduces risk for allergic responses that

may impair skin integrity or lead to life-

threatening systemic reactions.

Give simple and concise directions to the

sedated patient.

Impairment of thought process makes it

difficult for patient to understand lengthy

directions.

Prevent pooling of prep solutions under

and around patient.

Antiseptic solutions may chemically burn

skin, as well as conduct electricity.

Assist with induction as needed: stand by

to apply cricoid pressure during intubation

or stabilize position during lumbar

puncture for spinal block.

Facilitates safe administration of

anesthesia.

Ascertain electrical safety of equipment

used in surgical procedure: intact cords,

grounds, medical engineering verification

labels.

Malfunction of equipment can occur

during the operative procedure, causing

not only delays and unnecessary anesthesia

but also injury or death, short circuits,

faulty grounds, laser malfunctions, or laser

misalignment. Periodic electrical safety

checks are imperative for all OR


equipment.

Place dispersive electrode (electrocautery

pad) over greatest available muscle mass,

ensuring its contact.

Provides a ground for maximum

conductivity to prevent electrical burns.

Confirm and document correct sponge,

instrument, needle, and blade counts.

Foreign bodies remaining in body cavities

at closure not only cause inflammation,

infection, perforation, and abscess

formation, disastrous complications that

lead to death.

Verify credentials of laser operators for

specific wavelength laser required for

particular procedure.

Because of the potential hazards of laser,

physician and equipment operators must be

certified in the use and safety requirements

of specific wavelength laser and

procedure, open, endoscopic, abdominal,

laryngeal, intrauterine.

Confirm presence of fire extinguishers and

wet fire smothering materials when lasers

are used intraoperatively.

Laser beam may inadvertently contact and

ignite combustibles outside of surgical

field: drapes, sponges.

Apply patient eye protection before laser

activation.

Eye protection for specific laser

wavelength must be used to prevent injury.


Protect surrounding skin and anatomy

appropriately, wet towels, sponges, dams,

cottonoids.

Prevents inadvertent skin integrity

disruption, hair ignition, and adjacent

anatomy injury in area of laser beam use.

Handle, label, and document specimens

appropriately, ensuring proper medium and

transport for tests required.

Proper identification of specimens to

patient is imperative. Frozen sections,

preserved or fresh examination, and

cultures all have different requirements.

OR nurse advocate must be knowledgeable

of specific hospital laboratory

requirements for validity of examination.

Monitor intake and output (I&O) during

procedure. Ascertain that infusion pumps

are functioning accurately.

Potential for fluid volume deficit or excess

exists, affecting safety of anesthesia, organ

function, and patient well-being.

Administer IV fluids, blood, blood

components, and medications as indicated.

Helps maintain homeostasis and adequate

level of sedation and/or muscle relaxation

to produce optimal surgical outcome.

Collect blood intraoperatively as

appropriate.

Blood lost intraoperatively may be

collected, filtered, and reinfused either

intraoperatively or postoperatively. Note:

Alternatively red blood cell (RBC)

production may be increased by the


administration of epoetin (EPO), reducing

the need for blood transfusion whether

autologous or donated.

Administer antacids, H2 blocker,

preoperatively as indicated.

Neutralizes gastric acidity and may reduce

risk of aspiration or severity of pneumonia

should aspiration occur, especially in

obese or pregnant patients in whom there

is an 85% risk of mortality with aspiration.

Limit or avoid use of epinephrine to

Fluothane-anesthetized patient.

Fluothane sensitizes the myocardium to

catecholamines and may produce

dysrhythmias.

5. Risk for Infection


Broken skin, traumatized tissues, stasis of body fluids

Presence of pathogens/contaminants, environmental

exposure, invasive procedures





Desired Outcomes

Identify individual risk factors and interventions to reduce

potential for infection.

Maintain safe aseptic environment.


Adhere to facility infection control,

sterilization, and aseptic policies and

procedures.

Established mechanisms designed to

prevent infection.

