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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):
- 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
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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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Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
More care plans related to basic nursing concepts:
- Cancer (Oncology Nursing) | 13 Care Plans
- End-of-Life Care (Hospice Care or Palliative) | 4 Care Plans
- Geriatric Nursing (Older Adult) | 11 Care Plans
- Prolonged Bed Rest | 8 Care Plans
- Surgery (Perioperative Client) | 13 Care Plans
- Systemic Lupus Erythematosus | 4 Care Plans
- Total Parenteral Nutrition | 4 Care Plans
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