13 Surgery (Perioperative Client) Nursing Care Plans

By
Matt Vera, BSN, R.N.
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Surgery Nursing Care Plans
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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): 

  1. Deficient Knowledge (Pre-op)
  2. Fear/Anxiety
  3. Risk for Injury
  4. Risk for Injury (Pre-op)
  5. Risk for Infection
  6. Risk for Imbalanced Body Temperature
  7. Ineffective Breathing Pattern
  8. Altered Sensory/Thought Perception
  9. Risk for Deficient Fluid Volume
  10. Acute Pain
  11. Impaired Skin Integrity
  12. Risk for Altered Tissue Perfusion
  13. Deficient Knowledge (Post-op)
  14. Other Possible Nursing Care Plans
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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: 
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.
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See Also

You may also like the following posts and care plans:

Basic and General Nursing Care Plans

Miscellaneous nursing care plans that don’t fit other categories:

Surgery and Perioperative Care Plans

Care plans that involve surgical intervention.

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