Verify sterility of all manufacturers’ items. Prepackaged items may appear to be

sterile; however, each item must be

scrutinized for manufacturer’s statement of

sterility, breaks in packaging,

environmental effect on package, and

delivery techniques. Package sterilization

and expiration dates, lot/serial numbers

must be documented on implant items for

further follow-up if necessary.

Review laboratory studies for possibility of

systemic infections.

Increased WBC count may indicate

ongoing infection, which the operative

procedure will alleviate (appendicitis,

abscess, inflammation from trauma); or

presence of systemic or organ infection,

which may contraindicate or impact

surgical procedure and/or anesthesia


(pneumonia, kidney infection).

Verify that preoperative skin, vaginal, and

bowel cleansing procedures have been

done as needed depending on specific

surgical procedure.

Cleansing reduces bacterial counts on the

skin, vaginal mucosa, and alimentary tract.

Prepare operative site according to specific

procedures.

Minimizes bacterial counts at operative

site.

Examine skin for breaks or irritation, signs

of infection.

Disruptions of skin integrity at or near the

operative site are sources of contamination

to the wound. Careful shaving or clipping

is imperative to prevent abrasions and

nicks in the skin.

Maintain dependent gravity drainage of

indwelling catheters, tubes, and/or positive

pressure of parenteral or irrigation lines.

Prevents stasis and reflux of body fluids.

Identify breaks in aseptic technique and

resolve immediately on occurrence.

Contamination by environmental or

personnel contact renders the sterile field

unsterile, thereby increasing the risk of

infection.


Contain contaminated fluids and materials

in specific site in operating room suite, and

dispose of according to hospital protocol.

Containment of blood and body fluids,

tissue, and materials in contact with an

infected wound. Patient will prevent

spread of infection to environment and/or

other patients or personnel.

Apply sterile dressing. Prevents environmental contamination of

fresh wound.

Provide copious wound irrigation, e.g.,

saline, water, antibiotic, or antiseptic.

May be used intraoperatively to reduce

bacterial counts at the site and cleanse the

wound of debris, e.g., bone, ischemic

tissue, bowel contaminants, toxins.

Obtain specimens for cultures or Gram

stain.

Immediate identification of type of

infective organism by Gram stain allows

prompt treatment, while more specific

identification by cultures can be obtained

in hours or days.

Administer antibiotics as indicated. May be given prophylactically for

suspected infection or contamination.

6. Risk for Altered Body Temperature

Nursing Diagnosis

Risk for Altered Body Temperature


Exposure to cool environment

Use of medications, anesthetic agents

Extremes of age, weight; dehydration





Desired Outcomes

Maintain body temperature within normal range.


Note preoperative temperature. Used as baseline for monitoring

intraoperative temperature. Preoperative

temperature elevations are indicative of

disease process: appendicitis, abscess, or

systemic disease requiring treatment

preoperatively, perioperatively, and

possibly postoperatively. Note: Effects of

aging on hypothalamus may decrease fever

response to infection.

Assess environmental temperature and May assist in maintaining or stabilizing


modify as needed: providing warming and

cooling blankets, increasing room

temperature.

patient’s temperature.

Cover skin areas outside of operative field. Heat losses will occur as skin (legs, arms,

head) is exposed to cool environment.

Provide cooling measures for patient with

preoperative temperature elevations.

Cool irrigations and exposure of skin

surfaces to air may be required to decrease

temperature.

Note rapid temperature elevation or

persistent high fever and treat promptly per

protocol.

Malignant hyperthermia must be

recognized and treated promptly to avoid

serious complications and/or death.

Increase ambient room temperature (e.g.,

to 78°F or 80°F) at conclusion of

procedure.

Helps limit patient heat loss when drapes

are removed and patient is prepared for

transfer.

Apply warming blankets at emergence

from anesthesia.

Inhalation anesthetics depress the

hypothalamus, resulting in poor body

temperature regulation.

Monitor temperature throughout

intraoperative phase.

