Surgical intervention may be needed to diagnose or cure a specific disease process, correct a deformity, restore a functional process or reduce the level of dysfunction. Although surgery is generally elective or pre-planned, potentially life-threatening conditions can arise, requiring emergency intervention.
Nursing Care Plans
Nurses have a variety of roles and functions associated with the patient’s surgical management. Nurses provide care of a client before, during, and after surgical operation, this is collectively called as Perioperative Nursing. It is a specialized nursing area wherein a registered nurse works as a team member of other surgical health care professionals. Absence or limitation of preoperative preparation and teaching increases the need for postoperative support in addition to managing underlying medical conditions.
Here are 13 nursing diagnosis for a client undergoing surgery or perioperative nursing care plans (NCP):Â
- Deficient Knowledge (Pre-op)
- Fear/Anxiety
- Risk for Injury
- Risk for Injury (Pre-op)
- Risk for Infection
- Risk for Imbalanced Body Temperature
- Ineffective Breathing Pattern
- Altered Sensory/Thought Perception
- Risk for Deficient Fluid Volume
- Acute Pain
- Impaired Skin Integrity
- Risk for Altered Tissue Perfusion
- Deficient Knowledge (Post-op)
- Other Possible Nursing Care Plans
Deficient Knowledge
Nursing Diagnosis
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:Â | |
| 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. |
See Also
You may also like the following posts and care plans:
- Nursing Care Plan: The Ultimate Guide and Database – the ultimate database of nursing care plans for different diseases and conditions! Get the complete list!
- Nursing Diagnosis: The Complete Guide and List – archive of different nursing diagnoses with their definition, related factors, goals and nursing interventions with rationale.
Basic and General Nursing Care Plans
Miscellaneous nursing care plans that don’t fit other categories:
- Alcohol Withdrawal
- Benign Febrile Convulsions
- Cancer
- End-of-Life Care (Hospice Care or Palliative)
- Geriatric Nursing (Older Adult)
- Substance Dependence and Abuse
- Surgery (Perioperative Client)
- Systemic Lupus Erythematosus
- Total Parenteral Nutrition
Surgery and Perioperative Care Plans
Care plans that involve surgical intervention.
- Amputation | 4 Care Plans
- Appendectomy | 4 Care Plans
- Cholecystectomy | 4 Care Plans
- Cholecystectomy | 8Â Care Plans
- Fracture | 8 Care Plans
- Hemorrhoids | 3 Care Plans
- Hysterectomy | 6 Care Plans
- Ileostomy & Colostomy |Â 10 Care Plan
- Laminectomy (Disc Surgery) | 8 Care Plans
- Mastectomy | 14 Care Plans
- Mastectomy | 6 Care Plans
- Subtotal Gastrectomy | 2 Care Plans
- Surgery (Perioperative Client) | 13 Care Plans
- TAHBSO (Hysterectomy) | 8 Care Plans
- Thyroidectomy | 5 Care Plans
- Total Joint (Knee, Hip) Replacement | 5 Care Plans
Good app for information regarding advance nursing care
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