Nursing Care Plans
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Transcript of 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
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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.
Nursing Interventions Rationale
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
Possibly evidenced by
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.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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.
Nursing Interventions Rationale
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
Possibly evidenced by
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.
Nursing Interventions Rationale
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.
Nursing Interventions Rationale
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.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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
Risk factors may include
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
Possibly evidenced by
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
Identify individual risk factors.
Modify environment as indicated to enhance safety and use
resources appropriately.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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
Risk factors may include
Broken skin, traumatized tissues, stasis of body fluids
Presence of pathogens/contaminants, environmental
exposure, invasive procedures
Possibly evidenced by
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
Identify individual risk factors and interventions to reduce
potential for infection.
Maintain safe aseptic environment.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
(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.
Nursing Interventions Rationale
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
Risk factors may include
Exposure to cool environment
Use of medications, anesthetic agents
Extremes of age, weight; dehydration
Possibly evidenced by
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
Maintain body temperature within normal range.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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
Possibly evidenced by
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.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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.
Nursing Interventions Rationale
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
Possibly evidenced by
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.
Nursing Interventions Rationale
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.
Nursing Interventions Rationale
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.
Nursing Interventions Rationale
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
Risk factors may include
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
Possibly evidenced by
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
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.
Nursing Interventions Rationale
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),
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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
Possibly evidenced by
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.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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
Possibly evidenced by
Disruption of skin surface/layers and tissues
Desired Outcomes
Achieve timely wound healing.
Demonstrate behaviors/techniques to promote healing and to
prevent complications.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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).
Nursing Interventions Rationale
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).
Nursing Interventions Rationale
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
Risk factors may include
Interruption of flow: arterial, venous
Hypovolemia
Possibly evidenced by
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
Demonstrate adequate perfusion evidenced by stable vital
signs, peripheral pulses present and strong; skin warm/dry;
usual mentation and individually appropriate urinary output.
Nursing Interventions Rationale
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
Possibly evidenced by
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.
Nursing Interventions Rationale
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
Nursing Interventions Rationale
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.
Nursing Interventions Rationale
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.