Continuous warm or cool humidified

inhalation anesthetics are used to maintain


humidity and temperature balance within

the tracheobronchial tree. Temperature

elevation and fever may indicate adverse

response to anesthesia. Note: Use of

atropine or scopolamine may further

increase temperature.

Provide iced saline as indicated. Lavage of body cavity with iced saline

may help reduce hyperthermic responses.

Obtain dantrolene (Dantrium) for IV

administration.

Immediate action to control temperature is

necessary to prevent death from malignant

hyperthermia.

7. Ineffective Breathing Pattern

May be related to

Neuromuscular, perceptual/cognitive impairment

Decreased lung expansion, energy

Tracheobronchial obstruction


Changes in respiratory rate and depth

Reduced vital capacity, apnea, cyanosis, noisy respirations

Desired Outcomes

Establish a normal/effective respiratory pattern free of

cyanosis or other signs of hypoxia.


Maintain patient airway by head tilt, jaw

hyperextension, oral pharyngeal airway.

Prevents airway obstruction.

Auscultate breath sounds. Listen for

gurgling, wheezing, crowing, and/or

silence after extubation.

Lack of breath sounds is indicative of

obstruction by mucus or tongue and may

be corrected by positioning and/or

suctioning. Diminished breath sounds

suggest atelectasis. Wheezing indicates

bronchospasm, whereas crowing or silence

reflects partial-to-total laryngospasm.

Observe respiratory rate and depth, chest

expansion, use of accessory muscles,

retraction or flaring of nostrils, skin color;

note airflow.

Ascertains effectiveness of respirations

immediately so corrective measures can be

initiated.

Monitor vital signs continuously. Increased respirations, tachycardia, and/or

bradycardia suggests hypoxia.

Position patient appropriately, depending

on respiratory effort and type of surgery.

Head elevation and left lateral Sims’

position prevents aspiration of secretions

or vomitus; enhances ventilation to lower


lobes and relieves pressure on diaphragm

Observe for return of muscle function,

especially respiratory.

After administration of intraoperative

muscle relaxants, return of muscle function

occurs first to the diaphragm, intercostals,

and larynx; followed by large muscle

groups, neck, shoulders, and abdominal

muscles; then by midsize muscles, tongue,

pharynx, extensors, and flexors; and finally

by eyes, mouth, face, and fingers.

Initiate “stir-up” (turn, cough, deep

breathe) regimen as soon as patient is

reactive and continue in the postoperative

period.

Active deep ventilation inflates alveoli,

breaks up secretions, increases O2 transfer,

and removes anesthetic gases; coughing

enhances removal of secretions from the

pulmonary system. Note: Respiratory

muscles weaken and atrophy with age,

possibly hampering elderly patient’s

ability to cough or deep-breathe

effectively.

Observe for excessive somnolence. Narcotic-induced respiratory depression or

presence of muscle relaxants in the body

may be cyclical in recurrence, creating


sine-wave pattern of depression and re-

emergence from anesthesia. In addition,

thiopental sodium (Pentothal) is absorbed

in the fatty tissues, and, as circulation

improves, it may be redistributed

throughout the bloodstream.

Elevate head of bed as appropriate. Get out

of bed as soon as possible.

Promotes maximal expansion of lungs,

decreasing risk of pulmonary

complications.

Suction as necessary. Airway obstruction can occur because of

blood or mucus in throat or trachea.

Administer supplemental O2 as indicated. Maximizes oxygen for uptake to bind with

Hb in place of anesthetic gases to enhance

removal of inhalation agents.

Administer IV medications: naloxone

(Narcan) or doxapram (Dopram).

Narcan reverses narcotic-induced central

nervous system (CNS) depression and

Dopram stimulates respiratory muscles.

The effects of both drugs are cyclic in

nature and respiratory depression may

return.


Provide and maintain ventilator assistance. Depending on cause of respiratory

depression or type of surgery (pulmonary,

extensive abdominal, cardiac),

endotracheal tube (ET) may be left in place

and mechanical ventilation maintained for

a time.

Assist with use of respiratory aids:

incentive spirometer.

Maximal respiratory efforts reduce

potential for atelectasis and infection.

8. Altered Sensory/Thought Perception

Nursing Diagnosis

Altered Sensory Perception

Altered Thought Perception

May be related to

Chemical alteration: use of pharmaceutical agents, hypoxia

Therapeutically restricted environments; excessive sensory

stimuli

Physiological stress


Disorientation to person, place, time; change in usual

response to stimuli; impaired ability to concentrate, reason,

make decisions

Motor incoordination

Desired Outcomes

Regain usual level of consciousness/mentation.

Recognize limitations and seek assistance as necessary.


Reorient patient continuously when

emerging from anesthesia; confirm that

surgery is completed.

As patient regains consciousness, support

and assurance will help alleviate anxiety.

Speak in normal, clear voice without

shouting, being aware of what you are

saying. Minimize discussion of negatives

within patient’s hearing. Explain

procedures, even if patient does not seem

aware.

The nurse cannot tell when patient is

aware, but it is thought that the sense of

hearing returns before patient appears fully

awake, so it is important not to say things

that may be misinterpreted. Providing

information helps patient preserve dignity

and prepare for activity.

Evaluate sensation and/or movement of

extremities and trunk as appropriate.

Return of function following local or

spinal nerve blocks depends on type or

amount of agent used and duration of

procedure.

Use bedrail padding, restraints as

necessary.

Provides for patient safety during

emergence state. Prevents injury to head

and extremities if patient becomes

combative while disoriented.


Secure parenteral lines, ET tube, catheters,

if present, and check for patency.

Disoriented patient may pull on lines and

drainage systems, disconnecting or kinking

them.

Maintain quiet, calm environment. External stimuli, such as noise, lights,

touch, may cause psychic aberrations when

dissociative anesthetics (ketamine) have

been administered.

Investigate changes in sensorium. Confusion, especially in elderly patients,

may reflect drug interactions, hypoxia,

anxiety, pain, electrolyte imbalances, or

fear.

Observe for hallucinations, delusions,

depression, or an excited state.

May develop following trauma and

indicate delirium, or may reflect

“sundowner’s syndrome” in elderly

patient. In patient who has used alcohol to

excess, may suggest impending delirium

tremens.

Reassess sensory or motor function and

cognition thoroughly before discharge, as

indicated.

Ambulatory surgical patient must be able

to care for self with the help of SO (if

available) to prevent personal injury after

discharge.


Evaluate need for extended stay in

postoperative recovery area or need for

additional nursing care before discharge as

appropriate.

Disorientation may persist, and SO may

not be able to protect the patient at home.

9. Risk for Fluid Volume Deficit


Restriction of oral intake (disease process/medical

procedure/presence of nausea)

Loss of fluid through abnormal routes, e.g., indwelling tubes,

drains; normal routes, e.g., vomiting

Loss of vascular integrity, changes in clotting ability

Extremes of age and weight





Desired Outcomes

Demonstrate adequate fluid balance, as evidenced by stable

vital signs, palpable pulses of good quality, normal skin turgor,

moist mucous membranes, and individually appropriate

urinary output.


Measure and record I&O (including tubes

and drains). Calculate urine specific

gravity as appropriate. Review

intraoperative record.

Accurate documentation helps identify

fluid losses or replacement needs and

influences choice of interventions. Note:

Ability to concentrate urine declines with

age, increasing renal losses despite general

fluid deficit.

Assess urinary output specifically for type

of operative procedure done.

May be decreased or absent after

procedures on the genitourinary system

and/or adjacent structures (ureteroplasty,

ureterolithotomy, abdominal or vaginal

hysterectomy), indicating malfunction or

obstruction of the urinary system.

Provide voiding assistance measures as

needed: privacy, sitting position, running

water in sink, pouring warm water over

perineum.

Promotes relaxation of perineal muscles

and may facilitate voiding efforts.

Monitor vital signs noting changes in

blood pressure, heart rate and rhythm, and

respirations. Calculate pulse pressure.

Hypotension, tachycardia, increased

respirations may indicate fluid deficit

dehydration and/or hypovolemia. Although

a drop in blood pressure is generally a late

sign of fluid deficit (hemorrhagic loss),


widening of the pulse pressure may occur

early, followed by narrowing as bleeding

continues and systolic BP begins to fall.

Note presence of nausea and/or vomiting. Women, obese patients, and those prone to

motion sickness have a higher risk of

postoperative nausea and/or vomiting. In

addition, the longer the duration of

anesthesia, the greater the risk for nausea.

Note: Nausea occurring during first 12–24

hr postoperatively is frequently related to

anesthesia (including regional anesthesia).

Nausea persisting more than 3 days

postoperatively may be related to the

choice of narcotic for pain control or other

drug therapy.

Inspect dressings, drainage devices at

regular intervals. Assess wound for

swelling.

Excessive bleeding can lead to

hypovolemia and/or circulatory collapse.

Local swelling may indicate hematoma

formation or hemorrhage. Note: Bleeding

into a cavity (retroperitoneal) may be

hidden and only diagnosed via vital sign

depression, patient reports of pressure


sensation in affected area.

Monitor skin temperature, palpate

peripheral pulses.

Cool or clammy skin, weak pulses indicate

decreased peripheral circulation and need

for additional fluid replacement.

Administer parenteral fluids, blood

products (including autologous collection),

and/or plasma expanders as indicated.

Increase IV rate if needed.

Replaces documented fluid loss. Timely

replacement of circulating volume

decreases potential for complications of

deficit, e.g., electrolyte imbalance,

dehydration, cardiovascular collapse. Note:

Increased volume may be required initially

to support circulating volume and prevent

hypotension because of decreased

vasomotor tone following Fluothane

administration.

Insert and maintain urinary catheter with

or without urimeter as necessary.

Provides mechanism for accurate

monitoring of urinary output.

Resume oral intake gradually as indicated. Oral intake depends on return of

gastrointestinal (GI) function.

Administer antiemetics as appropriate. Relieves nausea and/or vomiting, which

may impair intake and add to fluid


losses. Note: Naloxone (Narcan) may

relieve nausea related to use of regional

anesthesthetic agents: morphine

(Duramorph), fentanyl citrate (Sublimaze).

Monitor laboratory studies: Hb/ Hct,

electrolytes. Compare preoperative and

postoperative blood studies.

Indicators of hydration and/or circulating

volume. Preoperative anemia and/or low

Hct combined with unreplaced fluid losses

intraoperatively will further potentiate

deficit.

10. Acute Pain

May be related to

Disruption of skin, tissue, and muscle integrity;

musculoskeletal/bone trauma

Presence of tubes and drains


Reports of pain

Alteration in muscle tone; facial mask of pain

Distraction/guarding/protective behaviors

Self-focusing; narrowed focus

Autonomic responses

Desired Outcomes

Report pain relieved/controlled.

Appear relaxed, able to rest/sleep and participate in activities

appropriately.


Note patient’s age, weight, coexisting

medical or psychological conditions,

idiosyncratic sensitivity to analgesics, and

intraoperative course.

Approach to postoperative pain

management is based on multiple variable

factors.

Review intraoperative or recovery room

record for type of anesthesia and

medications previously administered.

Presence of narcotics and droperidol in

system potentiates narcotic analgesia,

whereas patients anesthetized with

Fluothane and Ethrane have no residual

analgesic effects. In addition,

intraoperative local/ regional blocks have

varying duration, e.g., 1–2 hr for regionals

or up to 2–6 hr for locals.

Evaluate pain regularly (every 2 hrs noting

characteristics, location, and intensity (0–

10 scale). Emphasize patient’s

responsibility for reporting pain/ relief of

pain completely.

Provides information about need for or

effectiveness of interventions. Note: It may

not always be possible to eliminate pain;

however, analgesics should reduce pain to

a tolerable level. A frontal and/or occipital

headache may develop 24–72 hr following

spinal anesthesia, necessitating recumbent

position, increased fluid intake, and


notification of the anesthesiologist.

Note presence of anxiety or fear, and relate

with nature of and preparation for

procedure.

Concern about the unknown (e.g., outcome

of a biopsy) and/or inadequate preparation

(e.g., emergency appendectomy) can

heighten patient’s perception of pain.

Assess vital signs, noting tachycardia,

hypertension, and increased respiration,

even if patient denies pain.

Changes in these vital signs often indicate

acute pain and discomfort. Note: Some

patients may have a slightly lowered BP,

which returns to normal range after pain

relief is achieved.

Assess causes of possible discomfort other

than operative procedure.

Discomfort can be caused or aggravated by

presence of non-patent indwelling

catheters, NG tube, parenteral lines

(bladder pain, gastric fluid and gas

accumulation, and infiltration of IV fluids

or medications).

Provide information about transitory

nature of discomfort, as appropriate.

Understanding the cause of the discomfort

(e.g., sore muscles from administration of

succinylcholine may persist up to 48 hr

postoperatively; sinus headache associated

with nitrous oxide and sore throat due to


intubation are transitory) provides

emotional reassurance. Note: Paresthesia

of body parts suggest nerve injury.

Symptoms may last hours or months and

require additional evaluation.

Reposition as indicated: semi-Fowler’s;

lateral Sims’.

May relieve pain and enhance circulation.

Semi-Fowler’s position relieves abdominal

muscle tension and arthritic back muscle

tension, whereas lateral Sims’ will relieve

dorsal pressures.

Provide additional comfort measures:

backrub, heat or cold applications.

Improves circulation, reduces muscle

tension and anxiety associated with pain.

Enhances sense of well-being.

Encourage use of relaxation techniques:

deep-breathing exercises, guided imagery,

visualization, music.

Relieves muscle and emotional tension;

enhances sense of control and may

improve coping abilities.

Provide regular oral care, occasional ice

chips or sips of fluids as tolerated.

Reduces discomfort associated with dry

mucous membranes due to anesthetic

agents, oral restrictions.

Document effectiveness and side and/or Respirations may decrease on


adverse effects of analgesia. administration of narcotic, and synergistic

effects with anesthetic agents may occur.

Note: Migration of epidural analgesia

toward head (cephalad diffusion) may

cause respiratory depression or excessive

sedation.

Administer medications as indicated:

Analgesics IV (after reviewing anesthesia

record for contraindications and/or

presence of agents that may potentiate

analgesia); provide around-the-clock

analgesia with intermittent rescue doses;

Analgesics given IV reach the pain centers

immediately, providing more effective

relief with small doses of medication. IM

administration takes longer, and its

effectiveness depends on absorption rates

and circulation. Note: Narcotic dosage

should be reduced by one-fourth to one-

third after use of fentanyl (Innovar) or

droperidol (Inapsine) to prevent profound

tranquilization during first 10 hr

postoperatively. Current research supports

need to administer analgesics around the

clock initially to prevent rather than

merely treat pain.


Patient-controlled analgesia (PCA) Use of PCA necessitates detailed patient

instruction. PCA must be monitored

closely but is considered very effective in

managing acute postoperative pain with

smaller amounts of narcotic and increased

patient satisfaction.

Local anesthetics: epidural block or

infusion;

Analgesics may be injected into the

operative site, or nerves to the site may be

kept blocked in the immediate

postoperative phase to prevent severe

pain. Note: Continuous epidural infusions

may be used for 1–5 days following

procedures that are known to cause severe

pain (certain types of thoracic or

abdominal surgery).

NSAIDs: aspirin, diflunisal (Dolobid),

naproxen (Anaprox).

Useful for mild to moderate pain or as

adjuncts to opioid therapy when pain is

moderate to severe. Allows for a lower

dosage of narcotics, reducing potential for

side effects.

Monitor use and/or effectiveness of TENS may be useful in reducing pain and


transcutaneous electrical nerve stimulation

(TENS).

amount of medication required

postoperatively.

11. Impaired Skin/Tissue Integrity

May be related to

Mechanical interruption of skin/tissues

Altered circulation, effects of medication; accumulation of

drainage; altered metabolic state


Disruption of skin surface/layers and tissues

Desired Outcomes

Achieve timely wound healing.

Demonstrate behaviors/techniques to promote healing and to

prevent complications.


Reinforce initial dressing and change as

indicated. Use strict aseptic techniques.

Protects wound from mechanical injury

and contamination. Prevents accumulation

of fluids that may cause excoriation.

Gently remove tape (in direction of hair

growth) and dressings when changing.

Reduces risk of skin trauma and disruption

of wound.

Apply skin sealants or barriers before tape Reduces potential for skin trauma and/or


if needed. Use hypoallergenic tape or

Montgomery straps or elastic netting for

dressings requiring frequent changing.

abrasions and provides additional

protection for delicate skin or tissues.

Check tension of dressings. Apply tape at

center of incision to outer margin of

dressing. Avoid wrapping tape around

extremity.

Can impair or occlude circulation to

wound and to distal portion of extremity.

Inspect wound regularly, noting

characteristics and integrity. Note patients

at risk for delayed healing (presence

of chronic obstructive pulmonary

disease (COPD), anemia, obesity or

malnutrition, DM, hematoma formation,

vomiting, ETOH (alcohol) withdrawal; use

of steroid therapy; advanced age.)

Early recognition of delayed healing or

developing complications may prevent a

more serious situation. Wounds may heal

more slowly in patients with comorbidity,

or the elderly in whom reduced cardiac

output decreases capillary blood flow.

Assess amounts and characteristics of

drainage.

Decreasing drainage suggests evolution of

healing process, whereas continued

drainage or presence of bloody or

odoriferous exudate suggests

complications (e.g., fistula formation,

hemorrhage, infection).


Maintain patency of drainage tubes; apply

collection bag over drains and incisions in

presence of copious or caustic drainage.

Facilitates approximation of wound edges;

reduces risk of infection and chemical

injury to skin and tissues.

Elevate operative area as appropriate. Promotes venous return and limits edema

formation. Note: Elevation in presence of

venous insufficiency may be detrimental.

Splint abdominal and chest incisions or

area with pillow or pad during coughing or

movement.

Equalizes pressure on the wound,

minimizing risk of dehiscence or rupture.

Caution patient not to touch wound. Prevents contamination of wound.

Cleanse skin surface (if needed) with

diluted hydrogen peroxide solution, or

running water and mild soap after incision

is sealed.

Reduces skin contaminants; aids in

removal of drainage or exudate.

Apply ice if appropriate. Reduces edema formation that may cause

undue pressure on incision during initial

postoperative period.

Use abdominal binder if indicated. Provides additional support for high-risk

incisions (obese patient).


Irrigate wound; assist with debridement as

needed.

Removes infectious exudate or necrotic

tissue to promote healing.

Monitor or maintain dressings: hydrogel,

vacuum dressing.

May be used to hasten healing in large,

draining wound/ fistula, to increase patient

comfort, and to reduce frequency of

dressing changes. Also allows drainage to

be measured more accurately and analyzed

for pH and electrolyte content as

appropriate.

12. Risk for Altered Tissue Perfusion


Interruption of flow: arterial, venous

Hypovolemia





Desired Outcomes

Demonstrate adequate perfusion evidenced by stable vital

signs, peripheral pulses present and strong; skin warm/dry;

usual mentation and individually appropriate urinary output.


Change position slowly initially. Vasoconstrictor mechanisms are depressed

and quick movement may lead to

orthostatic hypotension, especially in the

early postoperative period.

Assist with range-of-motion (ROM)

exercises, including active ankle and leg

exercises.

Stimulates peripheral circulation; aids in

preventing venous stasis to reduce risk of

thrombus formation.

Encourage and assist with early

ambulation.

Enhances circulation and return of normal

organ function.

Avoid use of knee gatch and/or pillow

under knees. Caution patient against

crossing legs or sitting with legs dependent

for prolonged period.

Prevents stasis of venous circulation and

reduces risk of thrombophlebitis.

Assess lower extremities for erythema,

edema, calf tenderness (positive Homans’

sign).

Circulation may be restricted by some

positions used during surgery, while

anesthetics and decreased activity alter

vasomotor tone, potentiating vascular

pooling and increasing risks of thrombus

formation.

Monitor vital signs: palpate peripheral Indicators of adequacy of circulating

pulses; note skin temperature/ color and

capillary refill. Evaluate urinary

output/time of voiding. Document

dysrhythmias.

volume and tissue perfusion or organ

function. Effects of medications or

electrolyte imbalances may create

dysrhythmias, impairing cardiac output

and tissue perfusion.

Investigate changes in mentation or failure

to achieve usual mental state.

May reflect a number of problems such as

inadequate clearance of anesthetic agent,

oversedation (pain medication),

hypoventilation, hypovolemia, or

intraoperative complications (emboli).

Administer IV fluids or blood products as

needed.

Maintains circulating volume; supports

perfusion.

Apply antiembolitic hose as indicated. Promotes venous return and prevents

venous stasis of legs to reduce risk of

thrombosis.

13. Deficient Knowledge

May be related to

Lack of exposure/lack of recall, information misinterpretation

Unfamiliarity with information resources

Cognitive limitation


Questions/request for information; statement of misconception

Inaccurate follow-through of instructions/development of

preventable complications

Desired Outcomes

Verbalize understanding of condition, effects of procedure and

potential complications.

Verbalize understanding of therapeutic needs.

Correctly perform necessary procedures and explain reasons

for actions.

Initiate necessary lifestyle changes and participate in

treatment regimen.


Review specific surgery performed and

procedure done and future expectations.

Provides knowledge base from which

patient can make informed choices.

Review and have patient or SO

demonstrate dressing or wound and tube

care when indicated. Identify source for

supplies.

Promotes competent self-care and

enhances independence.

Review avoidance of environmental risk

factors: exposure to crowds or persons

with infections.

Reduces potential for acquired infections.

Discuss drug therapy, including use of

prescribed and OTC analgesics.

Enhances cooperation with regimen;

reduces risk of adverse reactions and/or


untoward effects.

Identify specific activity limitations. Prevents undue strain on operative site.

Recommend planned or progressive

exercise.

Promotes return of normal function and

enhances feelings of general well-being.

Schedule adequate rest periods. Prevents fatigue and conserves energy for

healing.

Review importance of nutritious diet and

adequate fluid intake.

Provides elements necessary for tissue

regeneration or healing and support of

tissue perfusion and organ function.

Encourage cessation of smoking. Smoking increases risk of pulmonary

infections, causes vasoconstriction, and

reduces oxygen-binding capacity of blood,

affecting cellular perfusion and potentially

impairing healing.

Identify sign and symptoms requiring

medical evaluation, e.g., nausea and/or

vomiting; difficulty voiding; fever,

continued or odoriferous wound drainage;

incisional swelling, erythema, or

Early recognition and treatment of

developing complications (ileus, urinary

retention, infection, delayed healing) may

prevent progression to more serious or life-

threatening situation.


separation of edges; unresolved or changes

in characteristics of pain.

Stress necessity of follow-up visits with

providers, including therapists, laboratory.

Monitors progress of healing and evaluates

effectiveness of regimen.

Include SO in teaching program or

discharge planning. Provide written

instructions and/or teaching materials.

Instruct in use of and arrange for special

equipment.

Provides additional resources for reference

after discharge. Promotes effective self-

care.

Identify available resources: home care

services, visiting nurse, outpatient therapy,

contact phone number for questions.

Enhances support for patient during

recovery period and provides additional

evaluation of ongoing needs and new

concerns.

Nursing Care Plans

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